Every finding on record at Bria of Elmwood Park

Based on interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R1) from physical abuse by R2, with a known documented history of verbal altercations between R1 and R2, who were roommates, yet R1 and R2 remained assigned to the same room despite these ongoing altercations. These failures affected one (R1) of four residents reviewed for abuse. These failures resulted in R1 being struck in the face with a glass vase by R2. R1 sustained pain, bruising, and swelling to the left side of the face and was transferred to the hospital for evaluation and treatment where R1 was admitted with a diagnosis of assault related to the injuries sustained during the incident.Findings include:R1's Initial FRI (facility reported incident), dated 7/5/25, documents, in part, Allegation Type: Abuse; Physical. On 7/5/26 at 8:50pm, V4 (Licensed Practical Nurse/LPN) stated she (V4) entered (R1 and R2's room) and saw R2 standing over R1 with a vase. She (V4) removed R2 from the room and checked on R1. V4 noticed R1's face was a little swollen and starting to bruise. Bruise left side of face. R1 will be sent out for an evaluation. R1 stated her (R1) face hurts. Resident (R1) given Tylenol. Internal investigation, Safety Audit.R1 unable to be interviewed. R1 is currently hospitalized for assault.R1's face sheet documents and admission date of 12/01/23 and diagnoses that include but are not limited to dementia and adjustment disorder.R1's BIMS (brief interview for mental status) score, dated 6/12/26, is 3 which indicates R1's cognition is severely impaired.R1's care plan, dated 1/08/24, documents, in part, (R1) has factors that may increase her vulnerability. (i.e. dementia poor ambulation, inability to ambulate/propel wheelchair, fragility/weakness) which may increase her (R1) susceptibility to abuse/neglect, with interventions, that document, in part, Investigate statements/allegations per facility protocol, Check for any physical marks, injury. Interview persons assigned to provide care and other individuals who have knowledge of specific situations, Follow up accordingly.R1's Abuse and Neglect Screening, dated 12/19/25, documents that R1 has risk factors that increase R1's vulnerability to be abused and does not have a history or presence of dysfunctional behavior (e.g., provoking aggressive, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking, and/or otherwise abrasive/inappropriate behavior).R1's progress note, dated 5/13/26 at 2:30pm, per V7 (Licensed Practical Nurse/LPN), documents, in part, Resident (R1) had a verbal altercation with her roommate (R2). Resident (R1) observed in her roommates (R2) closet and wearing her roommates (R2) shirt. Resident's (R1 and R2) separated. Roommate (R2) asked resident (R1) to give her (R2) shirt. Social services made aware and spoke to this resident's daughter (R1) regarding this. Will endorse to next shift.R1's progress note, dated 6/13/26 at 2:06pm, per V7 (Licensed Practical Nurse/LPN), documents, in part, Resident (R1) and roommate (R2) still having verbal altercations about this resident (R1) taking roommates (R2) clothing and wearing them. Both resident's (R1 and R2) redirected at this time. Writer (V7) will remind Social Services on Monday about this. Writer (V7) will also suggest a lock be placed on roommates (R2) closet. Daughter (R1)will also contact social Services on Monday.R1's progress note, dated 7/5/26 at 10:26pm, per V4 (Licensed Practical Nurse/LPN), documents, in part, Writer (V4) walked into the patient's (R1) room and observed the patient (R1) frightened by another patient (R2) who was hovering over her (R1) with a vase in her (R2) hand. Writer (V4) separated them (R1 and R2) immediately. Writer (V4) administered the patient (R1) Hydralazine and Tylenol. Writer (V4) gave patient (R1) an ice pack. family was called. Patient (R1) is getting sent out to the hospital for evaluation and treatment. Will continue to monitor.R1's eINTERACT SBAR Summary, dated 7/5/26 at 10:44pm, per V4 (Licensed Practical Nurse/LPN), documents, in part, Patient (R1) left side of face bruised. Writer (V4) gave Tylenol and an ice pack. The patient (R1) has been sent out to hospital.R1's progress note, dated 7/5/26 at 11:38pm, per V5 (Licensed Practical Nurse/LPN), documents, in part, This writer (V5) was informed by floor nurse (V4) that a possible physical altercation happened between resident (R1) and roommate (R2). Nurse (V4) separated residents (R1 and R2) immediately. Resident (R1) was brought to nursing station and roommate (R2) stayed in room on 1:1 supervision. Upon assessment resident (R1) was observed with bruising and swelling to left side of face, swelling to both hands and bruising to left upper arm. No visible open skin seen by staff. Ice packs provided to help ease pain and swelling. Resident (R1) stated that she (R1) was having pain to face rated an 8 on a 0-10 pain scale. PRN Tylenol administered. Vitals obtained, BP: 194/100, P: 111, R: 20, T: 97.8 and O2sat 97% on room air. PRN hydralazine 25mg administered. Resident (R1) confused on what happened, unable to give a detailed description, staff unable to put together any information from resident's (R1) statement. V6 (Nurse Practitioner/NP) ordered to send resident (R1) to (Hospital) ER (emergency room) to rule out any fracture/internal trauma. (Hospital) ER called and report was given to ER nurse. (Ambulance) called and arrived in facility. Resident (R1) left facility via (Ambulance) transportation.R1's progress note, dated 7/6/26 at 5:10am, documents, in part, Spoke with ER NOD (nurse on duty), resident (R1) admitted for dx: assault observation.R1's progress note, dated 7/6/26 at 8:54pm, documents, in part, Called (Hospital) confirmed resident (R1) diagnosis was assault.R1's Ambulance Run Sheet, incident date 7/5/26, documents, in part, Per nurse 'pt (R1) was attacked by roommate (R2). She (R1) was hit in the face and now has swelling and bruising. Pt (R1) states that '[her] roommate (R2) hit her with the door and then began hitting her (R1) face.' Pt (R1) has hx of dementia. Crew notes swelling under and around left orbital and bruising to the area. Pt (R1) reports pain upon palpation of face. Pt (R1) also states she (R1) has pain upon palpation in her (R1) left humeral head. Facial injury; Localized swelling mass and lump; Head: Swelling, Pain, Contusion; Face: Pain, Tenderness; Swelling, Contusion.R2 unable to be interviewed. R2 was sent to behavioral hospital and admitted due to R2's physical altercation with R1 on 7/5/26.R2's face sheet documents an admission date of 2/18/26 and diagnoses that include but are not limited to dementia and depression.R2's BIMS (brief interview for mental status) score, dated 6/18/26, is 8 which indicates R2's cognition is moderately impaired.R2's care plan, dated 7/08/26, documents, in part, Verbal and Physical Aggression: I (R2) demonstrate behavioral distress related to: Ineffective coping mechanisms. outward expression of internal pain. Poor verbal skills and inability to express self in more appropriate language. Poor self-esteem; feelings of inadequacy. Feeling powerless, out of control. Being challenged by mental illness. Being challenged by a dementia-related illness Other: The symptoms that I have are manifested by: Verbally aggressive behavior when agitated. Use of profanity, demeaning statements, verbal threats and yelling at others. Racial, ethnic. religious, gender slurs. Physically aggressive behavior when agitated. Attempting to push, shove, scratch, hit, slap; 05/13/26: Verbal Altercation, 06/04/26: Physical Aggression threw clothes across room, 07/06/26: Physical Altercation allegedly hitting with lamp.R2's progress note, dated 5/13/26 at 2:30pm, per V7 (Licensed Practical Nurse/LPN), documents, in part, Resident (R2) having a verbal altercation with her roommate (R1). Resident's (R2) separated from each other and social services made aware. Will endorse to PM nurse.R2's progress note, dated 5/31/26 at 1:39pm, per V12 (Registered Nurse/RN), documents, in part, Niece notified of PRN for pt (R1) agitation at this time. Pt (R1) is less agitated at this time. Behavior redirected . Sitting in chair at Nursing Station. Cont. to assess. Supervisor notified.R2's progress note, dated 6/02/26 at 2:40pm, documents, in part, Resident (R2) woke up from her (R2) nap stating she (R2) has to get out of here before the place blows up. Attempted to medicate resident (R2) with her PRN medication, resident (R2) refuses at this time. Rolling her (R2) wheelchair from door to door and to the elevator trying to get out. Resident (R2) contacted her (R2) sister. Writer spoke with her (R2) sister who tried to encourage her (R2) to take the medication, however resident (R2) refused told writer to take it myself. Social service director made aware.R2's progress note, dated 6/04/26 at 1:11pm, documents, in part, Resident (R2) in her (R2) room alone observed throwing all her (R2) items across the room toward the door. Very upset, had a family member on the phone. Resident (R2) wants to go home; does not understand why she (R2) is here. Staff attempted to redirect her (R2) and calm her (R2) down with some success. Resident (R2) offered her lunch tray but refused it.R2's progress note, dated 6/13/26 at 2:18pm, per V7 (Licensed Practical Nurse/LPN), documents, in part, Writer (V7) called to room by housekeeper and CNA. Observed resident (R2) and her roommate (R1) in a verbal altercation. This resident (R2) states she (her roommate/R1) is always wearing my (R2) clothes. She (R2) should not go in my closet. Both residents (R1 and R2) separated and easily redirected at this time. Writer will suggest this resident have a lock put on her closet on Monday.R2's progress note, dated 7/5/26 at 11:18pm, per V4 (Licensed Practical Nurse/LPN), documents, in part, Writer (V4) entered patients (R2) room and observed the patient (R2) hovering over another patient (R1) holding a vase in her (R2) right hand. Writer (V4) separated the patients immediately. The patient (R2) said she (R2) was protecting herself (R2). The patient (R2) is being sent out to (Hospital).R2's progress note, dated 7/5/26 at 11:38pm, per V5 (Licensed Practical Nurse/LPN), documents, in part, This writer (V5) was informed by floor nurse (V4) that a possible psychical altercation happened between resident (R2) and roommate (R1). Nurse separated residents immediately. Roommate (R1) was brought to nursing station and resident stayed in room on 1:1 supervision. Upon assessment resident (R2) denied having any pain or being in any distress. No visible open skin seen by staff. Resident (R2) stated that roommate (R1) came to her (R2) side of the room and hit her (R2) with a vase. Per resident (R2) they began to fight and that's how resident (R2) ended up on roommates (R1) side of the room hovered over roommate (R1). Per resident (R2) she (R2) had to protect herself. Vitals obtained, BP: 100/69, P: 88, R: 18, T: 98 and O2sat 99% on room air. NP (nurse practitioner) ordered to send resident to (Hospital) for a psych evaluation.R2's progress note, dated 7/6/26, documents, in part, Resident (R2) left facility at this time via ambulance to hospital for Psych eval.On 7/7/26 at 10:26am, V1 (Administrator) said, I didn't call the police originally because their (R1 and R2) BIMS (Brief Interview for Mental Status) are so low. I didn't know if it was intent. In hindsight, I should have. I didn't call the police later, because the police contacted me. I have 24 hours to report it to the police, and it was less than 24 hours when I talked to the police. The police contacted me yesterday and asked the same question. In hindsight, it was an error. I was thinking of the incident being like two toddlers that don't know what they are doing. I don't have a copy of the report (police) yet. I need to talk to the nurses still, and the police said they (police) will call me with a report number.On 7/7/26 at 11:03am, V4 (Licensed Practical Nurse/LPN) said, As I was doing my rounds, I seen R1 on the bed and R2 was hovering over her (R1). There was a green glass vase in R2's hands. R1 looked very frightened. R1 had a big bruise on her (R1) face. The left side of her face. R1's face was swollen. I figured R2 was in there hitting and beating on her (R1). R1 said, 'She (R2) is beating me (R1).' The other resident (R2) said that she (R2) was defending herself (R2) and R1 hit her (R2) first. Like R1 hit R2 with the vase, and R2 somehow got the vase from R1, and then R2 hit R1 with the vase. I didn't see her (R2) hitting R1. I didn't see R1 hit R2 either. There were no sounds or yelling. I was just doing my rounds. The male CNA (V8/Certified Nursing Assistant/CNA) came and helped separate R1 and R2 and got the vase from R2. She (R1) was complaining of pain to her (R1) face, so I gave her (R1) Tylenol and her (R1) blood pressure was up, so I had to give her (R1) something for that too. I can't remember what she (R1) rated her (R1) pain at, but she (R1) was in a lot of pain. She (R1) was frightened and in pain which is probably the reason her (R1) blood pressure was up. There were no other issues earlier in the day. They (R1 and R2) were completely fine earlier. They (staff) told me that they (R1 and R2) had some incidents before, like arguing with each other. I believe there was something else that happened before, but I'm not sure. I'm agency. That's all I know. I didn't witness it. R2 didn't have any injuries that I seen.On 7/7/26 at 11:12am, V5 (Licensed Practical Nurse/LPN) said, I came back (employed at facility) last March (3/2025). It was kinda busy that day (7/5/26). There were 2 agency nurses. V4 (Licensed Practical Nurse/LPN) said that there was an argument between R1 and R2. I saw the CNA (V9) bringing R1 out. The left side (R1's face) was swollen and bruised. I asked what happened. V4 said that R2 was hovered over R1 with a vase in hand. The CNAs, V4 (Certified Nursing Assistant/CNA), V9 (Certified Nursing Assistant/CNA), and V10 (Certified Nursing Assistant/CNA), helped with R1 and R2. V10 brought R1 out of the room. We (staff) tried to ask R1 what happened, but she (R1) was so confused she couldn't tell us anything. When we (staff) asked R2, R2 said R1 started it and hit R2 with the vase first. R2 said R1 came on her side of the room. R2 said they were rumbling and ended up on the other side of the room (R1's side of the room). According to R2, R1 started the fight. What R2 was saying did not make any sense. R1's hands were swollen, and there was bruising on her (R1) left upper arm too. She (R1) had to have gotten hit more than once. There were no injuries on R2. No, R2 did not have one mark on her (R2). I have not seen any aggression before between R1 and R2. I heard that R2 has arguments with R1. I never seen it. R1 and R2 have arguments, but not physically violent until now. In report from other nurse, I heard they (R1 and R2) have had them before but never seen it. I heard they (R1 and R2) argue like once or twice a week. They argue because R2 assumes R1 is wearing R2's clothes. They (facility management) should have changed their (R1 and R2) rooms due to their (R1 and R2) arguments and not getting along. That (R1 and R2 remaining roommates after multiple verbal altercations) I have no answer to. We (facility) usually change residents removes after verbal altercations. Well, most of the time depending on details of the argument.On 7/7/26 at 11:43am, V1 (Administrator) said, I found out yesterday that they (R1 and R2) have had verbal altercations in the past. I have no idea why they (R1 and R2) weren't separated and no longer made roommates. That (R1 and R2 not being roommates) would make sense and be the logical thing to do (assigning R1 and R2 to separate rooms).On 7/7/26 at 12:07pm, V9 (Certified Nursing Assistant/CNA) said, It'll be 13 years working here (facility). The only thing I know is they (R1 and R2) were eating earlier in the dining room. They (R1 and R2) went to the room by themselves (R1 and R2) to get ready for bed. I went on break. I heard R2 was over R1 with a vase and hit her (R1). I didn't see anyone hit anyone. When I got there, R2 was in the room, and R1 was at the nurse's station. R2 was telling me, 'I did not start that fight. Everyone keeps saying I started it. She (R1) had the vase and hit me (R1) first.' I work all floors. I do not know of any altercations, physical or verbal, between R1 and R2. I seen injuries on R1. R1 had a big bruise on the left side of the face. She (R1) kept saying her (R1) fingers hurt, and her (R1) left ear was a little swollen. I did not see any injuries on R2.On 7/7/26 at 12:27pm, V7 (Licensed Practical Nurse/LPN) said, I've been working here (facility) about 34/35 years. R1 and R2 had not had physical (altercations), but verbal altercations, yes. I have notes in there (R1 and R2's EMR/electronic medical record) about that (verbal altercations). I spoke with V11 (Social Services Director) about the verbal altercations. Yes, their (R1 and R2) rooms should have been changed a long time ago. It's both (R1 and R2). They (R1 and R2) both take each other's clothes. R1 has a history of doing it (taking resident's clothes). R2 is always accusing R1 of taking her (R2) stuff. R2 has said verbally to R1 I'm going to kick you're a**, but I never seen her (R2) physically touch her (R1) or hit her (R1). I wasn't working that day (7/5/26), so I don't know what happened.On 7/7/26 at 12:54pm, V10 (Certified Nursing Assistant/CNA) said, I've been here since October will be 2 years. I know the nurse (V4/LPN) was doing her (V4) rounds, and I guess she (V4) called one of the CNAs to see if R1 looked like that, asking about her (R1) face. The CNA that was working the floor wasn't too familiar with R1 either. V4 called me and asked me about her (R1) face. I'm like [NAME], it (R1's face) ain't ever look like that. That's all I know. Her (R1) left eye was swollen and there was an imprint of vase was on her (R1) face. No injuries that I know of to R2. Yes, I have heard that they (R1 and R2) had verbal altercations in the past. These altercations are silent. You don't even know that they are fighting until you walk into the room. There was one (verbal altercation with R1 and R2) last week. It was reported to the social worker that worked that day. They (R1 and R2) have had multiple altercations. I don't know why they (R1 and R2) weren't separated after all the verbal fights. Yeah, they (R1 and R2) should have been separated prior to this. I don't know anything about R2 having physical aggression, just ranting. Nothing physical.On 7/7/26 at 1:03pm V8 (Certified Nursing Assistant/CNA) said, I have no idea. I don't know who they (R1 and R2) are. I never heard of R1 and R2. I don't know of any altercation. V8 then raised his (V8) voice saying, What happened then?! Why are you calling me then?! Whatcha you asking me for?! On 7/7/26 at 1:09pm, V8 called surveyor back and said, I'm sorry. It just dawned on me. Me and one of the other aides helped separate them (R1 and R2). I took the green vase from R2. R2 had glasses and a black wig. I just don't know their (R1 and R2) names. R2 was over on the bed with R1, like almost on top of her (R1). R1's face was swollen. R1's face had an indentation of vase. I just went over to see if R1 was okay. It wasn't my assignment. I don't know what happened, I do apologize. You through me off guard. I thought I was getting in trouble for something. No residents said anything to me about what happened. That's it. I don't know anything else.On 7/7/26 at 1:15pm, V11 (Social Services Director) said, Yes, I know R1 and R2. 2 residents on the same floor. I was made aware of the altercation (7/5/26) through text. My understanding through text was that R2 was allegedly standing over R1 with a lamp. That's pretty much all I know. I was never notified of any verbal altercations prior to this. People (staff) tell me stuff all the time, sorry. I can't remember everything. Not that I recall (verbal altercations with R1 and R2). I'm sorry. I don't know. If I was notified of R1 and R2 having verbal altercations, I would have discussed it (verbal altercations) with the IDT (interdisciplinary team). If there was a history of verbal altercations between the 2 (R1 and R2), I would have moved them (R1 and R2). I am not aware of any aggression that R1 or R2 show or have shown.On 7/8/26 at 11:02am, V2 (Director of Nursing/DON) said, I received a call from the Administrator (V1) around 9pm (7/5/26), NOD (V4) informed him (V1) of a physical altercation between roommates (R1 and R2). He (V1) was starting an abuse reportable. Gave me the information that a R2 was seen with some object hovering over R1. I called the NOD (V4), asked V4 to complete a head-to-toe assessment, call doctor, and families. Asked her (V4) if EMS (emergency medical service) was called and said she (V4) spoke to the administrator (V1) and told her (V4) something about the residents having dementia. One-to-one monitoring and visible view was put in place for the residents. R1 was sent to the hospital because of the injury to the face. V4 needed assistance with petition for R2 to send for a psych evaluation and I contacted social services for a petition and R2 was transferred out for a psych eval. I do not know of any of the previous incidents between the 2 (R1 and R2). I started here first week of May (2026). When we (facility) have our IDT meetings and the things are presented, our SSD (social services director) and us, as team, congregate and look for the best suitable outcome. We all table off our ideas and start the room change process. We are supposed to interview the patients and find out problems and the nature of the problems. We would most likely separate them to avoid conflict. Yes, sir. Not make them (R1 and R2) roommates.On 7/8/26 at 1:12pm, V13 (Medical Director) said, I was informed today (7/8/26) about it (R1 and R2 altercation on 7/5/26). I was told one of the residents (R2) hit the other resident (R1) with a glass vase. R1 was sent to hospital for evaluation of the injuries and R2 sent to behavioral hospital. They (R1 and R2) are not my personal residents, so I am not aware of any history between them (R1 and R2). Yes, R1 had facial swelling so harm was caused. If residents have had verbal altercations in the past, some of the buildings are limited as far as rooms and staff have to talk to them (residents) and try the find out the problem. If it's (verbal altercations) an ongoing problem I would expect them (facility staff) to change the rooms of the residents. But if one violent incident I expect them to change rooms immediately.On 7/8/26 at 2:14pm, V1 (Administrator) said, My history is so limited. I can't even recall speaking to either one of them (R1 and R2). I don't know R2 at all. I don't know if I can say it was willful intent or not. I just don't know her (R2). I was not aware of any verbal altercations prior to this incident (7/5/26). I found out after the fact that there were verbal disagreements with them (R1 and R2) in the past. I would have changed roommates if I knew about these previous verbal disagreements. If these residents (R1 and R2) return to the facility they will be separated.Record review of facility's policy titled, Abuse Prevention Program, dated 9/2017, documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment and making the necessary changes to prevent future occurrences. VI. Protection of Residents. The facility will take steps to prevent potential abuse while the investigation is underway: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents.Record review of facility's policy titled, Behavior Management, dated 6/2025, documents, in part, It is the policy of (Name of Facility) to manage unruly behavior of a resident in the least restrictive manner that ensures the safety of residents, employees, and family members. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any waythat would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.).Record review of facility's policy titled, Caring for Residents with Dementia, dated 9/2025, documents, in part, It is the policy (Name of Facility) to care for residents with a dementia diagnosis in a manner and an environment that promotes maintenance or enhancement of each resident's quality of life. The facility will care for residents in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.Record review of facility policy titled, Facility Assessment Tool, dated 5/27/26, documents, in part, Diseases/conditions, physical and cognitive disabilities, behavioral health needs, and overall acuity. 1.1. Indicate if you may accept residents with, or your residents may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Psychiatric/Mood Disorders: Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. Neurological System: Alzheimer's Disease, Non- Alzheimer's Dementia, CVA, TIA, Stroke, Traumatic Brain Injuries.Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 4:CAA Process and Care Planning (dated October 2022) documents in part the following: 9. Behavioral Symptoms: In the world at large, human behavior varies widely and is often dysfunctional and problematic. While behavior may sometimes be related to or caused by illness, behavior itself is only a symptom and not a disease. The MDS only identifies certain behaviors but is not intended to determine the significance of behaviors, including whether they are problematic and need an intervention. Therefore, it is essential to assess behavior symptoms carefully and in detail in order to determine whether, and why, behavior is problematic and to identify underlying causes. The behavior CAA focuses on potentially problematic behaviors in the following areas: wandering (e.g., moving with no rational purpose, seemingly being oblivious to needs or safety), verbal abuse (e.g., threatening, screaming at, or cursing others), physical abuse (e.g., hitting, shoving, kicking, scratching, or sexually abusing others), other behavioral symptoms not directed at others (e.g., making disruptive sounds or noises, screaming out, smearing or throwing food or feces, hoarding, rummaging through other's belongings), inappropriate public sexual behavior or public disrobing, and rejection of care (e.g., verbal or physical resistance to taking medications, taking injections, completing a variety of activities of daily living or eating). Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident's life and the quality of the lives of those with whom the resident interacts. When this CAA is triggered, nursing home staff should follow their facility's chosen protocol or policy for performing the CAA. This CAA is triggered when the resident is identified as exhibiting certain troubling behavioral symptoms.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must provide services to keep your physical and mental health at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to follow physician orders, failed to follow the facility assessment tool, failed to schedule required nursing staff, and failed to ensure that sufficient nursing staff were available to meet the needs for four of four residents (R2, R3, R8, R9) reviewed for medication administration. These failures have the potential to affect 174 residents residing in the facility.Findings include:The 5/18/26 facility census includes 174 residents.The 8/1/25 Facility Assessment Tool includes Licensed Direct Care Nurses/Total # of staff needed or average range: LPN's (Licensed Practical Nurses) and RN's (Registered Nurses) staffed based on census x minimum staffing hours required. Other: All floors are staffed with 2 Nurses per shift. Staffing Plan: the facility checks daily staffing needs census, skilled and non-skilled residents. The facility is staffed to meet the acuity needs of facility residents. The facility also has a labor budget that it follows which meets the minimum staffing requirements according to regulations. [The facility has 4 floors - therefore a minimum of 8 Nurses is required].On 5/11/26, IDPH (Illinois Department of Public Health) received allegations that (R2's) medications were not administered (as directed) at the facility due to lack of nursing staff.On 5/18/26 at 1:04pm, V7 (Infection Prevention Nurse) was observed accessing the (1st floor) medication cart. Surveyor inquired about facility staffing concerns V7 stated I'm (V7) infection control but I'm working the cart, were (facility) short of Nurses. I (V7) think people called off and affirmed that she was currently assigned on the 1st floor. R2's (5/10/26) progress note states 9:14pm, patient called 911 and went out. Nurse reported that she went as nurse did not arrive to room in time to give her medication.R2's (3/27/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact).On 5/26/26 at 3:14pm, surveyor inquired why R2 called 911 (on 5/10/26). R2 stated, I (R2) didn't get my pain meds or any other meds, nothing and affirmed this occurred on 3pm-11pm shift due to no Nurse assigned. The 5/10/26 (3pm-11pm) Nursing Assignment Sheets include 1 nurse assigned to 1st floor (team 2 entry was blank), 1 nurse assigned to 4th floor (team 2 entry was blank), 2 nurses assigned to 2nd floor and 2 nurses assigned to 3rd floor therefore only 6 Nurses were scheduled [8 Nurses are required - per facility assessment tool].R2 resides on 4th floor (team 2).R2's POS (Physician Order Sheets) include (8/9/23) Metoprolol Tartrate 25mg two times a day, Topiramate 25mg at bedtime, and (1/3/26) Famotidine 20mg two times a day.R2's MAR (Medication Administration Record) affirms on 5/10/26 - evening shift (blank) entries were noted for Famotidine (scheduled for 4pm administration), Metoprolol Tartrate (scheduled for 5pm administration), and Topiramate (scheduled for 9pm administration).On 5/26/26 at 11:21am, surveyor inquired about required facility Nurse staffing V2 (DON/ Director of Nursing) replied It should be at least 2 nurses on each floor and affirmed this was for each shift. Surveyor inquired why only one (1) nurse was assigned to 4th floor on 5/10/26 (evening shift) if two (2) nurses were required. V2 stated, It probably was initially scheduled with 2 people and for whatever reason maybe the 2nd person didn't come. Surveyor inquired how one (1) Nurse (assigned to 56 - 4th floor residents) can administer medications timely. V2 responded, The Nurses come from the different floors and do the med pass. Surveyor inquired how someone determines who administered medications to the 4th floor residents on 5/10/26 evening shift (if excluded from the schedule). V2 replied, Typically the MAR (Medication Administration Record). Surveyor inquired about facility staffing concerns. V2 stated, We (facility) consistently look for more and more staff. Certain days are a little more challenged than others. This particular one (referring to Sunday 5/10/26) is the short weekend. We switched to using a staffing company and it started off a little rocky. When we are short, the nurses do get together and do the med passes on the floor, but we haven't had staffing issues moving forward. Surveyor inquired what a blank entry on the MAR indicates. V2 responded, If it's not documented, it wasn't done.__R8 resides on 4th floor (team 2).R8's (4/16/26) BIMS determined a score of 14.R8's POS includes (7/16/25) Hydralazine HCL 50mg three times a day and Metoprolol Tartrate 25mg two times a day. (4/29/26) Gabapentin 100mg three times a day. (5/3/26) Lantus 100units/ml, inject 22 units at bedtime. On 5/18/26 at 2:04pm, surveyor inquired if R8 has any medication administration concerns. R8 responded, No however R8's (5/10/26) MAR affirms (blank) entries were noted for Metoprolol Tartrate (scheduled for 5pm administration), gabapentin (scheduled for 5pm administration), Lantus (scheduled for 9pm administration), and Hydralazine (scheduled for 9pm administration). __R9 resides on 4th floor (team 2).R9's (4/24/26) BIMS determined a score of 15 (cognition intact).R9's (10/3/25) POS includes Advair Diskus Aerosol Powder 250-50 micrograms/dose. 1 inhalation every 12 hours. On 5/26/26 at approximately 3:14pm, surveyor inquired about concerns at the facility. R9 affirmed that on 5/10/26 (evening shift) there was no nurse assigned to the unit and stated, I (R9) have an inhaler I should get at 8:00pm, that's a problem.R9's (May 2026) MAR affirms (blank) entries were noted for Advair (scheduled for 9pm administration) on 5/4, 5/5, and 5/10.On 5/26/26 at 12:06pm, surveyor inquired about staffing concerns. V16 (LPN) stated, The weekends are short more often than during the weekdays. I (V16) don't know if it's because they have a new outside source doing the schedule and they find the people, or somebody calls off and they're in charge of finding a replacement. Surveyor inquired about required Nurse staffing. V16 responded, It's supposed to be 2 Nurses assigned to 1st, 2nd and 4th floor and 3 Nurses are assigned to 3rd floor in the mornings and evenings therefore a total of 9 Nurses. Surveyor inquired if V16 passed (4th floor) medications on 5/10/26 (evening shift) when she (V16) was assigned to the 2nd floor (per nursing assignment sheet). V16 responded, No, me personally? No. Surveyor inquired if V16 has time to assist with passing medications on other floors when assigned to roughly 25 (2nd floor) residents. V16 replied, Speaking for myself, no. On 5/10/26 (evening shift), V17 (Agency LPN) was the Nurse assigned to 4th floor per V2 (DON).On 5/26/26 at 1:59pm, surveyor inquired why R2 called 911 on 5/10/26 (evening shift). V17 stated, I (V17) didn't know that anybody called 911. I was all by myself and they (facility) didn't' have a Nurse on the other side (Team 2). I'm (V17) from the agency, not familiar with the patient and the supervisor wasn't responding to anything so I was all by myself. Nobody informed the Nurse, the resident (R2) didn't inform me (V17), and the CNA (Certified Nursing Assistant) didn't inform me. So, I wasn't aware. Surveyor inquired if other Nurses assisted with medication administration on 5/10/26 (evening shift). V17 responded, No, the supervisor came, she (supervisor) did nothing and she left. I couldn't get a login until 5:00pm and I started at 3:00pm. Surveyor inquired if all the 4th floor residents received (evening shift) medications on 5/10/26. V17 replied, I was able to pass meds to people on my side (Team 1) and the other side (Team 2) I only did some of the medications. They (residents) were all complaining, the people (residents) on the other side were angry, some were yelling, and I told the supervisor that you don't have somebody on the other side. On 5/27/26 at 11:02am, surveyor inquired about the required 3pm-11pm facility Nurse staffing. V20 (Nurse Supervisor) stated, 3-11 shift we (facility) run with 9 nurses: 2 on each floor (1st, 2nd, 4th), and 3 on 3rd floor and affirmed that this excludes the Nurse Supervisor. Surveyor inquired about the 5/10/26 (3pm-11pm) Nurse staffing. V20 responded, I (V20) didn't work that day, I work every other weekend and that was my (V2) day off. They (facility) normally have a MOD (Manager on Duty) from different departments that take turns, on the other weekends - sometimes it's a nurse. V20 reviewed the (5/10/26) evening shift Nursing Assignment Sheets (as requested) and stated We (facility) have 6 Nurses. Surveyor inquired if on 5/10/26 the (1st floor) had only one Nurse scheduled. V20 responded, That's what they (facility) have written on the paper. Surveyor inquired if on 5/10/26 the (4th floor) had only one Nurse scheduled. V20 replied, That's what they have written in. Surveyor inquired who assists with medication administration if only 1 Nurse is assigned to the unit. V20 stated, Since I've (V20) been the supervisor (2 weeks ago) when there's only 1 nurse, I help pass meds. Surveyor inquired who assists with passing medications if the MOD is not a Nurse. V20 responded, That I wouldn't be able to answer cause I'm (V20) not here.R3's R3's diagnoses include sepsis. R3's (4/10/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact).On 5/18/26 at 12:52pm, surveyor inquired about medication administration concerns at the facility. R3 stated They (facility) didn't have my (R3) Vancomycin, they ran out of it. I (R3) finally got it today.R3's (5/15/26) POS (Physician Order Sheets) include Vancomycin 25mg (milligrams)/ml (milliliter) give 5 ml (milliliters) every 6 hours. R3's (May 2026) MAR (Medication Administration Record) affirms 9 (See Nurses Note) was documented on 5/17 at midnight, 6am, 12pm, and 6pm. 9 was also documented on 5/18 at midnight and 6am. R3's (5/17/26) progress notes state 1:35pm, Vancomycin: spoke with pharmacy, medication will be delivered with delivery today. 9:31pm, Vancomycin: awaiting pharmacy delivery. On 5/21/26 at 12:57pm, surveyor inquired what 9 indicates on the MAR. V2 (Director of Nursing) stated, Other, see nurses note. Surveyor inquired about R3's 5/17/26-5/18/26 Vancomycin administration V2 reviewed R3's (May 2026) MAR and responded On the 17th, he (R3) has a 9 for midnight, 6am, 12pm, and 6pm. On the 18th he has a 9 for 12 midnight and 6am. Surveyor inquired if R3's Vancomycin was unavailable V2 reviewed R3's progress notes and replied, This says at 9:31pm on 5/17 the nurse signed out that she was awaiting pharmacy to deliver. On 5/17 at 1:35pm, she (Nurse) did not have the medication available. Surveyor inquired how many doses of Vancomycin R3 didn't receive. V2 stated, I'm (V2) seeing 6 doses. The medication administration policy (revised 10/2025) states verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. If medication is not given as ordered, document the reason on the MAR. The staffing policy (reviewed 9/2025) states staffing is based on the IDPH formula for determining numbers and levels of staff. Staffing is then increased based on the needs of the resident population. A schedule is made on a monthly basis and reviewed on an ongoing basis.

Based on record review and interview, the facility failed to follow policy procedures, failed to follow physician orders, failed to administer medication as prescribed, and failed to ensure that four of four residents (R2, R3, R8, R9) reviewed for medication administration remained free from significant medication errors. Findings include:On 5/11/26, IDPH (Illinois Department of Public Health) received allegations that medications were not administered (as directed) at the facility.R3's diagnoses include sepsis. R3's (4/10/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact).On 5/18/26 at 12:52pm, surveyor inquired about medication administration concerns at the facility R3 stated They (facility) didn't have my (R3) Vancomycin, they ran out of it. I (R3) finally got it today.R3's (5/15/26) POS (Physician Order Sheets) include Vancomycin 25mg (milligrams)/ml (milliliter) give 5 ml (milliliters) every 6 hours. R3's (May 2026) MAR (Medication Administration Record) affirms 9 (See Nurses Note) was documented on 5/17 at midnight, 6am, 12pm, and 6pm. 9 was also documented on 5/18 at midnight and 6am. R3's (5/17/26) progress notes state 1:35pm, Vancomycin: spoke with pharmacy, medication will be delivered with delivery today. 9:31pm, Vancomycin: awaiting pharmacy delivery. On 5/21/26 at 12:57pm, surveyor inquired what 9 indicates on the MAR V2 (Director of Nursing) stated Other, see nurses note. Surveyor inquired about R3's 5/17/26-5/18/26 Vancomycin administration V2 reviewed R3's (May 2026) MAR and responded On the 17th, he (R3) has a 9 for midnight, 6am, 12pm, and 6pm. On the 18th he has a 9 for 12 midnight and 6am. Surveyor inquired if R3's Vancomycin was unavailable V2 reviewed R3's progress notes and replied This says at 9:31pm on 5/17 the nurse signed out that she was awaiting pharmacy to deliver. On 5/17 at 1:35pm, she did not have the medication available. Surveyor inquired how many doses of Vancomycin R3 didn't receive V2 stated I'm (V2) seeing 6 doses. __R2's diagnoses include hypertension, epilepsy, and alcohol abuse. R2's (3/27/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact).R2's progress notes state (5/10/26) 9:14pm, patient called 911 and went out. Nurse reported that she went as nurse did not arrive to room in time to give her medication.On 5/26/26 at 3:14pm, surveyor inquired why R2 called 911 (on 5/10/26) R2 stated I (R2) didn't get my pain meds or any other meds, nothing and affirmed this occurred on 3pm-11pm shift. R2's POS includes (8/9/23) Metoprolol Tartrate 25mg two times a day for hypertension, Topiramate 25mg at bedtime for epilepsy, and (1/3/26) Famotidine 20mg two times a day for Gerd (Gastroesophageal Reflux).R2's (May 2026) MAR affirms on 5/10/26 evening shift (blank) entries were noted for Famotidine (scheduled for 4pm administration), Metoprolol Tartrate (scheduled for 5pm administration), and Topiramate (scheduled for 9pm administration).On 5/26/26 at 11:21am, surveyor inquired what a blank entry on the MAR indicates V2 responded If it's not documented, it wasn't done.__R8's diagnoses include type II diabetes mellitus.R8's (4/16/26) BIMS determined a score of 14.R8's POS includes (7/16/25) Hydralazine HCL 50mg three times a day for hypertension and Metoprolol Tartrate 25mg two times a day for hypertension. (4/29/26) Gabapentin 100mg three times a day for neuropathy. (5/3/26) Lantus 100units/ml, inject 22 units at bedtime for diabetes mellitus. On 5/18/26 at 2:04pm, surveyor inquired if R8 has any medication administration concerns R8 responded No however R8's (5/10/26) MAR affirms (blank) entries were noted for Metoprolol Tartrate (scheduled for 5pm administration), gabapentin (scheduled for 5pm administration), Sucralfate (scheduled for 5pm & 9pm administration), Lantus (scheduled for 9pm administration), and Hydralazine (scheduled for 9pm administration). __R9's diagnoses include shortness of breath, chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. R9's (4/24/26) BIMS determined a score of 15 (cognition intact).R9's (10/3/25) POS includes Advair Diskus Aerosol Powder (Corticosteroid) 250-50 micrograms/dose. 1 inhalation every 12 hours for decrease inflammation in lungs. On 5/26/26 at approximately 3:14pm, surveyor inquired about medication administration concerns at the facility R9 replied I (R9) have an inhaler I should get at 8:00pm, that's a problem.R9's (May 2026) MAR affirms (blank) entries were noted for Advair on 5/4, 5/5, and 5/10 at 9:00pm.The medication administration policy (revised 10/2025) states all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. If medication is not given as ordered, document the reason on the MAR.

Based on interview and record review the facility failed to follow policy procedures and failed to submit a facility reported incident to IDPH (Illinois Department of Public Health) within regulatory requirements for one of three residents (R6) reviewed for abuse. Findings include:On 3/20/26, IDPH (Illinois Department of Public Health) received an abuse allegation perpetrated by facility staff.On 5/18/26 at 11:10am, surveyor inquired about the facility abuse protocol V1 (Administrator) stated If there's an abuse allegation, they (staff) report it to me (V1). If the perpetrator is a staff member they are suspended, a police report is made, I (V1) interview the resident or the person making the allegation and send the State a report within 2 hours. I have 5 working days to investigate and submit a final. Surveyor requested R6's (5/14/26) facility reported incident/investigation at this time.On 5/18/26 at 11:34am, V1 presented an email (not a facility reported incident form) sent from a Gmail account which includes subject: alleged verbal abuse preliminary report. The email states Please accept this email as a preliminary report of alleged verbal abuse. I (V1) was called at 5:54pm today and told that there was an allegation of alleged abuse. The alleged incident happened on May 14th at approximately 4:30pm. CNA/Certified Nursing Assistant (V4's Name) was answering a call light. The resident is [R6's first name]. Resident's husband reported that he witnessed (V4) yell at resident to not sit up. (V4) has been suspended pending the investigation. Police were called and a report has been filed. The resident's physician had been notified. Resident's husband has been notified. No injuries reported. The email was submitted to IDPH on 5/15/26 at 7:46pm - however required information (R6's last name, age, diagnosis, and mental status) and facility reported incident form were excluded.On 5/19/26 at 11:37am, surveyor inquired if R6's (5/14/26) abuse allegation was reported to IDPH within 2 hours V1 responded Yes. Surveyor inquired why a Facility Reported Incident Form was not submitted to IDPH on 5/15/26 - when staff were notified of alleged abuse V1 replied I (V1) don't have a laptop yet. That's why I put on there (referring to email) I hope you'll accept this initial. Surveyor inquired if the (5/14/26) initial Facility Reported Incident was submitted to IDPH yet V1 replied Yesterday (5/18/28) I started putting it on an official form but when I submit the final, I'll submit the real form with all the data transferred over. Surveyor inquired why R6's last name was excluded from the email submitted to IDPH on 5/15/26 V1 stated I used my Gmail and there was HIPAA (Health Insurance Portability Accountability Act), I don't know if it was encrypted and didn't want to break any HIPAA laws. R6's (initial) facility reported incident form was submitted to IDPH (via email) on 5/20/26 (5 days after staff was made aware of alleged abuse).The facility Abuse policy (reviewed 9/2017) states that 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's regional office immediately by telephone or fax. The report shall include the following information, if known at the time of the report: Name, age, diagnosis of mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated. Date, time, location and circumstances of the alleged incident.

Based upon interview and record review, the facility failed to follow policy procedures and failed to conduct a thorough investigation for two of three residents (R4, R5) reviewed for abuse. Findings include:On 3/20/26, IDPH (Illinois Department of Public Health) received allegations that sometime in March and unknown male CNA (Certified Nursing Assistant) told R4 they could choke her.On 5/18/26 at 9:22am, surveyor inquired about R4's alleged abuse V3 (Family) stated I (V3) don't know who the staff was because they (facility) never followed up with me (V3). Surveyor inquired if R4 currently resides at facility V3 affirmed that she (R4) does not. The 3/23/26 (initial) facility reported incident form states (R4) alleged that a day or two after she admitted to the facility. She was calling a staff member for assistance, and she overheard (from outside her room) two staff members talking to each other saying that they will choke her out. She stated that a tall light skin staff member confirmed that was said. There is no known witness at this time. The 3/23/26 (final) facility reported incident form states we have received statements from several staff that are regularly assigned to work on the first floor and specifically assigned to work with (R4). No one has heard any of the statements that (R4) reports were made and no staff have had a conversation with (R4) stating that staff want to harm her. Based on staff statements, and the fact that staff respond to her room in pairs the allegation of verbal abuse is unsubstantiated. [The facility reported incident form includes interview of other residents: write summary of interview(s) with other residents who may have had contact with the alleged perpetrator however interviews of witnesses/documented statements - exclude R4's roommates and/or other facility residents]. On 5/18/26 at approximately 10:00am, V1 (Administrator) affirmed he's been employed at the facility for 1 month - therefore after the 3/23/26 alleged incident. On 5/19/26 at 1:40pm, surveyor inquired if resident interviews were obtained/documented during the 3/23/26 abuse investigation. V1 subsequently reviewed the statements with surveyor and affirmed that resident interviews were excluded. Surveyor inquired about required interviews for abuse investigations V1 stated I (V1) think the resident should be interviewed, the resident roommates, probably the resident across the hall that could hear something, staff that worked and the supervisor that worked so we have as much information as possible. __R5's diagnoses include quadraplegia. R5's (5/11/26) functional assessment affirms the resident is dependent on staff for all ADL (Activities of Daily Living) care. R5's (11/4/25) care plan includes Abuse/Neglect/Trauma. Resident states he has been a victim of gun violence, interventions: encourage resident to verbalize any instances of abuse. Provide a safe environment. R5's (5/11/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 5/18/26 at 1:30pm, surveyor inquired about concerns at the facility R5 stated Maybe 3 weeks ago, I (R5) was getting handled by 2 CNAS who talk how they want. (V5/CNA's name) put her (V5) hands on me (R5). I (R5) don't really turn to the left because it hurts. She (V5) turned me to the left and I said ah, ah, I'm in pain. I told her she was going too fast. She told me to shut up, I called her the B word because I was hurting. I told the supervisor that (V5) put my head in the pillow, and I couldn't breathe. The 5/5/26 (initial) facility reported incident form states (R5) stated (V5) allegedly hit him in the face. No injury identified. The 5/5/26 (final) facility reported incident form includes interview of alleged victim, interview of alleged perpetrator (V5), interview of witness (V12/CNA), interview of other residents states Due to the diagnosis of nearby residents, they were unable to interview. Conclusion: after a thorough investigation including witness statements from staff that were present during the alleged incident, the allegation of abuse is unsubstantiated. There was a witness in the room the entire time, when the alleged abuse was to occur. The witness says that (V5) did not abuse (R5) physically, mentally, or verbally. Furthermore, there was no evidence to support that any inappropriate physical actions occurred based on the nurse's assessment that was completed right after the alleged incident. On 5/20/26 at 10:26am, surveyor inquired about R5's (5/5/26) abuse investigation V1 stated I (V1) spoke to him (R5), I spoke to the person he (R5) accused (V5), I spoke to the CNA (V12) that went in there, I spoke to an RT (Respiratory Therapist) that didn't witness anything but she (RT) heard (R5) yelling and said it was (V5) saying that's disrespectful and said she (RT) saw the CNA leave. I think that was it. Surveyor inquired if any residents (besides R5) were interviewed during the investigation V1 responded I couldn't interview his roommates because they (roommates) were non-verbal. There was no one across the hall, there's' an office there and the 2 residents next door are non-verbal. Surveyor inquired if V1 interviewed residents that V5 was assigned to V1 replied I did not, it was my first investigation in an extremely long time and I followed a template, I haven't done one in 20 years. Surveyor inquired if the facility policy was followed V1 stated I haven't read the policy, I went according to the template (referring to the facility reported incident form) and some guidance of regional.The facility Abuse policy (reviewed 9/2017) includes investigation procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed.

Based on interview and record review the facility failed to follow policy procedures and failed to develop a baseline care plan within 48 hours of admission for three of four residents (R1, R4, R6) reviewed for abuse and falls. Findings include:R1 was admitted on [DATE]. R1's potential for abuse care plan was initiated on 4/27/26 - (18 days after admission). On 5/21/26 at 10:13am, surveyor inquired about baseline care plan requirements V14 (Care Plan Coordinator) replied Within 72 hours upon admission the nurses on the floor should be opening up a baseline care plan. It would be developed within 48 hours but would be in there within 72 hours. Surveyor inquired if R1's baseline care plan includes abuse V14 reviewed R1's EMR (Electronic Medical Records) and stated No, no abuse is in there. Surveyor inquired when R1's abuse care plan was initiated, V14 responded 4/27.R4 was admitted on [DATE].R4's (3/23/26) facility reported incident states (R4) alleged she overheard two staff members talking to each other saying that they will choke her out. R4's abuse/neglect care plan was initiated on 3/25/26 - after 3/23/26 abuse allegation (6 days after admission). On 5/21/26 at 10:25am, surveyor inquired when R4 was admitted V14 Care Plan Coordinator) stated 3/19 of 2026. Surveyor inquired if R4's baseline care plan includes abuse V14 reviewed R4's EMR and responded No. Surveyor inquired when R4's abuse care plan was initiated V14 replied 3/25.R6 was admitted on [DATE].R6's 5/5/26 (admission) fall risk evaluation determined a score of 11 (high risk).R6's (5/16/26) incident report states upon staff entering room to answer call light, resident was observed on the floor on the side of her bed. R6's fall care plan was initiated on 5/18/26 - after 5/16/26 fall (13 days after admission).R6's (5/14/26) initial facility reported incident states (R6's) husband stated the nurse aide (V4/Certified Nursing Assistant) allegedly yelled at resident. R6's abuse care plan was initiated on 5/17/26 - after 5/14/26 abuse allegation (12 days after admission). On 5/21/26 at 10:28am, surveyor inquired when R6's admission fall risk assessment was conducted V14 stated She (R6) has a 5/5 fall risk assessment. Surveyor inquired if R6 has a baseline fall care plan V14 responded She doesn't have one. Surveyor inquired when R6's fall care plan was initiated V14 replied 5/18. Surveyor inquired if R6 has a baseline abuse care plan V14 stated I (V14) only have 5/17 the comprehensive.The baseline care plan policy (revised 09/2025) states the baseline care plan will be developed within 48 hours of a resident's admission into the facility. The baseline care plan will include at minimum the following necessary information to properly care for a resident: fall risk.

Based on interview and record review the facility failed to follow policy procedures, failed to timely reorder medication, and failed to ensure that prescribed medication was available for one of four residents (R3) reviewed for medication administration. Findings include:On 5/11/26, IDPH (Illinois Department of Public Health) received allegations regarding medication administration.R3's diagnoses include sepsis. R3's (5/15/26) physician orders include Vancomycin 25mg (milligrams)/ml (milliliter) give 5 ml every 6 hours. R3's (4/10/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact).On 5/18/26 at 12:52pm, surveyor inquired about medication administration concerns at the facility R3 stated They (facility) didn't have my (R3) Vancomycin, they ran out of it. I (R3) finally got it today.R3's (May 2026) MAR (Medication Administration Record) affirms 9 (See Nurses Note) was documented on 5/17 at midnight, 6am, 12pm, and 6pm. 9 was also documented on 5/18 at midnight and 6am. R3's (5/17/26) progress notes state 1:35pm, Vancomycin: spoke with pharmacy, medication will be delivered with delivery today. 9:31pm, Vancomycin: awaiting pharmacy delivery. On 5/21/26 at 12:57pm, surveyor inquired about requirements for drug reordering V2 (Director of Nursing) responded With the antibiotic, we (staff) have to make sure the medication is on hand. You should reorder, call and alert the pharmacy when the medication is running low. Surveyor inquired what 9 indicates on the MAR V2 stated Other, see nurses note. Surveyor inquired about R3's 5/17/26-5/18/26 Vancomycin administration V2 reviewed R3's (May 2026) MAR and responded On the 17th, he (R3) has a 9 for midnight, 6am, 12pm, and 6pm. On the 18th he has a 9 for 12 midnight and 6am. Surveyor inquired if R3's Vancomycin was unavailable V2 reviewed R3's progress notes and replied This says at 9:31pm on 5/17 the nurse signed out that she was awaiting pharmacy to deliver. On 5/17 at 1:35pm, she did not have the medication available. Surveyor inquired how many doses of Vancomycin R3 didn't receive V2 stated I'm seeing 6 doses. On 5/26/26 at 11:21am, surveyor inquired what a blank entry on the MAR indicates V2 responded If it's not documented, it wasn't done.The medication administration policy (reviewed 10/2025) states if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication.The (January 2026) medication ordering and receiving from pharmacy policy states the refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. When available and legible, the pharmacy label is pulled and transmitted to the pharmacy, when electronic ordering is unavailable.

Based on observation, interview and record review, the facility failed to ensure one resident (R6) was free from unnecessary restraint use, failed to ensure restraints were applied in a manner that allowed for easy release, failed to obtain informed consent prior to restraint use, failed to release restraints in accordance with the facility's restraint program/policy and professional standards, failed to exhaust all required interventions prior to initiation of restraint use, failed to follow the facility's restraint protocol/policy. This failure affected one resident (R6) in a sample of 82 residents reviewed for restraints. Applying the reasonable person concept due to R6's inability to communicate and severe cognitive impairment, these failures would have subjected a reasonable person to avoidable psychosocial harm including but not limited to, agitation, anger, diminished sense of dignity, and feelings of dehumanization.Findings include:R6's face sheet documents in part the following diagnoses: nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcer of the sacrum/right ankle, unspecified convulsions, encounter for attention to tracheostomy/gastrostomy, dependence on ventilator status, osteoarthritis, depression, and hypertension. R6's physician orders document in part an active order for May apply mittens to bilateral hands related to pulling at trach (1/14/2026) and Remove mittens and monitor bilateral hands for any skin issues Any skin issues-y/n (1/14/2026). R6's medication administration record for 1/14/2026-3/2026 documents that mitt restraints were removed every shift. R6's Minimum Data Set (2/13/2026) documents in part that R6's is rarely/never understood and has a memory problem with short- and long-term memory. R6's Care Plan does not identify R6 uses restraints. On 3/23/2026 at 11:11 AM, observed R6 lying in bed resting. R6 appeared lethargic and was not responding to questioning. Bilateral mitt restraints were observed on R6's hands, with a brown substance on the outside of the left mitt restraint. V63 (Certified Nursing Assistant) confirmed the observation of the restraints. V63 stated, I'm not really sure why (R6) has restraints, I think it's because (R6) scratches at (R6's) self. On 3/23/2026 at 11:14 AM, V49 (Agency Registered Nurse) confirmed observation that R6 had bilateral mitt restraints applied to R6's hands. V49 was unsure why R6's had the restraints and stated that it was R49's first time in the facility and first time assigned to R6. V49 denied ever receiving training on restraints from the facility prior to working in the facility. V49 stated the standard of care was to release restraints every two hours and that restraints required close monitoring. V49 was unsure when the restraints were last released. V49 released the right mitt restraint and could not untie the left mitt restraint. V49 stated, This one is very tight, no I can't fit more than 2 fingers on this one. V49 was unable to get one finger in-between the restraint and R6's wrist. V49 stated, The other one (mitt) I could. There are so many knots in this (restraint) ugh . who tied this?! I think this one must be malfunctioning. It shouldn't be like this; they should be tied in a manner that allows the restraint to come off easily. No, it is not coming off easily. It took approximately 2-3 minutes for V49 to untie the knots and release V49 from the restraints. V49 retied the restraint in a double knot. V49 observed the brown substance on the mitt and affirmed the mitts were not clean. V49 said to R6, I'm going to go see if I can get you new ones and pointed at the mitts. R6 did not attempt to pull at the trach for the entire observation with V49 or V63.On 3/24/2026 at 11:15 AM, observed R6 lying in bed resting with no mitt restraints on (R6's) hands. V36 (R6's Family Member) was observed at the bedside pacing while talking to V37 (R6's Family Member) on the phone. V36 was upset and stated, This facility is (explicative). I have been complaining that (R6) has not been receiving proper treatment. I want her to have therapy or something to prevent her declining. They staff don't know what they are doing. V37 agreed via phone and added that there are a few CNAs (couldn't remember their names) that really don't know how to care for R6. V37 confirmed that V37 is the decision-making healthcare surrogate for R6. V36 continued, . one day we came in one day and we saw her hands were covered in mitts. We had no idea. V36 and V37 affirmed there was no informed consent given by R6's family prior to the initiation of the restraint. V36 stated, We come in and they are always on. They will never take them off; we have to take them off. There's no schedule for staff to take them off or to discontinue them. We have been asking for them (the restraints) to be stopped or decreased. I have removed them in the past and they were so tight there were blisters, that was like a few weeks ago. We are tired of telling them what to do, they should know how to care for (R6). These are people, yet this facility treats them so bad it's like they're just mannequins . Look at her restraints [NAME], they've got brown (feces) all over them. V36 flipped the inside of the restraint out and there was an approximately 3 inch x 2 inch patch of dried blood on the inside of the restraint located where the restraint is tied around R6's wrist. V36 stated, That's from where it is tied, she had blisters, I'm telling you. V36 stated, we have been trying to get her to another nursing home, (redacted), but we can't because of those mitts. They (the other nursing home) said they cannot meet resident needs if they require the mittens. We just want to get (R6) out of here, but we're stuck [NAME]. We can't. (R6) deserves to live in a place that cares about her, please help us. Look, the whole time we have been here, (R6) hasn't grabbed at the trach. She's fine when someone is here, me and (V37) try to come as much as I can. I don't know of anything else they tried prior to the restraints to stop (R6) from pulling. (R6) can follow commands if you tell (R6).R119's face sheet documents in part that R119 resides in the same room as R6 and has a history of the following diagnoses: type 2 diabetes with neuropathy, chronic obstructive pulmonary disease, chronic respiratory failure, anemia, obstructive sleep apnea, and schizophrenia. R119's minimum data set (1/5/2026) documents in part a brief interview of mental status summary score of 15, indicating that R119 is cognitively intact. On 3/24/2026 at 11:23 AM, R119 was observed lying in bed across from R6's in a shared room. R119 stated, They don't help her (R6). They don't help any of us. I watch the staff take care of (R6) they never take those mitts off. They are on 24/7. No one checks on them or anything, like I said. They don't check on any of us. My care was much better when I was on the 4th floor.On 3/24/2026 at 11;25 AM, V23 (Registered Nurse) confirmed the observation inside of the restraint to be dried blood. V23 left the room and went to look for clean mittens. V36 stated, They said they don't have any clean mittens. V37 added, Yeah they said they had to order them. I don't know if they have come in yet. R6 was not observed pulling at the trach collar or any other dangerous behavior while the restraints were observed off from 11:15 until 11:40. On 3/24/2026 at 11:40, V23 (Registered Nurse) and V2 (Director of Nursing) applied the mitt restraints to R6's bilateral hands. Surveyor completed continuous observation of R6/surrounding area (including hallways, room, etc.) to monitor staff releasing R6's restraint. The continuous monitoring continued until 3:50 PM. During this observation, no staff member released R6's restraints (over 4 hours). On 3/24/2026 at 2:53 PM, observed V23 complete rounding on R6. V23 stated that V23 had been working at the facility for about 3 months but was agency staff prior for the facility. V23 did not recall if V23 received training on restraints, V23 stated, I don't know. I know like restorative went over mechanical lifts; I think they might have talked about restraints then. V23 explained that to use restraints, you need a physician order, regular monitoring and they have to be applied to where 2 fingers can fit under the restraint. V23 said that it is important to monitor restraint use and that staff should be looking for things like impaired circulation or skin breakdown. V23 said that V23 thought the professional standard is to release the restraints every 2 hours. V23 (Registered Nurse) stated that V23 explained that V23 thought that restraints were supposed to be checked every 2 hours but there was an active order in R6's chart to check every shift. V23 was unsure if CNAs in the facility could remove the restraints. V23 stated, I don't know, that (taking off the restraints/who takes off the restraints) would be something that is described in R6's care plan. V23 accessed R6's medical record and reviewed R6's plan of care. V23 stated the restraints were not care planned and that there should be a care plan in place to guide the staff's use of the restraint. When asked how often V23 had released the restraints during her shift or if V23 was aware of any other staff member releasing the restraints, V23 said, To be honest, I hadn't released them since they were off with the family, so only like once today?. V23 confirmed that V36 is very adamant about the restraints not being on and stated that V37 has brought up concerns about the restraints. V23 confirmed that V37 is the healthcare decision maker. V23 recalled one time that V37 asked if they could get another squeeze stress ball to help keep R6's hands occupied-- it was a couple weeks ago. V23 stated, V23 thinks V67 (Nurse Practitioner) was going to talk to V37 about it. Cognitively V23 believed R6 is alert and oriented times 3 (person, place time) and can communicate by mouthing words and could follow basic directions. V23 was unsure if any other interventions were provided prior to the restraint use. V23 stated that V23 felt if R6 had more supervision or 1:1 with staff, the restraint wouldn't be needed. At 3:50 PM, the interview ended, and R6's restraints had not been released. During the observation, there were no observed behaviors that indicated R6 was attempting to pull at the trach or perform any other dangerous behaviors. On 3/24/2026 at 3:14 PM, V68 (Certified Nursing Assistant) was observed rounding on R6. V68 stated, Yeah, I am familiar with (R6). She always has those (restraints) on. They are never taken off. The aides are not allowed to take off or touch the restraints.On 3/24/2026 at 3:35 PM, V69 (Registered Nurse) rounded on R6 and did not assess or release the restraint. V69 confirmed that V69 is assigned to care for R6 and is familiar with R6. V69 recalled that R6 has restraints on because R6 has a history of pulling out midlines and tries to pull off the collar/tubing. V69 explained, Yes, we take off the restraints when the family (V36 and/or V37) are here, that way we know someone is watching her at all times. They have asked me before if they could take them off, but I don't think they meant like if we could stop it. The family would be able to let us know if she is pulling at anything there's alarms on the ventilator that go off too. We do try to take them off, and we would document that in R6's progress notes. Oh yeah, for sure if we had someone sitting with (R6), (R6) wouldn't need the restraints. Something like a sitter or something, she for sure wouldn't need it. We just don't have a lot of staff I don't know of any log or anything that we fill out for restraint monitoring. If we document in the progress notes, that's when it happened. V69 stated that restraint use can cause skin breakdown, agitation and worsening cognition. V69 stated restraints should be released every 2-4 hours and that V69 tries her best to release the restraints when she works. On 3/24/2026 at 3:50 PM, R6's mitt restraints had not been released. V2 (Director of Nursing) stated that restraints can have negative outcomes like agitation. V2 denied that V2 was ever trained on the facility's restraint policy. V2 stated that the facility should be following the restraint policy. The restraint policy/program was reviewed with V2 and V2 was unsure what interventions were tried prior to the restraint. V2 confirmed that physician orders and a care plan should be in place when a resident has restraints. V2 confirmed the restraints should be released every 2 hours per the policy. Surveyor requested documentation of the monitoring tools that are indicated in the facility's restraint program. V2 was unaware of the monitoring tools. V2 and V23 (Registered Nurse) checked the nurse's station and could not produce the documentation of the monitoring tools. V23 denied knowledge of monitoring tools and denied ever using monitoring tools for R6. V2 stated, Maybe there is something in the restorative office, they should be tracking restraints. On 3/24/2026 at 4:11 PM, V2 checked the restorative office for any evidence of the monitoring tools or QAPI documentation. V2 and V62 (MDS Nurse) looked through the office and could not produce any documentation. V62 affirmed that V62 is an MDS nurse in the facility and is familiar with R6. V62 confirmed that R6 uses mitt restraints. V62 reviewed R6's MDS (2/13/2026) and confirmed that the MDS does not have mitt restraints coded. V62 reviewed R6's physician orders and medication administration record and confirmed R6's MDS was miscoded. V62 affirmed that the mitt restraints should have been coded. V62 explained that it is important that MDS are coded accurately as MDS helps to guide the plan of care for the resident. V62 reviewed R6's care plan and affirmed that no care plan was developed to address R6's restraint use. V62 affirmed that restraint use requires a care plan to be developed. V62 was unaware of any prior alternatives used prior to restraining R6. No further monitoring or QAPI tools related to restraints were provided to the survey team that were completed prior to the start of the survey. On 3/25/2026 at 12:31 PM, V67 (Nurse Practitioner) affirmed that V67 is the provider that manages R6's care within the facility and ordered the restraints for R6. V67 explained that R6's baseline mental status can answer questions by mouthing words and can follow some commands. V67 stated, Yeah, so I have talked to her multiple times about pulling at the trach tubing. I don't know what the issue is if she gets anxious or confused. The reason she has them is because she pulls at the ventilator tubing and has pulled out midlines. When I see her, I have taken off the restraints, and she goes pulling at the tubing. I don't know how much of it is agitation vs. forgetfulness. V67 confirmed that the mitts limit R6's purposeful movement. V67 stated that V67 had ordered hydroxyzine to help with anxiety but was not aware of other interventions that have been tried and failed. V67 stated, I am not aware of any 1:1 intervention that were provided to (R6). I do agree with the others that if someone were to be with her all the time, (R6) wouldn't need the restraints, but I don't know if the facility can do that. V67 denied ever being educated on the facility's restraint policy. V67 explained that restraints should be closely monitored, released and checked for injury every 2 hours and be tied in manner that allows for easy release. V67 stated that restraints can cause wounds under the restraint, injury from the patient trying to take off the restraint. V67 confirmed V67 has talked to V36 and V37 about the restraints and that they verbalized understanding of the use and that V36 asked about things that could be provided like a PT evaluation, so V67 ordered that recently. V67 was aware that R6 was trying to be transferred to another facility and had talked to the other facility who told V67 they couldn't accept until the restraints were discontinued. V67 affirmed that V67 has assessed for other reasons why V67 might have agitation like pain, or toileting needs, infections prior to the restraint. When asked if R6 has ever had a psych consult to manage the behaviors or for medication management, V67 replied, No, R6 isn't seeing psych that I am aware of. R6's progress notes were reviewed. On 3/24/2026. the following timeline is documented within R6's progress notes from V67 (Nurse Practitioner): 12/12/2025: hydroxyzine increased dt agitation, patient attempting to pull at trach, will eval for mittens as needed.01/01/2026: R6's readmit notes: Treated with Cefepime ongoing on discharge from hospital. nephrology was consulted for elevated BUN. discharged with foley. No further paperwork of hospital course received. Patient decannulated self-due to anxiousness. RT able to reinsert without complication.R6's notes:01/06/2026: Mittens ordered for patient safety due to decannulation risk.01/12/2026: Received message from nurse that family is requesting that patient be sent to hospital for brain scan. family is concerned that patient is not mouthing words, and they want her to have a brain scan. Per hospital paperwork, patient has been nonverbal and does not answer questions.01/14/2026: readmitted with no new findings, treated for hypernatremia. readmitted with no new orders from hospital. Report that labs have improved and does not need HD.03/12/2026: Attempted to trial patient without mittens on while writer was in the room. When mitten was removed, patient attempted to pull at trach. SS aware. Family updated via phone in depth.03/13/2026: Attempted without mittens, patient still attempting to pull at trach.03/18/2026: Attempted again with no mittens with resulting pulling at tubing of trach/vent. 03/24/2026: Discussed with patient son at bedside. Explained the safety risk of removing mittens. Son verbalized understanding. requesting eval of PT- ordered.03/26/2026: Removed mittens while this writer was at bedside. Skin and circulation assessed, no redness or pain reported by patient. Patient asked multiple times to have this writer put mittens back on. When asked why, patient pointed to her trach. When asked why she pulls the trach tubing off, patient shrugged her shoulders and laughed, touched the trach tubing again. Attempted to educate patient on importance of keeping trach and tubing connected to breathing. Explained to patient the safety risk of disconnecting the tubing. Per staff report, patient had disconnected trach tubing this morning while mittens were off and again the night prior. Psych consulted to assess medication regimen for anxiety. Continue restraints with q2 hour skin/circulation checks, pain assessments and ADLS. No further interventions were documented within the progress notes or provided to the survey team prior to the exit of the survey. On 1/14/2026, V11 documented that V11 obtained informed consent for the restraints. On 3/25/2026 at 2:19 PM, V11 (Licensed Practical Nurse) affirmed that V11 was the original nurse that obtained consent from R6's family. When asked who V11 spoke to, V11 stated, I spoke to the resident and (R6's) sister (NOT V37) to get consent. Yes, her sister, she is up here all the time. V11 recalled that the restraints were ordered because R6 was pulling at the tubing. V11 stated, I have told her to stop, and sometimes she will look at me, and then grab the tubing again. I know she understands. I don't remember other interventions we have tried prior to the restraints. I don't think we have tried something like a 1:1 but she would definitely needs increased rounding. We try to remove the restraints whenever we (provide incontinence care). There is an order that reminds us to take them off, I don't know exactly how often. I think its twice per shift. If restraints aren't taken off regularly, it can cause skin breakdown. I don't know how I would feel if I wasn't released from the restraints, probably uncomfortable? I would want them released. I have met with (V36) and R6's sister, they didn't express issues with the restraint to me. I have overheard that (R6) can't be discharged to the other facility because of the restraints. On 3/25/2026 at 2:40 PM, V21 (Activity Director) affirmed that V21 is familiar with R6. V21 explained, Okay so. (R6) can't leave the room, so we provide pop-in visits. (R6) is able to understand things, (R6) used to be able to use a communication board but now, not so much. I assess the residents for activity needs, and I know (R6) likes music. I have told (V37) to bring in a radio multiple times, but I don't think (V37) has. (R6) likes music, that would help (R6). V37 is very involved. When I visit with R6, I have seen R6 pull at the tubing. I just redirect (R6). It helps if you give (R6) things like hand massages with lotion. I usually take the mitts off when I visit and massage her hands. Yes, (R6) was given a squish stress ball when (R6) was first here to occupy (R6's) hands, and R6 could kind of squeeze it. I haven't seen it in a while. When asked if providing more 1:1 care would allow R6 to be free from the restraints, V21 replied, I don't know, I think it depends on the person and if (R6) likes you. Like (R6) listens to me, and she is able to be redirected. V21 denied witnessing staff remove the restraints. V21 stated, When I go in there, I take them off, set an alarm for 15 minutes and give her a massage. Surveyor asked for documentation of activities provided for R6 (like the visits), V21 denied that the facility documents the visits. No further documentation was provided that indicates activities provided to R6. On 3/26/2026 at 10:37 AM, V47 (Medical Director) confirmed that V47 is a medical doctor (MD) and is the medical director for the facility. V47 affirmed that V47's job duties do not include supervising other physicians' medical practice in the facility, but is responsible for resident care-related things, including reviewing policies. When asked about restraint use in the facility, V47 replied, It was my understanding that we (nursing homes) can't have restraints in the facility. I am not aware of any restraint use in the facility. If we did, I guess yeah, we should be following that protocol. V47 affirmed that residents have the right to be free from physical restraints and that other interventions should be exhausted like redirection prior to initiating a restraint. V47 stated that providers should be assessing for other causes of behaviors like infections and that restraints require informed consent. V47 explained that complications of restraint use include physical harm from the resident trying to get out of the restraint and psychosocial harm by feeling restricted or imprisoned, could make someone depressed. V47 affirmed that restraint use should be monitored for when the restraint could be released. On 3/26/2026 at 12:11 PM, V56 (Restorative Nurse, Licensed Practical Nurse) affirmed that V56 is responsible for monitoring for restraint use in the facility. Surveyor requested to see any QA documentation that indicated the monitoring of restraint use as indicated in the restraint protocol, V56 was unable to provide documentation. V56 stated, It's in the computer I just can't get it open right now. There must be something wrong with the file. Besides we only have one resident on that has restraints, its (R95). V56 did not identify that R6 uses restraints during interview. No further documentation was provided to the survey team that indicated the facility was monitoring restraint use per the protocol. Record review of R6's restraint assessment completed by V56 (Restorative Nurse, Licensed Practical Nurse) documents that R6's restraint was not reviewed until 3/24/2026 after the survey had begun. Additionally, the assessment indicatest the order for restraints was given on 3/24/26 and consent was obtained from V37 on 3/24/2026, that the physician order was changed to remove every 2 hours, that R6's orientation was not assessed (blank). The following alternatives were not attempted prior to restraint use: reorientation/redirection, toileting, pain management, diversional activity, increased supervision, non-restrictive devices and repositioning. The order within the restraint assessment indicates that order was obtained on 3/25/2026 to apply bilateral mitt restraints daily, remove every 2 hours and check skin breakdown pain and ADLs. The duration of the restraint says, Daily remove every 2 hours and does not give a true duration for how long the restraint will be intended for use. No further documentation was provided to the survey team that indicated the restraint use was assessed prior to 3/24/2026. Record review of R6's care plan indicates that a care plan was initiated for restraint use on 3/24/2026. No care plan was developed of the restraint use occurred prior to 3/24/2026. Record review of R6's root cause analysis indicates that the root cause analysis was not completed until 3/24/2026. The root cause analysis indicates that R6 has anxiety/discomfort, and the only interventions tried prior to initiation was hydroxyzine and giving R6 stuffed animals to hold. No other root cause analysis was provided to the survey team that indicates root cause analysis was completed prior to 3/24/2026. Record review of an email chain (3/2/2026-3/25/2026) between the facility and the facility R6's family wished to be discharged to affirms that the next facility is unable to accept R6 while the restraints are in use. Facility Restraint Protocol (10/20/2025) documents in part, 1. PurposeTo ensure the safety, rights, dignity, and well-being of residents by preventing unnecessary or inappropriate restraint use in accordance with: Illinois Nursing Home Care Act (210 ILCS 45/), Illinois Administrative Code (Title 77, Part 300), CMS regulations (F604, F605), IDPH survey expectations.The program ensures: Restraints are not used for discipline, convenience, or staff shortage. Restraints are used only to treat a medical symptom, with the least restrictive option. Alternatives are attempted and documented. Continuous monitoring and regular reassessment occur.2. Illinois-Specific Legal RequirementA. Rights Under Nursing Home Care Act (210 ILCS 45/2-108)Residents have the right to: Be free from physical and chemical restraints, unless necessary to treat a medical symptom. Receive full explanation of the restraint, duration, alternatives attempted, and risks. Provide informed consent (resident or surrogate). Have restraint use reviewed every 30 days with documented justification.B. Requirements Under Title 77, Part 300 Written physician order required. Order must specify type, duration, clinical symptom, and monitoring frequency. Documentation must include:oAlternatives attemptedoOngoing clinical needoResident/family educationoRelease scheduleoOutcomes of monitoringDefinitionsPhysical RestraintAny device or method that restricts freedom of movement and is not easily removed by the resident.Examples : .Soft wrist restraints Mitts .4. Assessment RequirementsBefore initiating a restraint:1.RN assessment identifying medical symptom2.Provider order (no PRN orders)3.Review of untreated causes, such as:oPainoInfectionoUrinary retentionoHypoxiaoMedication side effectsoMental health symptoms4.Behavioral triggers analysis5.Functional evaluation by PT/OT if indicated6.Documentation of ALL alternatives attempted7.Informed consent documented and witnessed5. Acceptable Medical Symptoms Severe agitation placing resident/staff at risk Self-extubation risk Pulling essential medical devices (trach, feeding tube, central line) Life-threatening line removal Acute confusion with risk of injury Severe fall risk unresponsive to alternativesConvenience or staffing limitations are NEVER acceptable.6. Required AlternativesExamples: 1:1 or increased supervision Low bed, floor mats Pain management Reorientation Toileting schedule Medical review for infections, delirium, or dehydration Activities or diversion Environmental modification Therapy evaluation Medication review/adjustment Bed alarms/chair alarms (not restraints)All alternatives must be documented with outcomes.7. Procedure for Restraint UseA. Application Two staff apply the device. Use the least restrictive type. Ensure correct fit and skin protection. Explain procedure to the resident.B. Monitoring ScheduleFirst hour: Every 15 minutesNext two hours: Every 30 minutesOngoing: Every 1 hour (minimum), unless order specifies more frequentlyCheck and document: Circulation Skin Respiratory status Pain Cognitive statusC. Mandatory Release ScheduleEvery 2 hours minimum: Range of motion Mobility/ambulation Repositioning Toileting Hydration/Nutrition Skin checkDocument everything .9. Documentation RequirementsNursing Documentation Medical symptom requiring restraint Full list of documented alternatives Informed consent Physician order Monitoring checks Release episodes Behavioral outcomes Skin integrity Pain and comfort measures Provider notifications Family/resident education Rationale for ongoing needCare Plan RequirementsCare plan must include: Restraint type Reason/goal Interventions Monitoring Discontinuation plan Less restrictive alternatives Resident rights protectionsPhysician Documentation Medical symptom Expected outcome Duration 30-day review note Renewal or discontinuation10. Monitoring ToolsA. Illinois Restraint Monitoring Flow SheetTimeCirculationSkinBehaviorRespiratoryDistress (Y/N)Released?ROM/Toileting/HydrationContinued Need?Staff InitialsB. Restraint Release Log (Every 2 Hours| Time | Released | ROM Provided | Mobility | Toileting | Hydration/Nutrition | Reapplied? | Notes | Initials |C. Weekly Restraint Review Tool(Completed by DON/ADON/IP)| Resident | Restraint Type | Reason | Hours/day | Behavior Trends | Alternatives Tried | Injuries? | DON Signature |D. Monthly QAPI Audit ToolStandardCompliant (Y/N)NotesPhysician order present & completeConsent presentResident informed of rightsAlternatives documentedMonitoring completed per scheduleRelease every 2 hoursNo injuriesCare plan completeMonthly/30-day reviewOpportunity for reductionE. Restraint Root Cause Analysis (Required for: Injury, >72 hrs use, repeated restraint episodes)Questions:1. Was the underlying cause identified and treated?2. Were enough alternatives attempted?3. Was staffing adequate at the time?4. Did environment contribute?5. Were medications contributing (delirium, sedation)?6. Were family/representatives involved?7. Was the restraint clinically justified at each interval?8. Is modification or discontinuation appropriate?11. Staff Training RequirementsAnnual + upon hire: Resident rights (Illinois Nursing Home Care Act) Identifying and treating medical symptoms Alternatives to restraints De-escalation techniques Safe application Monitoring and circulation checks Emergency removal Documentation expectations Abuse/neglect prevention Recognizing adverse outcomes12. Program Goals1.Maintain a restraint-free environment.2. Reduce restraint use to below state average.3.Zero restraint-related injuries.4.Ensure compliance with Illinois regulations and CMS F-tags.5.Improve resident dignity, independence, and psychosocial well-being.Restraint Management Program specifically tailored for ILLINOIS Nursing Homes, aligned with: Illinois Administrative Code Title 77, Part 300 (Nursing Homes Licensure) Illinois Nursing Home Care Act (210 ILCS 45/) CMS F604 & F605Record review of CMS Resident Assessment Instrument (RAI) (10/2025) documents in part, Although the requirements describe the narrow instances when physical restraints may be used, growing evidence supports that physical restraints have a limited role in medical care. Physical restraints limit mobility and increase the risk for a number of adverse outcomes, such as functional decline, agitation, diminished sense of dignity, depression, and pressure ulcers. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored. In many cases, the risk of using the physical restraint may be greater than the risk of it not being used. The risk of restraint-related injury and death is significant when physical restraints are used. Planning for Care When the use of physical restraints is considered, thorough assessment of problems to be addressed by restraint use is necessary to determine reversible causes and contributing factors and to identify altern[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide R1 enteral nutrition as ordered by the physician/dietician, failed to follow the facility's tube feeding management policy, failed to provide nutrition and hydration to R11 as indicated in his Illinois Department of Public health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form, failed to notify the dietician of changes in resident's diet order, and failed to document those changes in resident's medical record. Applying the reasonable person concept due to R1's severe cognitive impairment and inability to make needs known, a reasonable person would have suffered unnecessary psychosocial harm by the delay of feeding and not abiding by resident's last wishes by feelings of hunger, pain, and headaches. This failure affected two residents (R1, R11) in a sample of 82 residents reviewed for quality of care. Findings include: 1. R11 is [AGE] years old admitted to the facility on [DATE]. R11's face sheet listed the following medical history: Anoxic brain damage, unspecified severe protein- calorie malnutrition, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, pressure ulcer of sacral region stage 4, tracheostomy status, gastrostomy status, personal history of sudden cardiac arrest, etc. Minimum data Set (MDS) assessment dated [DATE] section C (cognitive patterns) indicated R11 has severely impaired memory, section GG (functional) of the same assessment indicated R11 is dependent on staff for all Activities of Daily Living (ADL) care needs. Care plan initiated [DATE] documented R11 is on nothing by mouth (NPO) status and is receiving enteral feeding for all nutrition needs. Interventions include adjust tube feeding as needed, monitor tolerance of feeding, monitor weight, labs, skin and hydration, give additional fluids by feeding tube as ordered, refer to registered dietitian (RD) as needed, turn and reposition every two hours and as needed. Review of physician order summary for R11 showed the following: Consult with nutritionist to assess rate of feeding due to resident having an episode of emesis (order date [DATE]). Check residual. If greater than AND/OR equal 100 ml hold feeding. If feeding held: Check residual after 1 hour and if residual is still great than or equal to 100 ml notify MD (order date [DATE]). R11 did not have any active G-tube feeding order, only water flush and medications. On [DATE] 11:52AM, R11 observed in bed sleeping and unable to awake or respond to any questions. G-tube plunger at bedside, no feeding pump or feeding infusing. On [DATE] at 9:50AM, R11 was observed in bed again, still not receiving any feeding. Surveyor inquired about resident's feeding orders from V24 (RN) who said she was not sure but could find out. On [DATE] at10:05AM, V24 said that she finally found information about resident's feeding, it was discontinued by hospice on [DATE]. On [DATE] at 12:35PM, V44 (R11 family member/POA) said feeding was stopped because residents were throwing up, hospice came and decided to stop feeding. V44 had asked them if feeding could be restarted and they said no. V44 has no clinical experience and just went with what hospice told her, because resident is at the end of life, he does not need feeding. V44 added R11 does not get any water, just what they give him with medication. R11 is not being turned and repositioned every two hours, staff said he does not need it because he is on a special mattress. On [DATE] at 1:00PM, V45 (RN/Hospice Nurse) said R11 was admitted to hospice on [DATE], V44 (POA) wanted to do comfort measures, no intubation, no curative treatments, no full code. V45 said resident was able to open his eyes last year but currently not showing any progress, he has a new pain medication treatment that is helping now. G-tube feeding was stopped on [DATE], because resident was showing a lot of respiratory distress. R11 was previously getting 2 calories feeding at 50ml/hour with a total volume of 425ml. Hospice discussed how feeding can cause resident respiratory distress with family. Surveyor asked V45 if any other interventions were attempted, like reducing the feeding rate or volume rather than stopping the feeding entirely and V45 said, No, they thought resident was going to pass that week. V45 was asked if she told V44 (POA) R11 is at the end of life and does not need feeding and she said yes, V45 told V44 because it would cause R11 more respiratory distress. V45 was asked how she determined R11 was at the end of life. V45 said' His blood pressure is low, today's reading was 110/50 and heart rate of 110. Department of Public health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE] documented in part, section D: Provide artificial nutrition and hydration by any means, including new or existing surgically placed tubes. On [DATE] at 9:30AM V43 (Dietitian) said she was blindsided with this decision, no one notified her resident's feeding was stopped, most of the time she will make recommendations, but she is not aware of the decision. Surveyor asked V43 what effect not feeding can have on R11. V43 said because of resident's medical condition, it is hard to say, but without nutrition, resident can have weight loss and will not be getting nourishment. V43 said comfort measures do not include withholding feeding, not feeding the resident at all is 'extreme'. V43 added facility should be following resident's POLST form in determining resident's care. On [DATE] at 10:29AM, V2 (DON) said V2 was not aware that R11's feeding was discontinued and said no one informed her. V2 added the facility should follow resident's POLST form in providing care. On [DATE] at 10:52AM, V47 (MD) said he is familiar with R11, and she is aware R11's feeding was stopped by hospice. V47 was told it was because of risk for aspiration, the longer you feed the resident the longer he lives. Surveyor asked V47 if the feeding was stopped to hasten resident's death and she said she did not give the that order, it was recommended by hospice and resident's wife was okay with it. V47 was informed R11 is [AGE] years old and his POLST form signed by the wife indicated nutrition should be provided by any means, and she said facility should follow what is in the resident's POLST form, if the g-tube feeding is discontinued, the facility needs to readdress the POLST form and get a new one. Advance directive and do not resuscitate (DNR) policy reviewed 9/2023, stated in part: General: When a resident is admitted to the facility, aa discussion of advance directives will take place between the resident and family if the resident is unable to make decisions. This enables the staff to readily and clearly ascertain how to treat the residents in advance of an emergency. Advance directives: 1. Under state and federal law, people have the right to make decisions regarding health care treatment. This includes their right to determine in advance what life sustaining treatment will be provided, if any, in the future if they are unable to communicate those desires themselves. However, a resident is not required to be a DNR upon admission. 2. Life-sustaining treatments are the measures we take to sustain an individual's life and health. For example, in the event someone suffers a heart attack, we will perform CPR. Further we will take any other measures ordered by the provider, including IV's, tubes and the administration of medications, antibiotics, artificial hydration and nutrition to maintain life unless there are specific directions from the residents and/or family not to. Guideline: #3 If changes are needed to the advanced directives, then write void across the old form and initiate a new form with the appropriate information. 2. R1's face sheet documents in part the following diagnoses: acute and chronic respiratory failure, type 2 diabetes, unspecified protein calorie malnutrition, dysphagia, pressure ulcer of right buttock stage 3, personal history of traumatic brain injury, epilepsy, encephalopathy, tracheostomy and gastrostomy status. R1's Minimum Data Set ([DATE]) documents in part R1 is rarely/never understood and is severely impaired for cognitive decision making. Additionally, the minimum data set documents R1 receives 51% or more of R1's nutrition via enteral feeding. R1's care plan documents in part, R1 is at risk of hypoglycemia due to type 2 diabetes ([DATE]). R1 is NPO due to dysphagia, tube feeding will provide approximately 100% of estimated needs, and staff should be monitoring R1's tube feeding tolerance ([DATE]). Additionally, the care plan documents R1 may be at increased risk of abuse due to fragility/weakness, poor cognition, poor communication, and has a goal R1 will be free from mistreatment through the next review ([DATE]). R1's physician orders document in part an active enteral feeding order ([DATE]) for, every shift 2 Cal HN @ 40 ml/hr. x 20 hrs. On at 2 pm Off 10 am via GT if not available, may substitute Jevity 1.5 @ 52 ml/hr. x21 hrs. On at 2 pm Off 11 am R1's dietary evaluation completed by V43 (Registered Dietician) documents in part, PMH includes Tracheostomy, Dysphagia, HTN, Protein-Calorie Malnutrition, Seizure disorder, DMT2, Anemia Diet: NPO GT 2 Cal HN 40 ml/hr. x 20 hrs. On at 2 pm Off 10 am Water flush 300 ml every 4 hrs. (1800 ml) TF volume: 800 ml 1600 kcal 67 gm pro 560 ml fw+1800 ml wf=2360 TF provides 100% of estimated nutritional needs. Ht. 64 [DATE] 143.8 [DATE] 144.5 [DATE] 146.8 [DATE] 139 [DATE] 139.2 [DATE] 146 [DATE] 145.8 [DATE] 142.6 BMI=24.7 Normal range Est needs 65 kg: 1636-1964 kcal (25-30) 65-79 gm pro (1.0-1.2) 1964- 2291 ml (30-35 ml/kg) Weight fluctuates between 139-146$ in 6 mos. BMI within normal range Per nurses note [DATE], feeding held due to vomiting. KUB was done due to abdominal distention ([DATE]) Feeding was resumed [DATE] started as 10 ml/hr. and increased by 10 ml/hr. q 4hrs until goal rate of 40 ml/hr. was reached. No reported/documented feeding intolerance. Dependent on enteral feeding for nutrition support r/t dysphagia. [DATE] BUN 29 FBS 67 Cr 1.1 Na 138 L K 4.7 H/H 12.6/38.8 Skin intact, Hx of pressure ulcer Plan: Current order meets 100% of estimated nutritional needs . On [DATE] at 10:57 AM, R1 was observed lying in bed and was not able to be aroused for questioning. R1's enteral feeding pump was alarming with a FEED ERROR. R1's carton of enteral feeding formula was desiccant and devoid of any liquid formula within the carton. A quarter sized amount of dried formula was observed on the inside of the bottle was dry and cracking. The written date on the carton was [DATE] (NO TIME), indicating the date the formula was last changed. A clear tube was observed connected to R1's gastrostomy tube. Within the tubing was dry residual formula occupied less than 10% of the overall length of tubing. V7 assessed the alarm from the pump, and said the alarm was from an issue like the tube feeding not administering. V7 stopped the tube feeding and disconnected the tubing from the R1's gastrostomy tubing. V7 observed the feeding carton and identified the carton contained 1 liter of 2 cal. HN. V7 confirmed the observation that the enteral feeding carton and tubing appeared dry. V7 read the date at the top of the carton and affirmed [DATE] was the last date the enteral feeding was hung. V7 explained R7's tube feeding order is for 40 mL per hour, starting at 2pm and off at 10 AM. V7 stated, No, this is not good. R1 definitely should have had another (carton) administered by now based on order. It should have been dated at least [DATE] and changed yesterday, I don't know what happened here. On [DATE] at 11:03 AM, a second surveyor confirmed the carton observation. V2 (Director of Nursing) observed the carton and confirmed the observations. V2 stated, Yes, this carton was last hung on [DATE] and it runs at 40 cc an hour. Surveyor calculated the amount of enteral feeding based on the physician's order and total volume of the carton to last R1 approximately 25 hours from [DATE]. This was confirmed with V2. V2 stated, Yes, another carton should have been hung yesterday. V2 stated R1 is completely dependent on staff for enteral feeding/hydration. When asked what complications of the carton are not being changed/feeding not being administered, V2 stated, someone could get an infection. Record review of R1's progress notes confirm no progress notes were written between [DATE] and [DATE]. On [DATE] at 3:10 PM, V6 documented, Resident (R1) received in bed with HOB elevated, VSS, due meds given as ordered. GTF on going, on at 2pm off at 10am, trach/g-tube site intact, no s/s of infection. suprapubic cath draining amber yellow urine. Writer is notified of resident's secretion is greenish yellow. PA (Redacted) is made aware and reordered to do sputum cx and cbc bmp in am. Respiratory made aware to collect sputum. Resident repositioned q2h, kept clean and dry. call pad within reach. There is no documentation affirms any provider was made aware of the missing enteral feeding or a rationale as to why R1's feeding was not administered. On [DATE] at 10:38 AM, V1 (Administrator) confirmed V1 is the abuse prevention coordinator. V1 was asked what would happen to a reasonable person if they didn't get nourishment for a day. V1 replied, If I didn't get nourishment for a day other than being hungry, I'd be upset. V1 confirmed providing enteral feeding is a service the facility is able to provide. On [DATE] at 2:53 PM, V23 (Registered Nurse) affirmed V23 worked on [DATE] but was not assigned to R1. V23 stated, No I have never been assigned that set of patients. I don't even know who (R1) is. On [DATE] at 11:21 AM, V43 (Registered Dietician) affirmed V43 is the dietician for the facility and is familiar with R1. V43 explained the purpose of enteral feeding is to ensure a resident's nutritional needs are met without oral intake. V43 confirmed R1's physician order is nothing by mouth (NPO) and 100% of R1's nutritional needs are delivered by the tube feeding. V43 affirmed R1 has a history of diabetes, protein calorie malnutrition, and dysphagia, and the tube feeding is in place because R1 cannot tolerate oral intake with dysphagia. V43 recalled R1 was admitted to the facility with the gastrostomy tube and has always been dependent on staff for nutrition. V43 affirmed staff should be following the physician orders and V43's dietary recommendations. V43 stated, I spent time calculating all of (R1's) nutritional needs, they should be following. V43 explained if a reasonable person did not get enteral feeding for extended period of time, they obviously wouldn't get adequate nutrition and stated, You know, it would be similar to a normal person and what they would experience if they didn't eat for an entire day. You would be very hungry, have headaches, feel irritable, have weakness. V43 affirmed the tube feeding should not have been last hung on [DATE] and stated, Wow 3/21 to 3/23 .'s almost like 2 days without feeding. On [DATE] at 1:57 PM, V6 (Licensed Practical Nurse) affirmed V6 was assigned to care for R1 on [DATE] from 7:00AM-3:00PM. V6 recalled the R1's enteral feeding was checked around 10:00AM when it was turned off. V6 denied V6 hung a new carton of formula during the shift and feeding was to resume at 2:00PM. When asked why the new formula was not hung, V6 stated, I don't know I think I saw a little bit left in there. I don't recall (restarting it). On [DATE] at 10:37 AM, V47 (Medical Director) affirmed V47 is a medical doctor (MD) and the medical director of the facility. V47 explained if a patient with a history of diabetes and does not receive enteral feeding as ordered, you would expect the patient to have hypoglycemia (low blood sugar), dehydration, or electrolyte imbalances. On [DATE] at 2:22 PM, V61 (Licensed Practical Nurse) affirmed V61 worked both the PM and NOC shift on [DATE]. V61 denied V61 was assigned to R1 and stated, No, I had the other resident assignment. V61 said V61 recalled seeing R1 in bed while passing by R1's room at the start of the shift but did not enter the room, observe the tube feeding set, or hear any alarms coming from the room. On [DATE] at 5:25 PM, V24 (Registered Nurse, Nurse Supervisor) affirmed V24 worked on [DATE] on the PM shift. V24 did not recall who R1 was and stated, Yeah I won't know who is unless I am standing in front of them or can see them. I am not at the facility-- I was just working my other job as a nursing instructor. I haven't been employed at the facility for very long. My assignment set was up to room (which includes R1's room). If (R1) was in my set, then yeah, I took care of (R1). V24 denied ever changing any tube feeding cartons while working shift. V24 recalled doing rounds on all the patients and no one's tube feeding was alarming. V24 recalled 2 residents who received 2 cal, needed more tube feeding to be administered at the end of the shift. V24 could not recall which residents needed more tube feeding. V24 explained, I did not change them, that is night shifts responsibility to change the tube feeding set at midnight and hand more tube feeding if needed. I told (V66) in report the two residents needed more feeding hung. (V66) asked me if she writes the date of the start of the shift or the date at midnight. I told her it should be dated for the date at midnight when the set is changed. That is our standard, we document the date the feeding is hung and night shift is responsible for changing out the sets. (V66) was aware of (expectation). Record review of the facility staffing records documents in part on [DATE], V6 (Licensed Practical Nurse), V23 (Registered Nurse) were assigned to R1's unit for AM (7AM-3PM) shift, V61 (Licensed Practical Nurse) and V24 (RN Floor Manager) for PM shift (3PM-11PM), and V61 and V66 (Agency Registered Nurse) for NOC shift (11PM-7AM). During this survey, surveyor attempted to contact V66 (Agency Registered Nurse) multiple times for interview and was unable to complete an interview prior to the exit of the survey. Facility policy titled Tube Feeding Management documents in part, Nasogastric, gastrostomy, and jejunostomy tubes are used when an alternate method of nutrition is needed .1. Continuous tube feedings are based upon a 22-hour consumption period or other time frame based on individual resident need per Registered Dietician assessment and delivered over a 24-hour period .6. The Health Care Provider should be notified if tube-feeding amount is not infused as ordered .10. The tube feeding will be labeled with the resident's name, rate, total volume, date, and time hung . FEEDING PUMP:1. Use a feeding set for pump and assemble per manufacturer instructions. 2.Turn on pump, set prescribed rate and start feeding. 3. Flush the tube with water as ordered. 4.Pump should be cleared at the end of each shift. 5.Document tube feeding delivered. 6.Alert Health Care Provider of any issues or concerns.

Based on interview and record review, the facility failed to implement the facility's abuse policy, failed to establish coordination with the facility's QAA/QAPI program and the abuse prevention program, and failed to ensure agency staff were educated/competent on the facility's abuse policy upon hire. These failures affect all 107 residents that reside within the facility and place all residents at risk for abuse. Findings include:Facility census (3/23/2026) documents 170 residents reside within the facility. R6's face sheet documents in part the following diagnoses: nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcer of the sacrum/right ankle, unspecified convulsions, encounter for attention to tracheostomy/gastrostomy, dependence on ventilator status, osteoarthritis, depression, and hypertension. R6's physician orders document in part an active order for May apply mittens to bilateral hands related to pulling at trach (1/14/2026) and Remove mittens and monitor bilateral hands for any skin issues Any skin issues-y/n (1/14/2026). On 3/23/2026 at 11:14 AM, V49 (Agency Registered Nurse) was observed alone, trying to untie R's restraints. V49 affirmed V49 works for a staffing agency and it was V49's first day working on the facility. V49 affirmed V49 was assigned to care for a set of residents on the 3rd floor. V49 explained V49 has not received orientation from the facility or training on abuse from the facility. V49 affirmed V49 has worked in long term care before and is familiar with standard abuse policies. V49 stated the abuse prevention coordinator is the administrator, but V49 didn't know who the administrator was. Agency training documents provided by the facility do not document V49 was trained on the facility's abuse policy or trained in accordance with the abuse policy. On a document titled, ABUSE PREVENTION COMPETANCY TEST (no documentation of training prior to test). There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff as indicated in the abuse policy. No further evidence was provided to document that V49 was educated and competent on the facility's abuse policy. On 3/24/2026 at 11:10 AM, V25 (Agency Registered Nurse) was observed alone drawing insulin up for a resident at the medication cart on the 3rd floor. V25 affirmed V25 works for a staffing agency, and it was V25's first time in the facility. V25 affirmed V25 was assigned to care for a set of residents on the 3rd floor. V25 stated there was orientation paperwork online from the agency but did not recall what topics were in the paperwork. V25 stated, I don't know. I think (the paperwork) was about maybe about like abuse, positioning, falls, how to report an incident. I have prior experience (in long-term care) and had to acknowledge my prior experience. I don't know who the abuse prevention coordinator is, I'm sorry. Agency training documents provided by the facility do not document V25 was trained on the facility's abuse policy or trained in accordance with the abuse policy by the agency or facility. There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff; Procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; What constitutes abuse, neglect, exploitation, and misappropriation of resident property and resident abuse prevention as indicated in the abuse policy. An Agency Nurse Staff Duty Acknowledgement signed by V25 and V54 (Scheduler) does not list any acknowledgement of the facility's abuse prohibition program or policies. No further evidence was provided to document V25 was educated and competent on the facility's abuse policy prior to the exit of the survey. On 3/25/2026 at 10:38 AM, V1 (Administrator) provided the survey team the facility's QAPI binder contained data collection from departments within the facility. Record review indicated there was no documented quarterly review of accident reports, incidents reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, or mistreatment. V1 explained the purpose of QAPI is to self-identify areas of improvement, put in place plans to correct them, and see what improvements can be made. V1 confirmed V1 is the abuse prevention coordinator. V1 confirmed the QAPI binder did not have any quarterly review or collected data related to abuse (i.e., accident reports, incidents reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, or mistreatment). V1 explained the facility does not have a standard process to assess possible patterns or trends of potential abuse. V20 (Regional [NAME] President of Operations) asked V1, Is it you just don't have the documentation to prove you are doing it (tracking potential patterns of abuse/neglect) or is it you're not doing it. V1 affirmed the review process is not being completed. The facility's abuse policy was reviewed with V1 and V1 affirmed the facility should be following the abuse policy. When asked why the facility is not following their abuse policy by completing quarterly review of the identified items, V1 stated, I have no reason (why the facility is not following the abuse policy). V1 stated the purpose of tracking it would tell you if there were any potential problems with staff either with missing items with reports of abuse/neglect. It can help with education/training. V1 stated staff are trained on the abuse policy upon hire, quarterly, annually and as needed. V1 stated, We include agency staff on abuse training if they are in the facility. We have sent the agency our abuse policy and they get screened/trained and they send us all the documents, and they get told about how to access the facility. We have binders on the floors for agency nurse orientation and try to ensure an agency nurse is with a full-time employee. V1 affirmed the facility should be following the abuse policy.On 3/26/2026 at 9:25 AM, V20 stated the facility is tracking the required items per the abuse policy. V20 showed surveyor 3 months (1/2026, 2/2025, 3/2025) of documentation data was being collected regarding misappropriation/grievances by the social services director. No data was collected for accident reports, incidents reports, safety committee reports or environmental hazard report to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, mistreatment. Surveyor asked V20 for documentation shows data was being collected per the policy. V20 could not produce any further documentation. V20 stated, If we find anything else, we will send it to you. There was no evidence provided to the survey team regarding these items prior to the exit of the survey.On 3/26/2026 at 10:08 AM, V58 (Agency Registered Nurse) was observed alone documenting within a resident's medication administration record. V58 stated V58 works for a staffing agency and has picked up at the facility a couple of times. V58 affirmed V25 was assigned to care for a set of residents on the second floor. V58 denied V58 received any training/orientation prior to working shifts at the facility. V58 denied being trained on the facility's abuse policy. V58 denied any knowledge of who the abuse prevention coordinator for the facility was and apologized. V58 stated, If I saw abuse, I don't know. I would tell the DON?. Surveyor inquired if V58 if there were any binders instructed agency staff on the facility's policies/procedures/expectations at the nurse's station, V58 said, No, if I had a question, I'd probably just ask another staff member what to do.Agency training documents provided by the facility do not document V58 was trained on the facility's abuse policy or trained in accordance with the abuse policy. On a document titled, ABUSE PREVENTION COMPETANCY TEST (no documentation of training prior to test) V58 answered V2 (Director of Nursing) was the abuse prevention coordinator, not V1. There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff as indicated in the abuse policy. No further evidence was provided to document V58 was educated and competent on the facility's abuse policy. On 3/26/2026 at 12:08 PM, V55 (MDS Nurse) affirmed V55 is part of the QAPI committee and regularly attends meetings. V55 explained V55 was unsure if accident reports, incidents reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, mistreatment were reviewed in QAPI meetings. V55 affirmed grievances and missing items are tracked, but no other related reports/data for abuse is reviewed.On 3/26/2026 at 12:11 PM, V56 (Restorative Nurse, Licensed Practical Nurse) affirmed V56 is a part of the QAPI committee and regularly attends QAPI meetings. V56 did not recall if the facility was reviewing abuse/neglect data or other reports could constitute abuse/neglect within the QAPI meetings. On 3/26/2026 at 12:18 PM, V21 (Activity Director) affirmed V21 is a part of the QAPI committee and regularly attends QAPI meetings. V21 recalled grievances and missing items get discussed in QAPI but could not recall if abuse/neglect or things like suspicious bruises or other incidents were discussed with the QAPI committee. V21 said, I might not know though, because I'm not clinical. On 3/26/2026 at 3:26 PM, V8 (Infection Preventionist, Licensed Practical Nurse) affirmed V8 is a member of the QAPI committee and V8's attendance at QAPI meetings was required. V8 denied the QAPI committee discusses or collects data related to abuse, including incident reports, suspicious bruising, unexplained incidents, or unusual occurrences. On 3/26/2026 at 3:38 PM, V2 (Director of Nursing) affirmed V2 is a required member of the QAPI committee. The QAPI binder was reviewed with V2 and the only data collected within the binder related to abuse/neglect was grievances and missing items. 2 affirmed staff should be familiar with the abuse prevention policy, including agency staff. Agency documents provided were reviewed with V2, including V58 answering the abuse prevention coordinator incorrectly, and V2 affirmed no corrective action had been taken to ensure the agency staff were aware of the abuse policy. V2 stated, No, I didn't know. This is the first time I am seeing this (agency training documents).On 3/26/2026 at 4:10 PM, V1 (Administrator) affirmed the facility had created a QA tracking tool to ensure the facility would be following these requirements in the abuse policy. V1 affirmed the facility did not have a process or tool or tracking prior to creation of the tool. V1 stated the agency was not providing the abuse policy to the agency staff prior to working and a copy of the abuse policy had been resent to the agency so it can be reviewed by agency staff. V1 was unsure why the agency was not providing the abuse policy prior to agency nurses working at the facility. and the agency should have been providing it. A copy of the newly created tool was provided to the survey team. Facility abuse policy (reviewed 9/2017) documents in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.This will be done by: conducting pre-employment screening of employees and pre-admission screening of residents; orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; assuring physical restraints are used sparingly and properly, and chemical restraints are not used; and filing accurate and timely investigative reports.This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals .III. Orientation and Training of Employees During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs; What constitutes abuse, neglect, exploitation, and misappropriation of resident property; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident'spersonal space, as described in Section IV below. Procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; resident abuse prevention; How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff; . Environmental Assessment: At least annually, an interdepartmental team will tour the facility assessing the safety of the facility environment, and review both accident reports and concern identification reports to identify any physical features should be modified for greater resident and staff safety and protection. report will be presented to the Quality Management committee. This safety report will comply with the OBRA requirements under F226 and OSHA requirements for Violence Prevention . Pattern Assessment: At least quarterly, the Quality Management committee will review concern identification reports, accident reports, incidents reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, mistreatment or misappropriation of resident property. Based on an assessment of the reports, the Quality Management committee will further investigate and/or determine whether a change in facility practices is warranted .Facility assessment (reviewed 10/1/2025) documents the facility may use agency staff and for continuity of care, agency staff will be assigned to lower acuity units and provided a verbal education of facility procedures by a nursing supervisor upon arrival of their shift. To ensure competency of agency nurses, a competency skills checklist for each nurse is provided by the agency for the facility's review.

Based on observation, interview and record review, the facility failed to ensure certified nursing assistants received a performance review annually and received training based on areas identified in the performance review. These failures have the potential to affect all 170 residents that reside within the facility. Findings include:Facility census (3/23/2026) documents 170 residents reside within the facility. On 3/26/2026 at 9:58 AM, V50 (CNA Supervisor) affirmed V50 is a CNA has worked at the facility for about 21 years. V50 stated the CNAs do not get annual performance reviews and V50 has not gotten a performance evaluation. V50 affirmed V50 does not complete performance evaluations for the CNAs. On 3/26/2026 at 10:17 AM, V51 (Certified Nursing Assistant) could not recall if V51 had a performance evaluation in the last year. On 3/26/2026 at 10:30 AM, V52 (Restorative Certified Nursing Assistant) was unsure if V52 got a performance evaluation in the last year or if V52 got training related to a performance evaluation. V52 stated, I don't know, maybe they in-serviced me on something like handwashing?. On 3/26/2026 at 11:57 AM, documentation V50, V51, and V52 received an annual performance evaluation, in-service records, and the policy for annual performance evaluations. No records were provided prior to the exit of the survey V50, V51, V52, or any other nursing assistant received an annual performance evaluation, in-servicing on areas of improvement based on the annual performance evaluation, or a policy for annual performance evaluations of nursing assistants prior to the exit of the survey. On 3/26/2026 at 4:09 PM, V1 (Administrator) affirmed there was no policy on nursing assistants getting annual performance evaluations. V1 explained, We don't do annual performance evaluations. Our CNAs (certified nursing assistants) are a part of a union, and their pay is increased by a flat rate of 4% every year. Their pay isn't tied to their performance, so I was told that's why we don't do them. V1 was unsure if it was a regulatory requirement nursing assistants receive performance evaluations annually. The facility assessment (reviewed 10/1/2025) does not identify nursing assistants require an annual performance evaluation and training based on areas identified in the performance review. Facility Assessment Tool completion instructions (updated 9/5/2024) Staff training/education and competencies3.6 Describe the staff training/education and competencies are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education, training, competency instruction, and testing policies. It may be helpful to review specific references in the regulation regarding the facility assessment (see Attachment 1). Review current regulations and list all staff training and competencies needed by type of staff, including managers, nursing, and other direct care staff, as well as individuals providing services under a contractual arrangement and volunteers. Consider if it would be helpful to indicate which competencies are reviewed at the time the staff member is hired, and cadence of subsequent reviews .c.Are there any training, education and/ or competency needs based on resident and/or staff data or trends identified in the Facility Assessment?i. Does our current behavioral health training sufficiently address our resident population, as identified by the Facility Assessment?ii.Does our current CNA training program sufficiently address our resident population as identified by the Facility Assessment?iii.Are agency staff sufficiently trained to address needs of resident population?iv.Do we need to update job descriptions to coincide with new competencies identified?v.Are new requirements incorporated into our annual performance evaluation process? .

Based on observation, interview, and record review the facility failed to comply with proper food storage and sanitation protocols; failed to ensure that residents' food items in the facility kitchen are dated when removed from original box and when opened; failed to ensure that residents' food items in the facility kitchen are properly stored; and failed to ensure the scoops for bulk food items are stored appropriately. These failures have the potential to affect all 156 residents receiving an oral diet in the facility. Findings include:Facility census, dated 3/23/2026, documents 170 residents residing at the facility.Facility provided document titled, Liquid Consistency Tally, dated 3/23/26, that documents, in part, NPO (Nothing By Mouth): 14 Residents.On 3/23/26 at 9:48am, with V3 (Dietary Director), during observation of the facility's walk-in refrigerator, one opened bag of salad/lettuce, approximately three-quarters used, was observed undated, along with two unopened bags of salad/lettuce that were also undated. V3 said, They (salad/lettuce bags) should be dated. We (facility) say they (salad/lettuce bags) are good for 3 days (expire after 3 days).On 3/23/26 at 9:50am, with V3 (Dietary Director), one scoop was observed uncontained on top of a bulk sugar canister, and another scoop was uncontained on top of a bulk flour canister. V3 said, I told them (management) the scoops should be covered and not just laying on top. They (uncontained scoops) can get airborne bacteria.On 3/23/26 at 9:53am, with V3 (Dietary Director), during observation of the facility's walk-in dry food storage/pantry area, a box of napkins, a box of hot/cold cups, a box of rice, and a box of fruit cocktail was observed lying directly on the floor. V3 said, Man. these just got thrown in here. They (staff) know not to put the stuff (boxes) on the floor. Can't clean the floors with the stuff (boxes) on the floor, and you don't want anything getting in the items when you're cleaning.Record review of facility policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 8/12/2023, documents, in part, Food storage areas will be clean, dry and maintained at temperatures as required to ensure food safety. Food storage areas shall have all products no less than eighteen (18) inches from the ceiling and no less than six (6) inches from floor. Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded. Food stored in bins are removed from original packaging. Bins are labeled and dated. Scoops stored outside of bin in clean, designated space. Foods stored in these containers are used until bin is completely empty then sanitized. New package can then be opened and emptied into bins with updated date of open. All open products are sealed, labeled and dated. Refrigerated Foods: Open products are sealed, labeled and dated. Frozen Foods: If taken out of original packaging, product is label and dated.Record review of facility job description titled, Food Service Director, undated, documents, in part, The Food Service Director plans, organizes, develops, and directs the overall operation of the Culinary and Nutritional Department in accordance with company standards and federal, state, and local standards, guidelines, and regulations to ensure that quality nutritional services are provided on a daily basis and that the culinary services are maintained in a clean, safe and sanitary manner. Maintains an ongoing quality assurance program for the Culinary and Nutritional Services Department. Ensures that culinary services work areas and equipment are maintained in a clean, sanitary, and safe manner.Record review of facility policy titled, Resident Rights, dated 9/2024, documents, in part, The facility will provide a safe, clean, comfortable, and homelike environment. The residents' environment will be maintained in a homelike manner.

Based on observation, interview and record review, the facility failed to ensure that the outside dumpsters were closed. These failures have the potential to affect all 170 residents residing at the facility.Findings include:Facility census, dated 3/23/2026, documents 170 residents residing at the facility.On 3/23/2026 at 9:43am, during observation of the external facility dumpster area, accompanied by V3 (Dietary Director), both dumpsters were observed with their lids left open, containing a combination of bagged garbage filled beyond the point of proper closure and loose debris, along with an additional bag of trash outside the dumpsters. V3 said, I've been telling them (garbage company) that we (facility) need a steady flow of garbage pickup. They (garbage company) should have been and come already. They (garbage company) come around 7:30am, every day, even on weekends. Yes, the dumpsters lids should be closed so garbage doesn't fall out, racoons don't get into it (dumpsters), and so the garbage don't attract critters.On 3/23/26 at 9:52am, with V3 (Dietary Director), the exit door leading to the dumpster area was observed being held open with a dustpan. V3 said, What's going on here. V3 then preceded to remove the dustpan that was propping the door open and closed the exit door leading to the dumpster area. V3 said, Um, that's a critter issue too.Record review of facility policy titled, Disposal of Garbage and Refuse, dated 10/2025, documents, in part, Record review of facility policy titled, Disposal of Garbage and Refuse, dated 10/2025, documents, in part, The facility will dispose of garbage and refuse properly and in a timely manner. The facility will assure all garbage and refuse containers are in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids and covered. Garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests and rodents.Record review of facility policy titled, Resident Rights, dated 9/2024, documents, in part, The facility will provide a safe, clean, comfortable, and homelike environment. The residents' environment will be maintained in a homelike manner.

Based on interview and record review, the facility failed to employ a Registered Nurse (RN) to serve as the facility's assistant director of nursing (ADON) according to state regulations, failed to ensure the staff member covering/responsible for the ADON's duties was an RN as required by state regulations. This failure has the potential to affect all 170 residents that reside within the facility. Findings include:Facility census (3/23/2026) documents 170 residents reside within the facility. Facility CASPER 0003D Report (3/19/2026) documents that the facility has been licensed/certified for 245 beds. On 3/23/2026 at 9:40 AM an entrance conference was held with V2 (Director of Nursing). V2 explained that the facility does not have an ADON and that the prior ADON (V53) left approximately a month prior to the survey. V2 affirmed that the facility has pulled V11 (Licensed Practical Nurse) from the floor and V11 is covering the job responsibilities of the ADON. On 3/25/2026 at 10:30 AM, V1 (Administrator) confirmed the facility does not have an ADON on staff. V1 stated that V11 (Licensed Practical Nurse) has been pulled from providing direct care responsibilities and is assuming the responsibilities of the ADON while the facility does not have an ADON. V1 affirmed that based on the number of licensed beds and the state regulations, the facility requires an ADON that is an RN. V1 explained the prior ADON (V53) resigned and then took vacation through the duration of the resignation notice. V1 affirmed V53 (Former Assistant Director of Nursing) has not been employed for approximately a month. Record review of V53's time keeping records indicate that V53's final day of work was 2/24/2026. On 3/25/2026 at 2:19 PM, V11 (Licensed Practical Nurse) confirmed V11 is a licensed practical nurse and not a registered nurse. V11 affirmed V11 assumed the job duties of V53 a few weeks ago. V11 explained V11's new job duties include, but are not limited to, supervision of nurses (including licensed practical nurses and registered nurses), supervising the residents' care, to ensure staff are reporting lab values to providers, ensuring staff are processing physician orders, managing/monitoring psychotropic medication use within the facility, and helping V2 (Director of Nursing) or other nursing staff with any needed tasks. V11 affirmed V11 no longer has a direct care assignment unless a nurse calls in. V11 stated V11 has been working 4-5 days a week performing the newly assigned duties. On 3/26/2026 at 10:33 AM, V54 (Scheduler) confirmed V54 is responsible for scheduling staff within the facility. V54 confirmed the facility does not have an ADON and V11 is covering the role of ADON. On 3/26 2026 at 1:14 PM, V39 (HR Director) confirmed V53's final day of work was 2/20/2026. Record review of Illinois Department of Financial and Professional Regulation Professional License Lookup Database documents that V11 is a Licensed Practical Nurse. Illinois Administrative Code titled, TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1220 SUPERVISION OF NURSING SERVICES documents in part, a) Each facility shall have a director of nursing services (DON) who shall be a registered nurse. 1) This person shall have knowledge and training in nursing service administration and restorative/rehabilitative nursing. This person shall also have some knowledge and training in the care of the type of residents the facility cares for (e.g., geriatric or psychiatric residents). This does not mean that the director of nursing must have completed a specific course or a specific number of hours of training in restorative/rehabilitative nursing unless this person is in charge of the restorative/rehabilitative nursing program . 3) In skilled nursing facilities of l00 or more occupied beds, there shall be an assistant director of nursing (ADON) who is a registered nurse. This person shall also meet the qualifications specified in subsection (a)(1) of this Section for the director of nursing service . 5) The assistant shall be a full-time employee who is on duty a minimum of 36 hours, four days per week. The assistant may be assigned to work hours any time of the day or night. 6) The assistant shall assist the DON in carrying out his/her responsibilities .b) The DON shall supervise and oversee the nursing services of the facility, including: 1) Assigning and directing the activities of nursing service personnel. 2) Overseeing the comprehensive assessment of the residents' needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy . 7) Coordinating the care and services provided to residents in the nursing facility . Facility job description for the assistant director of nursing (undated) identifies the following job duties are the responsibility of the ADON: Will act as DON in absence of DON. Assist the DON in planning, developing, organizing, implementing the day to day functions of the nursing department in accordance with all governing rules .Chart Audits a) admission audit within 72-hours- follow 72 hour protocol b. Audit of all charts on each respective floor Quarterly 2. Lab reports; analyze for your floor all labs for Physician notification nurse noted lab and new orders New orders are followed through 3. PT/INR- in absence of evening supervisor, log all daily reports from lab and ensure that proper action is being taken .Assist in determining and maintaining staffing needs in the nursing department. Monitor nursing personnel to ensure that they are following established safety regulations in use of equipment and supplies .

Based on interview and record review, the facility failed to disclose their quality assurance performance improvement plan when requested by the state survey agency. This failure has the potential to affect all 170 residents that reside within the facility. Findings include: Facility census (3/23/2026) indicate that 170 residents reside within the facility.On 3/23/2026 at 9:40 AM, an entrance conference was held with V2 (Director of Nursing). During the entrance conference, the facility's QAPI plan was requested and required to be provided to the survey team within 4 hours of the entrance to the facility.On 3/23/2026 at 1:50 PM, the facility's QAPI plan was not provided to the survey team as required.On 3/25/2026 at 10:38 AM, V1 (Administrator) provided the survey team the facility's QAPI binder that contained data collection from departments within the facility. There was no QAPI plan within the QAPI binder. Surveyor requested the QAPI plan from V1 (Administrator). V1 confirmed the QAPI plan was not in the QAPI binder. V1 checked other binders within the office and stated, I don't know where the QAPI plan is. V1 explained that the purpose of QAPI is to self-identify areas of improvement, put in place plans to correct them, and see what improvements can be made.On 3/26/2026 at 3:38 PM, V2 (Director of Nursing) affirmed that V2 is a part of the facility's QAPI committee. V2 recalled seeing the QAPI plan at one point but couldn't recall what was stated on the QAPI plan. V2 affirmed that V2 did not have a copy of the QAPI plan. V2 was unable to provide surveyor with the QAPI plan. Record review of the facility's QAPI policy (1/2024) documents in part, GENERAL: At [NAME] Health Services we are committed to enhancing quality of life by nurturing individuality and independence. We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationships with all whose lives we touch. PURPOSE: The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care or/and engage with our residents, caregivers, and other partners so that we may realize our vision to be value driven. To do this, all employees will participate in ongoing QAPI efforts, which support meaningful relationships with the lives we touch. At a minimum, the executive leadership will report annually on the status of the current QAPI plan, the proposed QAPI plan, and goals for the coming year. This report will be made available to: Corporation/Board of Directors Entire management team of [NAME] Health Services Staff Resident/family council Other stakeholders, as designated. The facility's QAPI plan/report was not provided to the survey team prior to the exit of the survey, as indicated within the QAPI policy.

Based on interview and record review, the facility's quality assurance and performance improvement (QAPI) committee failed to complete a performance improvement project annually. This failure has the potential to affect all 170 residents that reside within the facility. Findings include: Facility census (3/23/2026) documents in part, 170 residents reside within the facility. On 3/25/2026 at 10:38 AM, V1 (Administrator) provided the survey team the facility's QAPI binder contained data collection from departments within the facility from 2/2025-1/2026. There was no evidence the facility had completed any corrective action from the data collected or a performance improvement project (PIP) within the last year. Surveyor requested documentation the facility completed a PIP in the last year. V1 stated, I don't think we (the facility) completed a PIP in the last year through QAPI. V1 was not aware if there was a regulation required the facility to complete a PIP yearly. V1 explained the purpose of QAPI is to self-identify areas of improvement, put in place plans to correct them, and see what improvements can be made. On 3/26/2026 at 10:37 AM, V47 (Medical Director) confirmed V47 is a medical doctor (MD) and is the medical director for the facility. V47 affirmed V47's job duties do not include supervising other physicians' medical practice in the facility, but is responsible for resident care-related things, including reviewing policies. V47 confirmed V47 has not attended the facility's QAPI committee meetings and stated, they (facility administration) do not invite me to the meetings, I (V47) am not made aware when the meetings happen. V47 denied involvement in completing a PIP within the last year in the facility. V47 denied knowledge of a PIP being completed in the last year. On 3/26/2026 at 12:08 PM, V55 (MDS Nurse, Licensed Practical Nurse) affirmed V55 is a part of the QAPI committee and regularly attends QAPI meetings. V55 could not recall completing a performance improvement project within the last year. On 3/26/2026 at 12:11 PM, V56 (Restorative Nurse, Licensed Practical Nurse) affirmed V56 is a part of the QAPI committee and regularly attends QAPI meetings. V56 could not recall completing a performance improvement project within the last year. On 3/26/2026 at 12:18 PM, V21 (Activity Director) affirmed V21 is a part of the QAPI committee and regularly attends QAPI meetings. V21 explained V21 has worked at the facility for over 30 years and was not sure when the last time the facility completed a performance improvement project. V21 stated, I remember doing one a while ago, but I would say was like 2 or 3 years ago by now since we have had one (a PIP). Maybe I didn't participate because I am not a member of the clinical team. On 3/26/2026 at 3:26 PM, V8 (Infection Preventionist, Licensed Practical Nurse) affirmed V8 is a member of the QAPI committee and V8's attendance at QAPI meetings was required. V8 explained V8 goes to QAPI meetings regularly and denied the facility has completed a performance improvement project in the last year. On 3/26/2026 at 3:38 PM, V2 (Director of Nursing) affirmed V2 is a required member of the QAPI committee. The QAPI binder was reviewed with V2 and V2 denied the facility's QAPI committee completed a PIP in the last year. V2 was unsure how often PIPs were supposed to be completed. On 3/26/2026 at 4:10 PM, V1 (Administrator) affirmed V1 is responsible for the overall implementation and monitoring of the QAPI program and its functions. Facility QAPI policy (1/2024) documents in part, .PURPOSE: The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care or/and engage with our residents, caregivers, and other partners so we may realize our vision to be value driven. To do this, all employees will participate in ongoing QAPI efforts, which support meaningful relationships with the lives we touch . The QAPI program at B*** Health Services will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's representative), by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis. We will utilize the best available evidence (such as data from the CASPER Report, national benchmarks, published best practices, clinical guidelines, etc.) to define and measure our goals. The governing body and/or administration of the skilled nursing facility will develop a culture involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. The facility's governing body is ultimately responsible for overseeing the QAPI Committee. The administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction . Performance Improvement Projects The QAPI team at B*** Health Services will review our sources of information to determine if gaps or patterns exist in our systems of care could result in quality problems; or if there are opportunities to make improvements. Examples of potential areas to consider when reviewing data include: MDS data for problem patternsNursing Home Compare (provides quality information about every certified nursing home in the country)State survey results and plans of correctionResident care plans for documented progress towards specified goalsTrends in complaintsResident and family satisfaction for trendsPatterns of caregiver turnover or absencesPatterns of emergency room visits and/or hospital useBased on the result of the review of information, the QAPI team at B*** Health Services will prioritize opportunities for improvement, taking into consideration the importance of the issues (high risk, high frequency, and/or problem prone). The QAPI team will determine which problems will become the focus for a performance improvement project (PIP). Depending on the PIP to be started, the QAPI team will charter a PIP Team who is entrusted with a mission to look into a problem area and come up with plans for correction and/or improvement to be implemented . Review of the facility's listing on CMS' Nursing Home Compare indicates the facility's overall star rating is 1 star, health inspection rating is 1 star, quality measures rating is 1 star, staffing is 1 star, which is much below average (and the lowest possible rating) in all categories, and a red hand, indicating the facility has a history of being cited for abuse. Additionally, the listing documents the following quality measures are worse than national/IL averages: facility has a 95.5% of long-stay residents report depression symptoms, (IL average 50.3%, lower is better), 8.4% of long-term stay with pressure ulcers (IL average 5.2%, lower is better), 5.1% of short-stay residents received a flu vaccine during the flu season (National average 97.87%, IL average 61%, higher is better), 19.84% of healthcare staff received a flu vaccine (National average 42%, higher is better), 3.53% of short-stay residents received a pneumonia vaccine (National average 97.38%, IL average 68.78%, higher is better), 0% of residents up to date with COVID vaccines (National Average 25.2%, higher is better), 7.89% of residents who experience a fall with major injury during their SNF stay (National Average 0.77%, lower is better), 17.39% of residents who are at or above an expected ability to care for themselves at discharge (National Average 53.69%, higher is better), 8.7% of residents who are at or above an expected ability to move around at discharge (National average 50.94%, higher is better), 29.28% Rate of successful return to home or community from a SNF (National average 50.57%, higher is better), 27% of long-stay residents who needed and got a flu shot for the current flu season (IL average 91.6%, higher is better), 38.8% of long-stay residents who needed and got a vaccine to prevent pneumonia (IL average 89.6%). V1 (Administrator) and V47 (Medical Director) are listed as having operational/managerial control of the facility.

Based on interview and record review, the facility failed to ensure the medical director was invited and attended quality assurance and performance improvement (QAPI) committee meetings. This failure has the potential to affect all 170 residents that reside within the facility. Findings include: Facility census (3/23/2026) documents 170 residents reside within the facility. On 3/25/2026 at 10:38 AM, V1 (Administrator) provided the survey team the facility's QAPI binder that contained data collection from departments within the facility. The sign in sheets for the QAPI meetings from 2/2025-1/2026 were provided to the surveyor. Per the sign in sheets, V47 (Medical Director) was not in attendance at any QAPI meeting since 2/2025. V1 confirmed that V47 has not been attending QAPI committee meetings. When asked why V47 was not attending QAPI meetings, V1 stated, Yeah, I dropped the ball. I never invited (V47) to (participate) in the QAPI meetings. V1 confirmed it is a regulatory requirement that V47 attends and participates in the QAPI meetings/process. V1 explained the purpose of QAPI is to self-identify areas of improvement, put in place plans to correct them, and see what improvements can be made. On 3/26/2026 at 10:37 AM, V47 (Medical Director) confirmed V47 is a medical doctor (MD) and is the medical director for the facility. V47 affirmed V47's job duties do not include supervising other physicians' medical practice in the facility, but is responsible for resident care-related things, including reviewing policies. V47 confirmed V47 has not attended the facility's QAPI committee meetings and stated, they (facility administration) do not invite me to the meetings, I (V47) am not made aware when the meetings happen. V47 stated V47 should be invited to QAPI committee meetings by the facility and is a required member of the QAPI committee. V47 recalled being invited to other facility's QAPI meetings and was unsure why V47 was not invited to this facility's meetings. V47 explained that QAPI is basically a quality review of the facility that happens monthly. On 3/26/2026 at 12:08 PM, V55 (MDS Nurse, Licensed Practical Nurse) affirmed V55 is a part of the QAPI committee and regularly attends QAPI meetings. V55 could not remember seeing V47 at QAPI meetings. On 3/26/2026 at 12:11 PM, V56 (Restorative Nurse, Licensed Practical Nurse) affirmed V56 is a part of the QAPI committee and regularly attends QAPI meetings. V56 denied V47 attends QAPI meetings. On 3/26/2026 at 12:18 PM, V21 (Activity Director) affirmed V21 is a part of the QAPI committee and regularly attends QAPI meetings. V21 explained V21 has worked at the facility for over 30 years and hasn't seen the medical director at a QAPI meeting in a long time. V21 could not recall when the medical director last attended a QAPI meeting. On 3/26/2026 at 3:26 PM, V8 (Infection Preventionist, Licensed Practical Nurse) affirmed that V8 is a member of the QAPI committee and that V8's attendance at QAPI meetings was required. V8 explained that V8 goes to QAPI meetings regularly and that V47 (Medical Director) does not attend the QAPI meetings. V8 affirmed that the medical director is also required to go to QAPI meetings. V8 stated that V8 is not responsible for inviting V47 to the QAPI meetings and that V1 or V2 probably would be the person to invite them. On 3/26/2026 at 3:38 PM, V2 (Director of Nursing) affirmed that V2 is a required member of the QAPI committee. V2 denied that the medical director has been in attendance at the QAPI meetings. On 3/26/2026 at 4:10 PM, V1 (Administrator) affirmed that V1 is responsible for the overall implementation and monitoring of the QAPI program and its functions. Facility QAPI policy (1/2024) documents in part PURPOSE: The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care or/and engage with our residents, caregivers, and other partners so that we may realize our vision to be value driven. To do this, all employees will participate in ongoing QAPI efforts, which support meaningful relationships with the lives we touch .The administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction .

Based on observation, interview, and record review, the facility failed to ensure staff wore appropriate PPE (personal protective equipment) when providing care for residents on isolation, failed to ensure EBP (enhanced barrier precautions) sign was posted for a resident on EBP, failed to ensure staff doffed isolation gown appropriately, failed to ensure staff kept personal item outside of resident's room, and failed to ensure hand sanitizers were available. These failures affected three (R46, R87, and R139) residents reviewed for infection control and have the potential to affect all 47 residents on the second floor. Findings include: R46 is [AGE] years old and has resided at the facility since 2025. Past medical history includes, but is not limited to parkinsonism, anemia, schizoaffective disorder, personal history of COVID 19, dementia, unspecified psychosis, etc. Minimum Data Set (MDS) assessment dated [DATE], section C (cognitive patterns) scored R46 with a brief interview for mental statue (BIMS) score of 6, section GG (functional status) of the same assessment shows that R46 is dependent. substantial/maximal assistance from staff for all activities of daily living (ADL) care needs. On 3/23/2026 at 11:10am during random screening on the second floor, V10 (CNA) was observed providing bed bath to R46, wearing only gloves. Surveyor observed a contact isolation sign on resident's door and presented this observation to V10 who said, 'I don't know why that sign is there, resident is not on isolation. Contact precaution sign on R46's door stated in part: Everyone must clean their hands including before entering and when leaving the room. Put on gloves before room entry, discard gloves before room exit. Put on gown before room entry, discard gown before room exit. On 3/23/2026 at 11:14AM, V8 LPN/Infection Prevention Nurse) said that R46 is on contact precaution isolation for Klebsiella Pneumonia, staff are supposed to wear gown and gloves when providing care to residents. Surveyor presented all the empty hand sanitizer containers on the whole of second floor (hallways and residents' rooms) to V8 who said, The housekeeping department is responsible for refilling them, I don't know why they did not. Review of physician order and care plan for R46 shows R46 does not have any order for contact isolation, her care plan indicated that she is on enhanced barrier precaution. On 3/24/2026 at 11:40AM V8 was presented with this observation. V8 said she has not had time to change the care plan to contact isolation, R4 has been on EBP for about 2 years now for MDRO colonization with E-Coli, V8 recently called the MDRO register and found out that resident was never colonized with E-Coli. No one in the facility checked the registry prior to V8 taking the IP role, the previous IP staff did not check the registry. On 03/23/2026 at 10:32 am, there was an EBP sign posted by R87's room. V2 (Director of Nursing) stated she (R87) has MDRO (Multi Drug Resistant Organism) in urine. On 03/23/2026 at 10:34 am with V12 (Licensed Practice Nurse), inside R87's room. R87 stated she was wet. This surveyor requested V12 (Licensed Practice Nurse) to have staff change her. V12 stepped outside of R87's room and requested V13 (Certified Nursing Assistant) to change R87. V13 stated she would do it. On 03/23/2026 at 10:40 am with V12 still inside R87's room, V14 (Certified Nursing Assistant) went inside R87's room, hung her blue coat on the closet located inside R87's room, then donned gown and gloves. This was pointed out to V12. V12 stated V14 was not supposed to hang her coat inside the resident's room for infection control. On 03/23/2026 at 10:42 am, V14 positioned herself on R87's right side. V13 went inside R87's room and positioned herself on R87's left side. V12 held R87's sheet and informed R87 they (V13 and V14) were going to turn her on her side. V13 had gloves on with no isolation gown. This was pointed out to V12 and inquired if she was supposed to wear gown when performing ADL care to R87. V12 stated V13 should be wearing gown and gloves when taking care of residents. V12 instructed V13 to wear isolation gown. V13 then told V14, I thought you are going to bring me one. V13 stepped outside and came back in R87's room with gown and gloves. On 03/23/2026 at 10:48 am outside of R87's room, inquiring about the importance of donning gown and gloves when performing ADL care, V12 stated the purpose is to prevent whatever the resident has to get into her (V13) uniform, to prevent the spread of infection. On 03/23/2026 at 10:51am, V13, Certified Nursing Assistant (CNA) went outside of R87's room wearing isolation gown. V15 (Certified Nursing Assistant) was also outside of the room and asked if she (V13) needed help. Inquiring if she was supposed to go outside of a resident's room wearing isolation gown, V13 stated 'I am so sorry. V13 went inside R87's room and went out without an isolation gown. On 03/23/2026 at 11:29am inside R139's room with V17, Registered Nurse (RN). There was a bag of high-calorie therapeutic nutritional supplement hanging on a pole. V17 stated he (R139) has a gastrostomy on his mid abdomen and tube feeding was off at 8am and on at 2pm. This surveyor checked R139's door, there was no EBP (enhanced barrier precautions) sign posted. Inquiring about the EBP sign, V17 stated there is no sign posted. V17 stated there should be a sign posted by his door to inform staff what PPE (personal protective equipment) to wear for infection control. On 03/23/2026 at 11:31am, V8, Infection Preventionist/Licensed Practical Nurse (LPN) stated residents on EBP are residents with indwelling medical devices like indwelling urinary catheter, g-tube, and dialysis port, or on continuous oxygenation via nasal canula. V8 stated he (R139) was transferred to the hospital and was readmitted to a different room. V8 stated the expectation was for the admitting nurse to post the EBP sign on his new room. V8 stated the purpose of posting the EBP sign outside of the resident's room so staff would know the appropriate PPE to wear when they have to provide ADL (Activities of Daily Living) care to the resident for infection control. On 03/23/2026 at 11:34am, V8 stated staff were not supposed to hang their coats inside the resident's room and should hang it instead by the nurse's station to prevent contamination. V8 stated staff were supposed to wear gloves and gown when they were providing care to the resident or when they expected to have contact with residents on EBP to protect the resident and other residents. V8 also stated gown should be removed prior to exiting the room to prevent contamination of equipment and linens outside of the resident's room. The (undated) list of residents on EBP documented, in part R87. Isolation: EBP. Notes: CRE (Carbapenem Resistant Enterobacterales) ABDOMINAL wound, MDRO (Multi Drug Resistant Organism) Urine, NDM (New Delhi [NAME] beta lactamase. RECTAL Candida Auris, Enterobacter Cloacae, Acinetobacter baumannii. R139. Isolation: EBP. Notes: G-tube/foley. R87's admission Record documented that R87's diagnoses include but are not limited to morbid obesity, osteomyelitis, and hypertension. R87's (02/25/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R87's mental status as cognitively intact. R87's (03/10/2026) care plan documented, in part Special Instruction: Enhanced Barrier Precautions related to CRE Abdominal wound MDRO. R139's (On or After: 03/24/2026) Medication Review Record documented, in part Diagnoses (include but are not limited to) encounter for attention to gastrostomy, Type 2 Diabetes Mellitus, and cerebral infarction. Enteral Feed: Enteral Feed Order every 6 hours Water flush 275 ml every 6 hrs. Active Order Date: 01/21/2026. Start Date: 01/21/2026. Enteral Feed Order every shift Nepro 1.8 @ 70 ml/hr x 18 hrs. On 2 pm, Off 8am, total volume to infuse: 1260 ml. Order Summary: CHANGE URINARY CATHETER BAG AND TUBING AS NEEDED WHEN MALFUNCTIONING as needed. Enhanced Barrier Precautions – g tube feeding. Active. Order Date: 01/20/2026. R139's (01/26/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R139's mental status as severely impaired. R139's (01/20/2026) care plan documented, in part Focus: Enhanced Barrier Precautions – g tube Feeding. Goal: Resident will have no signs or symptoms of active infection. Interventions: Isolation as per Physician orders. The (03/26/2026) email correspondence with V8 (Infection Preventionist/LPN) documented, in part Any policy as it relates to staff member hanging coat in resident's room. V8 response: Expectations for staff personal belongings is to keep it away (from) the resident's room to avoid contamination especially with residents on isolation. Expected to keep it in inside the plastic bag, locker rooms or it can be hang (hung) at the chair at the nurses station. The (undated) Certified Nurses Aide Job Description documented, in part To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state and federal guidelines, and as directed by your supervisor. Essential Duties: 26. Wash hands before and after performing any service for the resident and follow infection control guidelines and universal precautions. The (undated) How To Safely Remove Personal Protective Equipment documented, in part Remove all PPE before exiting the patient room except a respirator, if worn. The (undated) Enhanced Barrier Precautions signage documented, in part Everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High Contact Resident Care Activities. Providing hygiene, changing briefs or assisting with toileting. The (10/16/2025) Enhanced Barrier Precaution (EBP) documented, in part POLICY: Our facility employs the use of Enhanced Barrier Precautions to reduce transmission of MDROs (Multi Drug Resistant Organism) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: an indwelling medical device regardless of MDRO status or colonization with a targeted MDRO. Process: Staff utilize gown and gloves for high contact resident care activities when residents require EBP; high contact activities may include: changing briefs or assisting toileting. Implementation: Post EBP signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g. gown and gloves) and listing high contact resident care activities. Transmission based isolation precaution policy dated 3/2025 states in part. General: It is the policy of this facility to follow and implement isolation precautions according to recommendations of the center for disease control and prevention (CDC) in order to aid I the prevention and transmission of pathogens. The types of isolation precautions have been divided into the following categories: C. Contact precautions: are used for residents with suspected or known infections of colonized microorganisms that can be transmitted by direct contact with the patient or resident or indirect contact. Examples of such illnesses include Clostridium Difficile, Escherichia coil, multidrug resistant organisms (MDROS), etc. Contact precautions are used along with standard precautions and include the following: Iii Gowns are to be worn when entering the resident's room if direct care is to be provided or when potential for clothing to be contaminated exits. The gown is removed before leaving the room and ensures that clothing is not contaminated by environmental surfaces.

Based on interview and record review, the facility failed to maintain documentation of staff screening, education, offering and current COVID-19 vaccination status of all staff. This failure has the potential to affect all 170 residents currently residing at the facility.Findings include:On 03/24/2026 11:40 AM Infection control task with V8, Licensed Practical Nurse (LPN)/ Infection Preventionist (IP) nurse, said that the facility does not offer COVID 19 vaccination to staff, they preferred to get it from outside due to insurance. V8 will provide the proof of vaccination provided by staff and the education material the facility provided to staff, residents and or family members.03/26/2026 9:55AM, surveyor requested for the staff immunization status, V8 (IP Nurse) said the facility does not have a list of immunization status for the staff. The only thing she has is what the staff provided her from last year. V8 stated the person who was in charge of infection control before her did not keep any list, so V8 does not have one. V8 stated she will start to make a line list going forward. V8 could not provide any educational materials given to staff regarding the risks and benefits of COVID 19 vaccination.Facility employee vaccination policy revised 11/06/2025 stated in part: it is the policy of the facility to follow federal, state and local regulations regarding the requirements for staff vaccination. The purpose of this policy is to provide guidance on vaccinations for COVID, influenza, measles, hepatitis B, and any other vaccination requirements for healthcare personnel per CDC, CMS, State and local regulations.Process: B COVID 19 vaccination.Per CDC guidance, healthcare personnel should be offered resources and counseling about the importance of receiving the COVID 19 vaccine. According to the State Operational Manual (SOM), S483.80(d)(3) COVID-19 immunizations:The facility must maintain documentation that each staff member was educated on the benefits and potential side effects of the COVID-19 vaccine and offered vaccination or provided information on obtaining the vaccine unless medically contraindicated or the staff member has already been immunized. The facility must document the vaccination status of each staff member (i.e., immunized or not).

Based on observation, interview and record review, the facility failed to ensure agency staff were trained on the abuse prevention program/policy as indicated within the facility abuse policy and facility assessment. This failure has the potential to affect all 170 residents that reside within the facility. Findings include:Facility census (3/23/2026) documents 170 residents reside within the facility. R6's face sheet documents in part the following diagnoses: nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcer of the sacrum/right ankle, unspecified convulsions, encounter for attention to tracheostomy/gastrostomy, dependence on ventilator status, osteoarthritis, depression, and hypertension. R6's physician orders document in part an active order for May apply mittens to bilateral hands related to pulling at trach (1/14/2026) and Remove mittens and monitor bilateral hands for any skin issues Any skin issues-y/n (1/14/2026). On 3/23/2026 at 11:14 AM, V49 (Agency Registered Nurse) was observed alone, trying to untie R's restraints. V49 affirmed V49 works for a staffing agency, and it was V49's first day working on the facility. V49 affirmed V49 was assigned to care for a set of residents on the 3rd floor. V49 explained V49 has not received orientation from the facility or training on abuse from the facility. V49 affirmed V49 has worked in long term care before and is familiar with standard abuse policies. V49 stated the abuse prevention coordinator is the administrator, but V49 didn't know who the administrator was. Agency training documents provided by the facility do not document V49 was trained on the facility's abuse policy or trained in accordance with the abuse policy. On a document titled, ABUSE PREVENTION COMPETANCY TEST (no documentation of training prior to test). There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff as indicated in the abuse policy. No further evidence was provided to document V49 was educated and competent on the facility's abuse policy. On 3/24/2026 at 11:10 AM, V25 (Agency Registered Nurse) was observed alone drawing insulin up for a resident at the medication cart on the 3rd floor. V25 affirmed V25 works for a staffing agency, and it was V25's first time in the facility. V25 affirmed V25 was assigned to care for a set of residents on the 3rd floor. V25 stated there was orientation paperwork online from the agency but did not recall what topics were in the paperwork. V25 stated, I don't know. I think (the paperwork) was about maybe about like abuse, positioning, falls, how to report an incident. I have prior experience (in long-term care) and had to acknowledge my prior experience. I don't know who the abuse prevention coordinator is, I'm sorry. Agency training documents provided by the facility do not document V25 was trained on the facility's abuse policy or trained in accordance with the abuse policy by the agency or facility. There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff; Procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; What constitutes abuse, neglect, exploitation, and misappropriation of resident property and resident abuse prevention as indicated in the abuse policy. An Agency Nurse Staff Duty Acknowledgement signed by V25 and V54 (Scheduler) does not list any acknowledgement of the facility's abuse prohibition program or policies. No further evidence was provided to document V25 was educated and competent on the facility's abuse policy prior to the exit of the survey. On 3/25/2026 at 10:38 AM, V1 (Administrator) provided the survey team the facility's QAPI binder contained data collection from departments within the facility. Record review indicated there was no documented quarterly review of accident reports, incidents reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, or mistreatment. V1 explained the purpose of QAPI is to self-identify areas of improvement, put in place plans to correct them, and see what improvements can be made. V1 confirmed V1 is the abuse prevention coordinator. V1 confirmed the QAPI binder did not have any quarterly review or collected data related to abuse (i.e., accident reports, incidents reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, or mistreatment). V1 explained the facility does not have a standard process to assess possible patterns or trends of potential abuse. V20 (Regional [NAME] President of Operations) asked V1, Is it you just don't have the documentation to prove you are doing it (tracking potential patterns of abuse/neglect) or is it you're not doing it? V1 affirmed the review process is not being completed. The facility's abuse policy was reviewed with V1 and V1 affirmed the facility should be following the abuse policy. When asked why the facility is not following their abuse policy by completing quarterly review of the identified items, V1 stated, I have no reason (why the facility is not following the abuse policy). V1 stated the purpose of tracking it would tell you if there were any potential problems with staff either with missing items with reports of abuse/neglect. It can help with education/training. V1 stated, Staff are trained on the abuse policy upon hire, quarterly, annually and as needed. We include agency staff on abuse training if they are in the facility. We have sent the agency our abuse policy and they get screened/trained and they send us all the documents, and they get told about how to access the facility. We have binders on the floors for agency nurse orientation and try to ensure an agency nurse is with a full-time employee. V1 affirmed the facility should be following the abuse policy.On 3/26/2026 at 9:25 AM, V20 stated the facility is tracking the required items per the abuse policy. V20 showed surveyor 3 months (1/2026, 2/2025, 3/2025) of documentation data was being collected regarding misappropriation/grievances by the social services director. No data was collected for accident reports, incidents reports, safety committee reports or environmental hazard report to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences may constitute abuse, neglect, mistreatment. Surveyor asked V20 for documentation shows data was being collected per the policy. V20 could not produce any further documentation. V20 stated, If we find anything else, we will send it to you. There was no evidence provided to the survey team regarding these items prior to the exit of the survey.On 3/26/2026 at 10:08 AM, V58 (Agency Registered Nurse) was observed alone documenting within a resident's medication administration record. V58 stated V58 works for a staffing agency and has picked up at the facility a couple of times. V58 affirmed V25 was assigned to care for a set of residents on the second floor. V58 denied V58 received any training/orientation prior to working shifts at the facility. V58 denied being trained on the facility's abuse policy. V58 denied any knowledge of who the abuse prevention coordinator for the facility was and apologized. V58 stated, If I saw abuse, I don't know. I would tell the DON?. Surveyor inquired if V58 if there were any binders instructed agency staff on the facility's policies/procedures/expectations at the nurse's station, V58 said, No, if I had a question, I'd probably just ask another staff member what to do.Agency training documents provided by the facility do not document V58 was trained on the facility's abuse policy or trained in accordance with the abuse policy. On a document titled, ABUSE PREVENTION COMPETANCY TEST (no documentation of training prior to test) V58 answered V2 (Director of Nursing) was the abuse prevention coordinator, not V1. There was no documentation of training on other areas such as sensitivity to resident rights and resident needs; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident's personal space, or how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff as indicated in the abuse policy. No further evidence was provided to document V58 was educated and competent on the facility's abuse policy. On 3/26/2026 at 3:38 PM, V2 (Director of Nursing) affirmed staff should be familiar with the abuse prevention policy, including agency staff. Agency documents provided were reviewed with V2, including V58 answering the abuse prevention coordinator incorrectly, and V2 affirmed no corrective action had been taken to ensure the agency staff were aware of the abuse policy. V2 stated, No, I didn't know. This is the first time I am seeing this (agency training documents).On 3/26/2026 at 4:10 PM, V1 (Administrator) stated the agency was not providing the abuse policy to the agency staff prior to working and a copy of the abuse policy had been resent to the agency so it can be reviewed by agency staff. V1 was unsure why the agency was not providing the abuse policy prior to agency nurses working at the facility. and the agency should have been providing it. A copy of the newly created tool was provided to the survey team. Facility abuse policy (reviewed 9/2017) documents in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.This will be done by: conducting pre-employment screening of employees and pre-admission screening of residents; orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; assuring physical restraints are used sparingly and properly, and chemical restraints are not used; and filing accurate and timely investigative reports.This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals .III. Orientation and Training of Employees During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs; What constitutes abuse, neglect, exploitation, and misappropriation of resident property; The prohibitions against taking, using, keeping, or distributing photographs or recordings of residents or a resident'spersonal space, as described in Section IV below. Procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; resident abuse prevention; How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way protects both residents and staff.Facility assessment (reviewed 10/1/2025) documents the facility may use agency staff and for continuity of care, agency staff will be assigned to lower acuity units and provided a verbal education of facility procedures by a nursing supervisor upon arrival of their shift. To ensure competency of agency nurses, a competency skills checklist for each nurse is provided by the agency for the facility's review.

Based on interview and record review, the facility failed to ensure that a resident received care and services in accordance with professional standards of practice by failing to monitor potassium levels after initiation and continuation of potassium supplementation and by failing to recognize and act upon a critically abnormal laboratory value. The facility did not ensure timely laboratory monitoring for a resident receiving potassium and failed to notify the provider or initiate emergent medical intervention when a critically high potassium level of 8.4 mEq/L (normal range 3.5-5.1) was identified. These failures applied to one (R1) of three residents reviewed for nursing care and resulted in R1 not receiving medical intervention for critically high potassium level; R1 subsequently experienced cardiac arrest in the facility and expired four days after the laboratory result was obtained. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility was notified of R1's lab report that showed a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1) and the facility failed to provide R1 with care and services to address this abnormal value. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00PM. The survey team confirmed by observation, interviews, and record reviews that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R1 was a [AGE] year-old female admitted to the facility in [DATE]. R1 expired in the facility on [DATE]. R1 medical diagnoses included (but not limited to): chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, aneurysm of the descending thoracic aorta, without rupture, and aneurysm of the ascending aorta, without rupture.Review of R1's facility medical record show that R1 was being treated for low potassium levels (hypokalemia).R1 lab report dated [DATE] documents potassium level of 3.0 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. This lab report was reviewed by V4 (Licensed Practical Nurse) on [DATE] 12:34. Nurse progress note written by V4 dated [DATE] 12:36 reads: CBC and CMP reviewed by NP and new order given for Potassium 40 Meq p.o. 1 x, noted and carried out. Review of Medication Administration Record (MAR) for R1 for [DATE] does not include any documentation that this order was administered to R1. There is no documentation or order showing that labs were ordered to be repeated after this intervention.R1 lab report dated [DATE] documents potassium level of 2.0 mEq/L (normal range 3.5 - 5.1); report flagged as critical. This lab report was reviewed by V4 on [DATE] 23:02. Nurse progress note written by V4 on [DATE] 23:53 reads: Spoke to V5 (Nurse Practitioner) to relay abnormal lab K+ 2.0, new orders given for Potassium 40 Meq p.o. x 3 days, repeat BMP in a.m., and give 5% dextrose 0.45% sodium chloride at 75ml/hr x 500ML. Noted and carried out. Supervisor is aware. R1 lab report dated [DATE] documents potassium level of 2.5 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. This lab report was reviewed by V6 (Registered Nurse) on [DATE] 14:51. There is no documentation that V6 took any actions after reviewing this lab report in regard to the abnormal lab value. [DATE] at 2:02PM V6 (RN) was asked if she recalled caring for R1 and reviewing R1's lab values. While reviewing R1's EMR (electronic medical record) with surveyor present, V6 said yes, that she was the one who reviewed R1's labs on [DATE]. V6 confirmed that she would have documented in the progress notes if there were any new orders regarding the lab results. V6 was asked if she communicated this low potassium level to the nurse practitioner and V6 said that she recalled V5 (nurse practitioner) being in the building that morning and that they briefly talked about R1's labs but she didn't recall getting any new orders or instructions related to R1 and potassium levels. V6 also said that she took over that morning for V4 (LPN) because V4 was the overnight nurse but that she did not get report from V4 that morning because she thought that V4 had already left at the time that V6 got to work that morning. V6 was asked if she asked the nurse practitioner if there should be any new orders with the low potassium and V6 said she didn't since she assumed V5 was here and would have told her if she wanted any new orders. V6 confirmed that it is important to monitor potassium because of its relationship to the heart so it needs to be monitored closely.Review of physician orders for R1 show the following orders: - Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablets by mouth two times a day for hypokalemia (Order and Start Date [DATE] with no End Date noted)- Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ for 2 Days x 3 days (Order Date [DATE], Start Date [DATE], End Date [DATE])- Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ x 3 days (Order Date [DATE], Start Date [DATE], with no End Date noted)Medication Administration Record (MAR) for R1 [DATE] documents that R1 received Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablet by mouth two times a day for hypokalemia -Order Date- [DATE] 1435 -D/C Date-[DATE] 1002; MAR shows that R1 was administered this medication on [DATE] and then twice daily (at 0800 and 1600) from [DATE] thru [DATE] and then in the morning on [DATE]. In total, R1 received 34 doses of this medication. [DATE] at 5:10PM V7 (Regional Consultant) confirmed that the nurse entered the order incorrectly, the resident was only supposed to get the potassium for 3 days but instead they kept giving it. Despite continued potassium supplementation, there was no documentation that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. There was no evidence that repeat potassium levels were obtained until [DATE], 13 days later. Record review further revealed that a laboratory result dated [DATE] indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value or that the provider was confirmed to be made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Employee disciplinary report for V4 documents - discharge: Date of Incident: 10/15: Description of what happened: Employee failed to contact MD regarding a critical lab. Employee should contact MD immediately for critical lab and receive respond [sic] before marking labs reviewed by Physician. Failure to adhere resulting in termination. V1 (Administrator) confirmed that V4 was terminated on [DATE].Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or Administrator.V4's Orientation Checklist signed on [DATE] documents that employee was instructed on reporting change of resident conditionXXX[DATE] at 1:52PM V9 (Licensed Practical Nurse/LPN) said that lab results come right to the dashboard (in the EMAR) and the nurse should print them out and notify the nurse practitioner (NP) right away. If it's in the evening after 6pm, the nurses can call telehealth and they will give orders or send the resident to the hospital. V9 said, if I call the provider and they don't respond and it's been an hour, depending on the resident assessment, I will call 911 and notify the director of nursing. I can also call the medical director. In the meantime, I would be monitoring the resident by checking vitals frequently and updating the manager. V9 added that when there is a critical lab value the lab will also call the facility in addition to uploading the reportXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:46pm V3 (Assistant Director of Nursing /ADON) said, after the resident coded, I was auditing the chart and I noticed that there was a critical lab and didn't see that there was any action or follow up done on that lab. I reported it to V2 (DON). After that, we talked to V4 and corporate did as well. She said that she text-ed or left a voicemail to the NP or the doctor but there was no response so she cleared it and then she left. As a nurse, if I see an 8.4 potassium, I understand that this is life threatening and something has to be done. By any means, I would have to reach the doctor. I would not leave without talking to the doctor. The NP said she didn't get any voice or text message. We also have telehealth. V4 used to work mornings and didn't normally work PM shift. Our afternoon nurses always know that after 5pm they can contact telehealth. They also know that they can contact the medical director. Just as a nurse, I would expect her to know that that was a serious lab value. On top of that she cleared it, so then no one else would have picked it up. They know that before the end of the shift they need to have all of their labs relayed and cleared so it's not left for the next shift. The expectation is that they will handle the complete action and document it. Since then, every week we go back to the labs and I check on a sample of labs. At least 3-4 times a week I go back and make sure that the full cycle has been completed with the labs. In the morning before morning meeting, I read the notes to see if they've documented that labs were relayed to the MD, etc. We in-service staff to know that they have to report critical labs immediately and if the doctor doesn't respond, they have been told to contact the medical directorXXX[DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response. I was told that V4 (LPN) relayed the lab. She (V4) told me that she took a screenshot of the lab and sent it to the NP (nurse practitioner V5). V5 (NP) used to be in the building but she's not here anymore. V4 said that she sent a screenshot to V5 and then forgot about it. I called V5 to confirm that and she said that she couldn't see it clearly. We get the labs via results in (electronic medical record). The providers all have access to the EMR to see the results as well. My expectation is that the nurses should call the provider and get a response and document it. If it's a critical lab I would expect them to get a response as soon as possible, at least by the end of their shift, or contact the medical director. The medical director's information is on the face sheet so the nurses know how to contact her. She is always available when we call her. The lab will call here directly when it's a critical lab value. All the lab values get automatically uploaded into (the EMAR). With a potassium of 8.4 I would have expected V4 to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium. She could have contacted telehealth or the medical director because I don't think the NP works that late, it was night shift. With an 8.4 the resident was at risk of cardiac issues with a potassium that high. Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. I have not had any issues come up related since thenXXX[DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs. When correcting potassium, after treatment, I would have checked it the next day because potassium responds pretty quickly; or at least within a week or so. Potassium less than 2.5 would have been appropriate for hospitalization so they could administer IV. A value of 3.0 is reasonable to give oral potassium supplement and then recheck. I would have expected the NP to call me or send the patient to the hospital. When the NP ordered the supplement, I would have told her to recheck it the same day, a few hours after or at least the next day early morning. I did do a talk with the NP's after this happened and discussed what are critical labs and when to repeat. It also depends on the facility capabilities for labs, I don't know what the facility capabilities are some can give IV and some can't. If we need to recheck labs then that can play a role in the management as well. I have not been aware of this issue for any other residents. I don't remember if the NP called me about this resident in particular. I would have definitely remembered a potassium of 2.0. I know she has called me before. One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab they need to call me or they can also call telehealth after hours. I recommended educating nursing to understand what is meaning of critical lab values. If we had been following her, we would have seen the potassium trending up and intervened. The main concern with a potassium of 8.4 is the risk of arrhythmia (irregular or abnormal heart rhythm).Record review showed that R1 was found unresponsive in the facility on [DATE], four days after the facility obtained the critically abnormal potassium result.Nurse Progress Note dated [DATE] 17:25:39 reads: @2:35pm Nurse is completing final rounds noted resident unresponsive. Code blue initiated with 911 being called and immediately begins CPR. With in minutes crash cart and live saving devices are utilized. @arouund 2:40pm Paramedics arrived and take control. @ around 3:30pm Paramedics pronounce resident as expired. Resident is clean and remain in room with door closed @ around 4pm Nurse place call to resident responsibility party (family). Nurse informs (family) that resident has expired. (Family) states that he has little to no money and they did not have a plan in place for this situation. Family does agree to have resident cremated. @ around 4:30pm Call placed to (Donor Services). Nurse speaks with (rep) who states they will give (family) a call and further assist in the process. Nurse informs on coming Nurse of situation who will await further instruction from (Donor Services).R1's death certificate lists date of death as [DATE] and includes cause of death as cardiopulmonary arrest with other comorbidities. Per the American Academy of Family Physicians: As with hypokalemia (low potassium), the immediate danger of hyperkalemia (high potassium) is its effect on cardiac conduction and muscle strength, and initial efforts should focus on determining the need for urgent intervention .The absence of symptoms does not exclude severe hyperkalemia, because hyperkalemia is often asymptomatic .Severe hyperkalemia (more than 6.5 mEq per L [6.5 mmol per L]) can cause muscle weakness, ascending paralysis, heart palpitations, and paresthesias. Chronic kidney disease, diabetes, heart failure, and liver disease all increase the risk of hyperkalemia.The physical examination should include assessment of blood pressure and intravascular volume status to identify potential causes of kidney hypoperfusion, which can lead to hyperkalemia. Neurologic signs of hypokalemia include generalized weakness and decreased deep tendon reflexes.LABORATORY ANALYSIS AND ECGRepeat measurement of serum potassium can help identify pseudohyperkalemia, which is common and typically results from potassium moving out of cells during or after sample collection. Other laboratory studies include measurement of serum blood urea nitrogen and creatinine, measurement of urine electrolytes and creatinine, and assessment of acid-base status. Further evaluation may include measurement of serum glucose to evaluate for hyperglycemia, and measurement of serum renin, aldosterone, and cortisol to further investigate kidney and adrenal function.ECG should be considered if the potassium level is greater than 6 mEq per L; if there are symptoms of hyperkalemia; if there is suspicion of rapid-onset hyperkalemia; or among patients with underlying kidney disease, heart disease, or cirrhosis who have a new case of hyperkalemia.Hyperkalemia-induced arrhythmias include sinus bradycardia, sinus arrest, ventricular tachycardia, ventricular fibrillation, and asystole.Treatment of HyperkalemiaGENERAL PRINCIPLESThe goals of acute treatment are to prevent potentially life-threatening cardiac conduction and neuromuscular disturbances, shift potassium into cells, eliminate excess potassium, and resolve the underlying disturbance .Indications for prompt intervention are symptoms of hyperkalemia, changes on ECG, severe hyperkalemia (greater than 6.5 mEq per L), rapid-onset hyperkalemia, or underlying heart disease, cirrhosis, or kidney disease. Potassium should be monitored often because patients are at risk of redeveloping hyperkalemia until the underlying disorder is corrected and excess potassium is eliminated.Facility policy for Critical Lab Result Reporting (Review Date 9/2022) reads:DEFINITIONS:Critical Test Results are those results that fall significantly outside the normal range and/or may represent life-threatening values, even from routine tests and that require rapid communication of results to the responsible licensed practitioner.Licensed Practitioners/Providers are Physicians, Physician Assistants, and Nurse Practitioners.RESPONSIBLE PARTY:DON, Nursing Supervisors, RN, LPNGUIDELINE:The facility will communicate the results of tests considered critical to patient care to the responsible licensed caregiver in a timely and reliable manner according to established guidelines.PROCEDURE:1. The acceptable length of time between identifying the critical result and notification of a licensed practitioner will be within one hour unless:a. The provider documents specific diagnostic notification range values in the medical record b. The critical value is improved from a previous value and the provider is aware of the previous value.2. Any critical Lab value will be communicated to facility nursing staff by the Laboratory via phone.3. Critical Lab results will not be faxed to facility from the Laboratory.4. Facility nursing staff will not communicate Critical Lab results to the responsible licensed practitioner using fax machine.5. Facility nursing staff will communicate Critical Lab Results either in person or via telephone.6. The nursing staff member who is notified by Laboratory of the critical lab result is accountable for communication to the responsible licensed practitioner.7. In the event that the patient's provider cannot be reached and/or does not respond to call/page, the call will be repeated every 15 minutes until one hour has been reached.8. If successful contact with the patient's licensed provider cannot be established, the medical director will be paged. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy. On [DATE], the survey team verified by observations, interviews, and record review, that the facility implemented the following to remove the immediacy.Actions Taken:PLAN OF REMOVALPreparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. 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. F684 Affected resident corrective actions.A. Resident R1 no longer resides in the facility. 2. Immediate Actions and Actions to prevent recurrence. (Initiated on [DATE] at 5:30PM and will continue until all staff are in-serviced and trained prior to the start of their shift) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. There was no concern identified. (This immediate action was initiated and was completed on [DATE] at 6:00pm)B. All Nurses staff were provided with education by the DON/ Designee. The training included but is not limited to ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. (This immediate action was initiated and was completed on [DATE] at 9:30pm)C. The Medical Director, Administrator and DON reviewed the facility's policies which include but are not limited to:Policy of Critical Lab Result Reporting Critical Medications Requiring Laboratory MonitoringThis was initiated, reviewed and completed on [DATE] at 6:05 pmD. New hires will be in-serviced by the DON, ADON or Designee.All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials. E. The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. (This immediate action was initiated and was completed on [DATE] at 9:30pm)Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.F. The DON/ADON/designee will conduct daily audits to identify any potential concerns related to this plan of removal. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3)G. The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, daily to gauge knowledge retention and determine if additional training is required. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3) H. I. During the weekends, the assigned Nursing Supervisor/Designee will conduct the daily audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. Any identified concern will be addressed immediately. (This immediate action was initiated on [DATE] daily for 4 weeks then weekly times 8 weeks, then monthly x 3) J. To ensure compliance, the results of the audit will be reviewed daily during the meeting which is attended by the clinical leadership which includes but is not limited to the: DON, ADON, MDS, IP, Restorative, and the Administrator/Designee. (This immediate action was initiated on [DATE] daily for 4 weeks then weekly times 8 weeks, then monthly x 3) K. Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI. The facility will reinforce the following process.L. All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3) M. The Administrator, DON and Designee will monitor completion of this plan of removal. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: Completion Date: [DATE]

Based on interview and record review, the facility failed to ensure that laboratory results were communicated to the ordering provider in accordance with facility policy and procedures for notification. This failure applied to one (R1) of three residents reviewed for notification of laboratory results and resulted in no provider being notified that R1 had a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1), putting R1 at risk of cardiac arrythmia (irregular or abnormal heart rhythm). R1 subsequently experienced cardiac arrest in the facility and expired four days after the laboratory result was obtained. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility was notified of R1's lab report that showed a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1) and the facility failed to notify the provider of this critical value in order for it to be addressed. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00PM. The survey team confirmed by observation, interviews, and record reviews that the Immediate Jeopardy was removed on [DATE], when the facility initiated an audit process to verify code status and the deficient practice was corrected on [DATE]. This is being cited as past noncompliance.Findings include:R1 was a [AGE] year-old female admitted to the facility in [DATE]. R1 expired in the facility on [DATE]. R1 medical diagnoses included (but not limited to): chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, aneurysm of the descending thoracic aorta, without rupture, and aneurysm of the ascending aorta, without rupture.Record review for R1 revealed a laboratory result dated [DATE] which indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value nor was there confirmation that the provider was made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Employee disciplinary report for V4 documents - discharge: Date of Incident: 10/15: Description of what happened: Employee failed to contact MD regarding a critical lab. Employee should contact MD immediately for critical lab and receive respond [sic] before marking labs reviewed by Physician. Failure to adhere resulting in termination. V1 (Administrator) confirmed that V4 was terminated on [DATE].Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or Administrator.V4's Orientation Checklist signed on [DATE] documents that employee was instructed on reporting change of resident conditionXXX[DATE] at 1:52PM V9 (Licensed Practical Nurse/LPN) said that lab results come right to the dashboard (in the EMAR) and the nurse should print them out and notify the nurse practitioner (NP) right away. If it's in the evening after 6pm, the nurses can call telehealth and they will give orders or send the resident to the hospital. V9 said, if I call the provider and they don't respond and it's been an hour, depending on the resident assessment, I will call 911 and notify the director of nursing. I can also call the medical director. In the meantime, I would be monitoring the resident by checking vitals frequently and updating the manager. V9 added that when there is a critical lab value the lab will also call the facility in addition to uploading the reportXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:46pm V3 (Assistant Director of Nursing /ADON) said, after the resident coded, I was auditing the chart and I noticed that there was a critical lab and didn't see that there was any action or follow up done on that lab. I reported it to V2 (DON). After that, we talked to V4 and corporate did as well. She said that she text-ed or left a voicemail to the NP or the doctor but there was no response so she cleared it and then she left. As a nurse, if I see an 8.4 potassium, I understand that this is life threatening and something has to be done. By any means, I would have to reach the doctor. I would not leave without talking to the doctor. The NP said she didn't get any voice or text message. We also have telehealth. V4 used to work mornings and didn't normally work PM shift. Our afternoon nurses always know that after 5pm they can contact telehealth. They also know that they can contact the medical director. Just as a nurse, I would expect her to know that that was a serious lab value. On top of that she cleared it, so then no one else would have picked it up. They know that before the end of the shift they need to have all of their labs relayed and cleared so it's not left for the next shift. The expectation is that they will handle the complete action and document it. Since then, every week we go back to the labs and I check on a sample of labs. At least 3-4 times a week I go back and make sure that the full cycle has been completed with the labs. In the morning before morning meeting, I read the notes to see if they've documented that labs were relayed to the MD, etc. We in-service staff to know that they have to report critical labs immediately and if the doctor doesn't respond, they have been told to contact the medical directorXXX[DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response. I was told that V4 (LPN) relayed the lab. She (V4) told me that she took a screenshot of the lab and sent it to the NP (nurse practitioner V5). V5 (NP) used to be in the building but she's not here anymore. V4 said that she sent a screenshot to V5 and then forgot about it. I called V5 to confirm that and she said that she couldn't see it clearly. We get the labs via results in (electronic medical record). The providers all have access to the EMR to see the results as well. My expectation is that the nurses should call the provider and get a response and document it. If it's a critical lab I would expect them to get a response as soon as possible, at least by the end of their shift, or contact the medical director. The medical director's information is on the face sheet so the nurses know how to contact her. She is always available when we call her. The lab will call here directly when it's a critical lab value. All the lab values get automatically uploaded into (the EMAR). With a potassium of 8.4 I would have expected V4 to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium. She could have contacted telehealth or the medical director because I don't think the NP works that late, it was night shift. With an 8.4 the resident was at risk of cardiac issues with a potassium that high. Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. I have not had any issues come up related since thenXXX[DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs.One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab they need to call me or they can also call telehealth after hours. I recommended educating nursing to understand what is meaning of critical lab values.The main concern with a potassium of 8.4 is the risk of arrhythmia (irregular or abnormal heart rhythm).Record review showed that R1 was found unresponsive in the facility on [DATE], four days after the facility obtained the critically abnormal potassium result.R1's death certificate lists date of death as [DATE] and includes cause of death as cardiopulmonary arrest with other comorbidities. The National Institute of Health website, cites the following: Critical limits of laboratory results need urgent notification to the clinician because they are an indicator of a critical or even life-threatening condition of the patient.Facility policy for Critical Lab Result Reporting (Review Date 9/2022) reads:DEFINITIONS:Critical Test Results are those results that fall significantly outside the normal range and/or may represent life-threatening values, even from routine tests and that require rapid communication of results to the responsible licensed practitioner.Licensed Practitioners/Providers are Physicians, Physician Assistants, and Nurse Practitioners.RESPONSIBLE PARTY:DON, Nursing Supervisors, RN, LPNGUIDELINE:The facility will communicate the results of tests considered critical to patient care to the responsible licensed caregiver in a timely and reliable manner according to established guidelines.PROCEDURE:1. The acceptable length of time between identifying the critical result and notification of a licensed practitioner will be within one hour unless:a. The provider documents specific diagnostic notification range values in the medical record b. The critical value is improved from a previous value and the provider is aware of the previous value.2. Any critical Lab value will be communicated to facility nursing staff by the Laboratory via phone.3. Critical Lab results will not be faxed to facility from the Laboratory.4. Facility nursing staff will not communicate Critical Lab results to the responsible licensed practitioner using fax machine.5. Facility nursing staff will communicate Critical Lab Results either in person or via telephone.6. The nursing staff member who is notified by Laboratory of the critical lab result is accountable for communication to the responsible licensed practitioner.7. In the event that the patient's provider cannot be reached and/or does not respond to call/page, the call will be repeated every 15 minutes until one hour has been reached.8. If successful contact with the patient's licensed provider cannot be established, the medical director will be paged. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy. On [DATE], the survey team verified by observations, interviews, and record review, that the facility implemented the following to remove the immediacy.Actions Taken:Steps Taken to Remove the Immediacy1. On [DATE], DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to md for any abnormal labs and to escalate to medical director if md/p did not answer the call in- services are ongoing. V4 termed date was [DATE].2. On [DATE], DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to md for any abnormal labs and to escalate to medical director if md/np did not answer the call. This was completed on [DATE].3. All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation in- service is ongoing.4. On [DATE], DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.5. The facility identified that all residents can be affected by the deficient practice, and none were identified as of [DATE].6. A QA tool was developed on [DATE] to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to md for any abnormal labs and to escalate to medical director if md/p did not answer the call and was completed on [DATE].7. A QA tool was developed on [DATE] to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order and was completed on [DATE].8, On [DATE], the Medical Director was made aware and in agreement with the abatement and on [DATE], an in-service was conducted with her Nurse practitioner regarding critical labs.

Based on interview and record review, the facility failed to ensure that a resident was provided with continued assessment and monitoring while receiving potassium supplementation. This failure applied to one resident (R1) who was being treated for low potassium of 2.5 mEq/L and then continued to receive the potassium supplement with no plan for monitoring or follow up labs scheduled, in order to confirm the continued need for treatment. As a result, R1 was found to have a critically high potassium level of 8.4 mEq/L (normal range 3.5-5.1) when labs were re-checked 13 days later. Findings include:R1 was a [AGE] year-old female admitted to the facility in [DATE]. R1 expired in the facility on [DATE]. R1 medical diagnoses included (but not limited to): chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, aneurysm of the descending thoracic aorta, without rupture, and aneurysm of the ascending aorta, without rupture.Review of R1's facility medical record show that R1 was being treated for low potassium levels (hypokalemia).R1 lab report dated [DATE] documents potassium level of 3.0 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. Nurse progress note written by V4 dated [DATE] 12:36 reads: CBC and CMP reviewed by NP and new order given for Potassium 40 Meq p.o. 1 x, noted and carried out. Review of Medication Administration Record (MAR) for R1 for [DATE] does not include any documentation that this order was administered to R1. There is no documentation or order showing that labs were ordered to be repeated after this intervention nor was there any indication of monitoring to be done related to this order. R1 lab report dated [DATE] documents potassium level of 2.0 mEq/L (normal range 3.5 - 5.1); report flagged as critical. Nurse progress note written by V4 on [DATE] 23:53 reads: Spoke to V5 (Nurse Practitioner) to relay abnormal lab K+ 2.0, new orders given for Potassium 40 Meq p.o. x 3 days, repeat BMP in a.m., and give 5% dextrose 0.45% sodium chloride at 75ml/hr x 500ML. Noted and carried out. Supervisor is aware. R1 lab report dated [DATE] documents potassium level of 2.5 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. There is no documentation that V6 took any actions after reviewing this lab report in regard to the abnormal lab value. There is no documentation or order showing that labs were ordered to be repeated at this time. [DATE] at 2:02PM V6 (RN) was asked if she recalled caring for R1 and reviewing R1's lab values. While reviewing R1's EMR (electronic medical record) with surveyor present, V6 said yes, that she was the one who reviewed R1's labs on [DATE]. V6 confirmed that she would have documented in the progress notes if there were any new orders regarding the lab results.V6 said that she recalled V5 (nurse practitioner) being in the building that morning and that they briefly talked about R1's labs but she didn't recall getting any new orders or instructions related to R1 and potassium levels .V6 was asked if she asked the nurse practitioner if there should be any new orders with the low potassium and V6 said she didn't since she assumed V5 was here and would have told her if she wanted any new orders. V6 confirmed that it is important to monitor potassium because of its relationship to the heart so it needs to be monitored closely.Review of physician orders for R1 show the following orders: - (Order and Start Date [DATE] with no End Date noted) Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablets by mouth two times a day for hypokalemia - (Order Date [DATE], Start Date [DATE], End Date [DATE]) Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ for 2 Days x 3 days - (Order Date [DATE], Start Date [DATE], with no End Date noted) Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ x 3 days Medication Administration Record (MAR) for R1 [DATE] documents that R1 received Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablet by mouth two times a day for hypokalemia -Order Date- [DATE] 1435 -D/C Date-[DATE] 1002; MAR shows that R1 was administered this medication on [DATE] and then twice daily (at 0800 and 1600) from [DATE] thru [DATE] and then in the morning on [DATE]. In total, R1 received 34 doses of this medication. [DATE] at 5:10PM V7 (Regional Consultant) confirmed that the nurse entered the order incorrectly, the resident was only supposed to get the potassium for 3 days but instead they kept giving it. Despite continued potassium supplementation, there was no documentation that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice or ongoing assessment for continued need based on assessment, monitoring, or consultation with the ordering provider in relation to potassium supplementation being administered from 10/2 - [DATE].There was no evidence that repeat potassium levels were obtained until [DATE], 13 days later. R1 laboratory result dated [DATE] indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value or that the provider was confirmed to be made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or AdministratorXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response.With a potassium of 8.4 I would have expected V4 (LPN) to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium.Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. [DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs. When correcting potassium, after treatment, I would have checked it the next day because potassium responds pretty quickly; or at least within a week or so. Potassium less than 2.5 would have been appropriate for hospitalization so they could administer IV. A value of 3.0 is reasonable to give oral potassium supplement and then recheck. I would have expected the NP to call me or send the patient to the hospital. When the NP ordered the supplement, I would have told her to recheck it the same day, a few hours after or at least the next day early morning. I did do a talk with the NP's after this happened and discussed what are critical labs and when to repeat. It also depends on the facility capabilities for labs, I don't know what the facility capabilities are some can give IV and some can't. If we need to recheck labs then that can play a role in the management as well. I have not been aware of this issue for any other residents. I don't remember if the NP called me about this resident in particular. I would have definitely remembered a potassium of 2.0. I know she has called me before. One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab they need to call me or they can also call telehealth after hours. I recommended educating nursing to understand what is meaning of critical lab values. If we had been following her, we would have seen the potassium trending up and intervened. The main concern with a potassium of 8.4 is the risk of arrhythmia (irregular or abnormal heart rhythm).Record review showed that R1 was found unresponsive in the facility on [DATE], four days after the facility obtained the critically abnormal potassium result.R1's death certificate lists date of death as [DATE] and includes cause of death as cardiopulmonary arrest with other comorbidities. Per the American Academy of Family Physicians: Treatment of Hyperkalemia: GENERAL PRINCIPLES: The goals of acute treatment are to prevent potentially life-threatening cardiac conduction and neuromuscular disturbances, shift potassium into cells, eliminate excess potassium, and resolve the underlying disturbance .Indications for prompt intervention are symptoms of hyperkalemia, changes on ECG, severe hyperkalemia (greater than 6.5 mEq per L), rapid-onset hyperkalemia, or underlying heart disease, cirrhosis, or kidney disease.24,30,33-35 Potassium should be monitored often because patients are at risk of redeveloping hyperkalemia until the underlying disorder is corrected and excess potassium is eliminated.Facility Policy, Critical Medications Requiring Laboratory Monitoring [DATE], reads: Purpose:To ensure resident safety by identifying medications that require ongoing laboratory monitoring, early detection of adverse effects, and timely clinical intervention to prevent deterioration, medication errors, and unplanned hospitalization.Definition: Critical MedicationA critical medication is any medication that:Has a narrow therapeutic rangeCan cause serious harm if levels are too high or too lowRequires scheduled or symptom-triggered lab monitoringHas a high risk for hospitalization if not monitored appropriatelyGeneral Monitoring Expectations (All Critical Medications)Baseline labs obtained prior to initiation (or verified on admission).Routine lab monitoring per Medical Provider order.PRN / symptom-triggered labs when change in condition occurs.Critical values reported immediately to provider.Nursing assessment documented with lab review.Care plan updated to reflect medication risk and monitoring needs.High-Risk Medications & Required Lab Monitoring but not limited to: 1. Potassium (KCl oral)2. Warfarin (Coumadin)3. Digoxin4. Vancomycin

Based on interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain vital signs, failed to conduct a thorough assessment, failed to fill out an SBAR (Situation Background Assessment Recommendation) form, and failed to ensure that EMS (Emergency Medical Services) was made aware of resident status/vital signs prior to arrival for one of three residents (R2) reviewed for change in condition. These failures contributed to R2's [DATE] death.Findings include: On [DATE], IDPH (Illinois Department of Public Health) received allegations that EMS was dispatched for sick, later upgraded to trouble breathing not recent - (R2's) feet were blue. (R2) was on oxygen, staff had little to no knowledge but said it was only a few minutes, it clearly had been longer that no one checked on R2 - not handled quick enough. R2 was [AGE] years old with diagnoses which include but not limited to COPD (Chronic Obstructive Pulmonary Disease), hypertensive heart disease with heart failure and peripheral vascular disease. R2's ([DATE]) care plan states resident has potential for difficulty in breathing related to COPD, intervention: observe for changes in breathing pattern. Monitor vital signs and lung sounds. R2's Physician Order Sheets include ([DATE]) Oxygen at 2 liters per minute per nasal cannula to maintain oxygen saturation readings between 90-96%. Oxygen saturation every shift for monitoring oxygen saturation readings. R2's ([DATE]) Medication Administration Record affirms oxygen saturation ranged from 95-98%. R2's progress notes include ([DATE]) 10:35pm, writer observed resident breathing heavy checked oxygen 81%, nasal cannula was applied resident oxygen level raised to 91%. 911 was called and resident was transported to Hospital. Doctor was informed [liters of oxygen, respirations, blood pressure, pulse, temperature and lung sounds were excluded]. ([DATE]) Called and spoke to Nurse who stated that resident was intubated in ambulance by paramedics and is being admitted in Intensive Care Unit with shortness of breath, hypotensive, and is being given hypertensive medicines. ([DATE]) Contacted the hospital to inquire about resident status. Nurse informed that resident expired yesterday at 9:02am. On [DATE] at 1:11pm, surveyor inquired about R2's ([DATE]) change in condition V7 (Licensed Practical Nurse) stated I (V7) normally have her (R2) and I always check on my residents. She's (R2) always taking her nasal cannula off, when I walked in it was off and her breathing wasn't normal, she was breathing heavy. I put her nasal cannula on, and her oxygen level was low it was 91%. I don't know how long the cannula was off and didn't like the way she was breathing so I got an order from the doctor to send her out 911. Surveyor inquired how many liters of oxygen R2 was placed on prior to transfer V7 responded I'm not even gonna guess I don't remember. Surveyor inquired how many liters of oxygen R2 was supposed to be on (per physician order) V7 affirmed she did not know. Surveyor inquired if R2's vital signs were obtained prior to transfer V7 replied, The EMS I think they (EMS) did obtain her vital signs when they came, I can't remember. I'm pretty sure I did them because I have to give EMS the vital signs but again my nursing action was just send her out. Surveyor inquired where R2's vital signs were documented V7 stated They would be documented in the Nurses notes. Surveyor inquired if R2's vital signs may have been documented elsewhere V7 responded I'm not for certain, I can't recall. I just reacted and called 911. Surveyor inquired if R2's feet were blue prior to transfer V7 replied, I looked at her whole body, and her feet wasn't blue. Surveyor inquired if R2 was breathing prior to EMS transfer V7 stated Yes, she was. Surveyor inquired if EMS requested R2's status upon arrival. V7 responded, I think they (EMS) asked me if she has COPD, but they didn't ask me anything else. R2's ([DATE]) vital signs documentation affirms at 1:40pm, blood pressure was 108/62, temperature was 97.8, pulse was 60, and respirations were 18. At 7:59pm, R2's oxygen saturation was 98%. No additional vital signs were documented (R2's change in condition occurred at 10:35pm). On [DATE] at 1:50pm, surveyor inquired about staff requirements for resident change in condition. V2 (Director of Nursing) stated, They (staff) need to do an assessment and notify the doctor. Surveyor inquired what an assessment entails. V2 responded, A head to toe assessment and vitals. Surveyor inquired where resident vital signs are documented. V2 replied, In the chart. Surveyor inquired if V7 charted R2's vital signs on ([DATE]) V2 stated I'm not really sure I do have to go back into the notes to see. V2 subsequently reviewed R2's ([DATE]) progress note and responded, Not in this note, she (V7) didn't have any vital signs in this particular note (except oxygen saturation). Surveyor inquired how many minutes it usually takes for EMS to arrive to the facility when 911 is called V2 replied It take em a couple of minutes to come here between 5 and 10 minutes they come rolling up. Surveyor inquired if V7 filled out an SBAR (which provides a structured framework for healthcare professionals to quickly and clearly share critical information about a patient, especially during handoffs) for R2's ([DATE]) change in condition V2 stated I (V2) didn't see one. Surveyor inquired if an SBAR is supposed to be filled out for resident change in condition V2 responded Yes, it is. On [DATE] at 11:13am, surveyor inquired about facility staff requirements for resident change in condition. V8 (Medical Director) stated, I would expect them (staff) to get vitals and then contact the provider. Surveyor inquired which vital signs should be obtained for a resident experiencing respiratory distress. V8 responded, The oxygen saturation, heart rate, blood pressure, all of them. Surveyor inquired if a resident is in respiratory distress which assessments should be conducted V8 replied I would expect them to see if they're alert, diaphoretic, are they struggling using accessory muscles, listen to their lungs to see if they have wheezing, crackles, or no sounds at all. Surveyor inquired about potential harm to a resident if staff fail to obtain vital signs, fail to conduct a physical assessment and/or fail to report actual changes in condition to EMS and/or healthcare provider. V8 stated, I guess increased mortality and morbidity. R1's Certificate of Death affirms death occurred on [DATE]. The ([DATE]) facility change in resident condition policy states nursing will notify the resident's physician or nurse practitioner when: there is a significant change in the resident's physical, mental or emotional status [Physical Assessment, Vital Signs, and SBAR are excluded]. The facility Respiratory Care Monitoring policy (revised 10/2024) states any change in the resident's condition will be identified such as difficulty breathing, changes in color, change in mental status, or other changes that my signal further evaluation is needed. If the change requires immediate intervention (resident is in distress, having difficulty breathing) the assessment will be completed and appropriate interventions implemented.

Based on observation, interview and record review, the facility failed to prevent multiple fall incidents for a resident assessed to be high risk for fall. Facility also failed to follow proper post fall procedure and transferred resident back to bed who complained of right leg pain upon ROM (Range of Motion) assessment. This deficient practice affects one resident (R1) of three residents reviewed for fall incidents. R1 was sent out to the hospital and admitted with Right Closed Hip Fracture.Findings Include:R1 is a [AGE] year-old female resident with diagnoses of but not limited to: Muscle Weakness, Abnormal Posture, Depression, Profound Intellectual Disabilities, Seizure, Atherosclerotic Heart Disease, Dementia without Behavioral Disturbance, Anemia, Anxiety, and Generalized Osteoarthritis. admitted in the facility on 4/12/2010.R1 had a fall incident on 3/25/25 and 7/5/25.Fall incident Report dated 3/25/25, reads in part: R1 observed by staff member to be on the floor next to her bed on her left side. When the writer entered the room, R1 was lying on the floor, noted a bump in a small cut over left eye. Nurse Practitioner in the building and notified of incident with orders to send to local hospital via 911. R1 returned the same day to the facility with no major findings from the hospital. Care plan reviewed and noted 3 interventions added for this fall (3/25/25): Promote placement of call light within reach and assess residents' ability to use; encouraged to use call light for any assistance needed; Therapy to evaluate and treat.On 9/3/25 at 11:00AM, V2 (Director of Nursing) stated that the IDT (Interdisciplinary Team) meet and analyze the root cause of the fall. The intervention then will be added on resident plan of care based on the root cause. V2 stated they are unable to identify the root cause and call light intervention was added on 3/25/25. V2 also stated V2 does not know the reason why call light intervention was added and that the fall incident did not mention anything about the call light concerns related to this fall incident.Facility Reported Incident to IDPH, final report dated 7/11/25, reads in part: fall date incident 7/5/25. CNA observed R1 lying on the floor. The CNA informed the nurse. The doors immediately performed a head-to-toe assessment and noticed facial grimace and R1 would not extend the right leg. The nurse informed telehealth and was ordered to medicate to send out for further evaluation. Conclusion: the nurse had medicated R1 and left the room. The nurse noticed the door was closed. The nurse preceded to open the door and noticed R1 on the floor lying in the dorsal position. The nurse immediately assessed the resident. Nurse performs range of motion on all extremities, R1 could that extend right leg and in doing so the residents had facial grimaces. R1 is nonverbal and cannot recall what happened. Nurse called the physician and was ordered to send out for x-ray and pain management. Pain medication given and transported to local hospital for evaluation. Progress Note reviewed and dated 7/6/25: R1 admitted in the hospital with closed right hip fracture. Care plan interventions added for this fall (7/5/25) was Floor mat and therapy to evaluate and treat. On 9/2/25 at 1040AM, V3 (CNA) assigned to R1. Stated that V3 observed R1 on the floor next to her bed during her round right before dinner. V3 stated that the last time she saw the resident was during the beginning of V3's shift. V3 stated that V3 provided incontinent care during this time. V3 stated that R1 was calm, not in distress when V3 left the room. V3 stated she placed the bed in lowest position as always. Does not recall if the side rails were in use at the time. Assisted in transferring back the resident to bed using Hoyer lift.On 9/2/25 at 11:40AM, V4 (Nurse) assigned to R1. Stated that V4 was doing medication pass when the V3 informed V4 of the incident. Stated that the last time V4 saw R1 was during medication administration to R1 approximately 4pm to 5pm. That R1 was not in distress, calm and in the center of the bed. Bed in low position. V4 stated that after the report of the unwitnessed fall, V4 immediately checked on the resident. Check the surroundings to see if anything might have hit R1's head during the fall. No sign of head injury but stated that during the assessment R1 was making facial grimace when right leg was moved and right leg does not look right. V4 called the physician and ordered to send R1 out for further evaluation and to medicate for pain management. V4 stated that R1 was placed back to bed with 3 persons assist using a blanket.On 9/3/25 at 9:05AM, V7 (Restorative Nurse) stated that R1 requires substantial/maximal assistance, which requires more than half of staff effort. R1 needs guidance in holding and placing hand to side rail to reposition herself. IDT met and analyzed the root cause. It was unwitnessed and maybe R1 was not reposition in the bed right, or R1 was closer to the edge of the bed and rolled off the bed onto the floor.On 9/3/25 at 9:20AM, V2 (Director of Nursing) stated that R1 was observed by the CNA on the floor next to her bed. No floor mat at the time, floor mat was added as one of the interventions after this fall incident (7/5/25). Nurse assessed R1 and head to toes and ROM (Range of Motion), facial grimace on right leg movement. Our expectation if suspected of any possible injury is for staff not to move the resident because we do not want to further injure the resident, until paramedics come. Root cause analysis for R1 fall incident completed; the fall was unwitnessed. Resident was not able to tell us what happened and because the bed was so close to the floor that we concluded that R1 rolled off the bed onto the floor.On 9/4/25 at 9:10AM, V2 (Director of nursing) Placing call light intervention for the 3/25/25 fall incident is ineffective because it does not stop R1 rolling off her bed. We would probably consider room change, closer to the nurses' station to have a closer visual monitoring for R1 and prevent further fall incident.R1 has a care plan for Bed Mobility with a revision date of 1/4/24, reads in part: R1 has a self-care deficit in bed mobility related to decreased ability to position or reposition self in bed due to diagnoses of Seizure, Alzheimer's, Anemia and Osteoarthritis.Care plan for ADL (Activities of Daily Living) with a revision date of 1/4/24, reads in part: R1 is an extensive assist of one staff member for bed mobility, toileting and transfer.Section GG-Functional Abilities dated 5/12/25, reads in part: R1 coded 02 (Substantial/Maximal Assistance)-helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort for:A. Roll left and right: the ability to roll lying on back to left and right side and return on back the bed.B. Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed.C. Lying to sitting on side of bed: the ability to move from lying on back to sitting on the side of the bed and with no back support.D. Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair or on the side of the bed.E. Chair/Bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair).R1 Fall Risk Evaluation dated 5/12/25 scored 15 and 7/13/25 scored 19. Scoring a 10 or higher makes resident high risk for falls. R1 has a care plan for Fall with a revision date of 4/8/24, reads in part: R1 is at risk for fall related to diagnoses and history of Dementia, Seizures, MDD (Major Depressive Disorder), Anxiety, and Muscle weakness.Fall Prevention and Management policy with a review date of 10/2018, reads in part: This facility is committed to maiming each resident's 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 preventative strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the residents' existing plan of care shall be evaluated and modified.A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls. As score less than 10 indicates at risk for fall.Care Plan to be updated with new intervention based on root cause analysis after each fall occurrence.

Based on observation, interview, and record review, the facility failed to adequately transcribe hospital nutrition support orders for one resident (R1) who readmitted to the facility on [DATE] and failed to follow physician orders for three residents (R2, R3, and R4) who require nutrition support. This failure resulted in R3 having a severe weight loss of 11.7% in six months and R1 who was severely underweight with multiple pressure ulcers to not receive adequate nutrition. Findings Include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE]. R1 was hospitalized on [DATE], readmitted to the facility on [DATE], and sent to the hospital again on 6/2/2025. R1 remains in the hospital at the time of this survey. R1 has multiple diagnoses including but not limited to the following: Respiratory failure, protein calorie malnutrition, intracranial injury, hydrocephalus, traumatic brain injury, seizures, dysphagia, tracheostomy, gastrostomy, oxygen dependence, AFib, and dependence on oxygen. Hospital discharge records dated 5/26/2025 show tube feeding diet of TwoCal (2.0) at 35 mililiters per hour to be ran continuously. Also shows resident was to receive the following nutritional supplements: Prosource one time a day and Juven two times a day. R1's physician orders dated 5/26/2025 state in part but not limited to the following: TwoCal at 35 mililiters/hour to be started at 11AM and off at 6AM. It is to be noted that the the nutritional supplements of Juven was not started until 5/29/2025 and Promote was not started until 5/30/2025. It is to be noted that R1's body weight measurements were as follows: 88.8 lbs (Admission-3/17/2025); 77.0 lbs (Readmission-5/29/2025); and 74.4 lbs (6/2/2025) R1 experienced a weight loss of 3.4% in four days, is considered to be severely underweight, and had multiple pressure ulcers. R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: respiratory failure, emphysema, alcoholic liver disease, COPD, tracheostomy, gastrostomy, anxiety, epilepsy, dysphagia, schizophrenia, and dependence on respirator. On 6/10/2025 at 10:50AM, R2 was observed laying in bed with no tube feeding running. R2's physician orders state in part but not limited to the following: Jevity 1.5 at 70 mililiters/hour x 22 hours (On at 10AM and off at 8AM). R3 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R3 has multiple diagnoses including but not limited to the following: respiratory failure, dysphagia, tracheostomy, gastrostomy, seizures, dementia, psychoactive substance abuse, anoxic brain damage, and pneumonia. At 10:52AM, R3 was observed laying in bed with no tube feeding running. R3's physician orders state in part but not limited to the following: Jevity 1.5 at 50 mililiters/hour x 21 hours (On at 2PM and off at 11AM). Nutritional assessment dated [DATE] states in part but not limited to the following: R3 exhibited a significant weight loss of 11.7% in six months and 9.2% weight loss in two months. Recommended to increase tube feeding to help promote weight stability. At 11:00AM, V5 (Licensed Practical Nurse) said when I arrive for my shift at 7AM, R3's tube feeding is usually not running. I know it starts at 2PM which is when I start it. I am looking at R3's physician orders now and I see it says run till 11AM, so I am not sure why it is not running when I get here at 7AM. V5 said sometimes the CNA's will turn off the tube feedings when they are performing ADL care. R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: cerebral infarction, DM, pressure ulcer, gastrostomy, epilepsy, psychosis, adjustment disorder, neuromuscular dysfunction of bladder, and respiratory failure. At 11:20AM, R4 was observed laying in bed with no tube feeding running. R4's physician orders state in part but not limited to the following: Osmolite 1.5 at 85 mililiters/hour x 22 hours (On at 2pm and off at 12PM). At 11:30PM, V7 (Licensed Practical Nurse) was on break when this surveyor asked to speak to her. V7 said I gave her medication around 10AM and I turned it off then. I typically turn it off for 30 minutes-1 hour to let the medication absorb and then I turn it back on after this. At 11:45AM, V8 (Registered Dietitian) said when a resident admits from the hospital. The admitting nurse is to follow the orders from the hospital discharge. When a resident comes from the hospital on a continuous feeding, they should follow this order until I come in to evaluate and make the recommendation to change it. I did not make a recommendation to change R1's tube feeding and recommended to keep it as continuous. I wanted to monitor R1's tolerance of this new formula and since he has multiple comorbidities including weight loss, was severely underweight, and had pressure ulcers, a continuous feeding makes sense for now. When I evaluated him on 5/28/2024, I recommended to continue the continuous feeding. V8 said if residents do not receive the correct nutritional support order, this can lead to weight loss. At 2:11PM, V9 (Nursing Supervisor) said when R1 was readmitted on [DATE], I transcribed the orders from the hospital. The hospital discharge paperwork had the formula and rate but not how many hours it should be run. I thought his order was the same as when he discharged so I reactivated the previous order. It is my understanding that the nursing management staff will double check it from there. I found out later that he was supposed to be on a continuous feeding. V9 said when CNA's provide ADL care such as changing and repositioning, they ask the nurse to stop the feeding temporality and the nurse is to restart it immediately after they are done with care. When medication is given, the nurse is to stop the feeding, give the medication and flush with water, then resume the feeding. Per physician orders, resident was receiving Osmolite1.5 at 60 militers/hour to start at 11AM and stop at 6AM at time of hospitalization on 3/23/2025 and hospital discharge paperwork dated 5/26/2025 state TwoCal at 35 mililiters/hour continuous. It is to be noted that R1 was not on the same formulary as prior to hospitalization. At 2:30PM, V3 (Assistant Director of Nursing) said when CNA's provide ADL care, the nurse will turn off the feeding and restart it when they are done. When the nurses give the residents medication, the tube feeding can be stopped, the medication given, they will flush the tubing, and if everything looks good, they can restart the feeding. To my knowledge, there is no reason to hold the feeding more than this after giving medication unless indicated. Facility policy titled Tube Feeding with review date of 9/2024 states in part but not limited to the following: Gastrostomy tubes are used when an alternate method of nutrition is needed. Continuous tube feedings are based upon a 22-hour consumption period or other time frame based on individual resident need per Registered Dietitian assessment and delivered over a 24-hour period. Facility policy titled Physicians Orders with last revision date of 01/2023 states in part but not limited to the following: physician orders are followed as written.

Based on observations, interviews, and record review, the facility failed to provide a credentialed certified respiratory staff, as required by state law, to perform respiratory assessment, treatment, and monitoring for residents requiring respiratory care for 3 of 19 (R67, R79, R149) residents reviewed for respiratory care in the sample of 58. The Immediate Jeopardy began on 01/27/2025 at 12:07 PM when V5 (Respiratory Technician/Student) was observed independently providing tracheostomy care to R149. V1 (Administrator) was notified on 01/29/2025 at 03:12 PM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on 02/03/2025 The surveyor conducted onsite investigation on 02/03/2025 to confirm the removal plan was implemented. V1 (Administrator) was informed that the Immediate Jeopardy was removed on 02/03/2025. Findings include: R67 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure, Nontraumatic Intracranial Hemorrhage, Dysphasia following Nontraumatic Intracerebral Hemorrhage, Neurocognitive Disorder with Lewy Body; Encounter for Attention to Tracheostomy, and Quadriplegia. R67's physician order dated 10/06/2024 reads in part, Tracheostomy tube Portex 6. R67's physician order dated 12/04/2024 reads in part, Oxygen: TP/TC 40% FiO2. R79 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure with Hypoxia, Dysphasia following Cerebral Infarction, Tracheostomy Status, Dementia, Encephalopathy, Generalized Anxiety Disorder, and Anoxic Brain Damage. R79's physician order dated 12/13/2024 reads in part, TRACH: Other: Flex cuffless, SIZE: 6. R79's physician order dated 12/13/2024 reads in part, Oxygen: Trach collar 40%. R149 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Respiratory Failure, Chronic Obstructive Respiratory Disease, Heart Failure, Epilepsy, Tracheostomy Status, and Anemia. R149's physician order dated 01/24/2025 reads in part, Trach: Shiley, Size: 6 FLEX. R149's physician order dated 01/24/2025 reads in part, VENTILATOR SETTINGS: Mode: A/C, Rate: 14 Tidal Volume: 450, PEEP: 5, FIO2: 40, Continuous? Yes. On 01/27/25 at 11:43 AM V4 (Respiratory Therapy Director) said, It's me and another staff, she's a student, working today (on the respiratory unit). There are 20 residents, 19 have been assessed as needing respiratory therapist attention. V5 (Respiratory Technician/Student) is not a student, but she is not certified yet. Some of our tasks, respiratory therapist, include suctioning, tracheostomy care, ventilator checks, assessments, responding to respiratory emergencies, and transporting tracheostomy dependent residents to the dialysis. On 01/27/25 at 12:07 PM Surveyor observed V5 (Respiratory Technician/Student) independently providing tracheostomy care to R149. V5 (Respiratory Technician/Student) said upon interview, I have 10 residents assigned to me today, in rooms 310-322. As a respiratory technician, I do assessments, tracheostomy care, I check vital signs, and I also give medications. On 01/27/25 at 01:37 PM Surveyor observed V5 (Respiratory Technician/Student) gathering tracheostomy care supplies and independently going into R79's room. Shortly after, upon leaving R79's room, V5 said, I just finish R79's tracheostomy care and will be giving medications, breathing treatment, to R67 next. On 01/27/25 at 01:40 PM V5 (Respiratory Technician/Student) said in the follow up interview, I've been working in the facility since January of 2022. At first, I was shadowing respiratory therapists to get my clinical experience; however, I have been working independently since January of 2023. I've always been a full-time employee. My assignment changes, essentially, I provide care to all residents on the respiratory unit. When I was initially hired (January of 2022), I wasn't told that I have to finish respiratory program within any time period. The facility administration recently started to push me to finish the program. I am supposed to graduate in June of 2025, and then I can register for the Certified Respiratory Therapist (CRT) test that will allow me to obtain my license. Upon observation, V5's employee badge does not designate V5 as a student. On 01/27/25 at 01:45 PM Surveyor observed V5 (Respiratory Technician/Student) independently administer medications consisted of breathing treatment to R67. R67's physician order dated 12/04/2024 reads in part, IPRATR/ALBUT 0.5MG-3MG/3ML NEB 3 ml via trach every 8 hours related to CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA. On 01/27/25 at 02:09 PM V4 (Respiratory Therapy Director) said in the follow up interview, The condition given to V5 (Respiratory Technician/Student) was 6 to 12 months to obtain the credentials to get respiratory certification, but it is not documented. The requirement to work in the facility as a respiratory therapist, is to have an active license. V5 hasn't obtained her license yet. I think she finished the respiratory program in December of 2024 but won't graduate until May of 2025, so there is no documentation to confirm that. There are no limitations as to what tasks V5 can perform as a respiratory staff at this point, V5 can do everything that's listed under respiratory therapist job description, such as assessments, tracheostomy care, and medication administration. V5 works independently and does not require supervision while completing her tasks. On 01/28/2025 10:52 AM V6 (Human Resources Director) said, I facilitate process of new hire orientation, employee relations, and corrective actions in the facility. I also run background checks and check licenses (upon hire only) to make sure to make sure new hired staff gave active licenses but don't check after the initial check. I was not here when V5 (Respiratory Technician/Student) was hired (January of 2022). V5 does not have respiratory therapy license. I've been made aware when I started in October of 2024 of it by V4 (Respiratory Therapy Director). When V4 brought it to my attention, I didn't do anything. Knowing now, that V5 doesn't have a license, I'll have to go through regulations and make sure she's not practicing respiratory therapist duties if she's not a respiratory therapist. On 01/28/2025 at 11:05 AM V7 (Regional Respiratory Program Director) said, V5 (Respiratory Technician/Student) does not have respiratory therapy license. V5 was originally hired as a student. V5 was allowed to work as she's completing her study. V5 is assigned with a licensed respiratory therapist while she's on the duty, she has not been working independently. There is never a time when she's worked solely. A licensed respiratory therapist should be available to V5 for any reference. The supervising staff should be on the same unit but does not have to have direct eyesight on the individual. V5 only does routine respiratory care. We gave V5 time to obtain her license until June of 2025. V5 has been a student since January of 2022. V5 has been passing medication, completing assessments and monitor respiratory therapy dependent residents under licensed respiratory therapist supervision since then (01/2022). We've been monitoring and supervising V5 for approximately two years now. V5's job responsibility is respiratory therapist job, but she's not allowed to do ventilator set up, testing, and changes to ventilator setting. The respiratory therapist job description doesn't differentiate specific job duties limited to respiratory technician. On 01/28/2025 at 11:24 AM V1 (Administrator) said, Respiratory department is new to me. When I started (October 2024), I was made aware we have a student working and that she should be supervised by a licensed respiratory staff. Licensed respiratory staff has to work with her on the same unit. I don't know the acceptable time frame for unlicensed personnel to complete the school and obtain their license. On 01/28/2025 at 1:27 PM In the follow up interview V1 (Administration) said, I was told that we need two respiratory therapists for each 12 hour shift. V5 is counted as one of the two respiratory therapists needed on the shift. On 01/28/2025 at 1:55 PM V7 (Regional Respiratory Program Director) said in the follow up interview, There is no particular calculation to come up with respiratory therapist to resident ratio, but we keep it under 1:14, so 1 respiratory therapist to 14 residents. The ratio was created by the company, but there is no federal or state standard for that. It seems reasonable. On 01/28/2025 at 01:56 PM V9 (Medical Director) said, All direct patient care staff have to be licensed in order to provide patient care. Unless they are students. If direct patient care staff consist of students, they should be directly supervised, in the supervisor's presence, when performing their tasks. Students cannot provide direct care by themselves. Students should identify themselves as a student. The resident safety is the number one concerns if care by unlicensed staff. Even licensed staff makes mistake, nonetheless, unlicensed. On 01/28/2025 at 2:00 PM surveyor asked V6 (Human Resources Director) to present active respiratory therapy licenses for all active respiratory therapist working in the facility. Shortly after, V6 (HR Director) brought everyone's but V10 (Respiratory Technician/Student) and said, V10 was hired under the same conditions as V5 and does not have a respiratory therapy license. On 01/29/2025 at 11:42 AM V7 (Regional Respiratory Director), V6 (Human Resource Director) and V4 (Respiratory Therapy Director) should be checking credentials every 2 years when licenses are due to be renewed, and active licenses should be in an employee file. The agreement was to have V5 and V10 obtain their credentials upon graduation, [DATE] for V10 and June 2025 for V5. Their respiratory program is three years I think, normally, the respiratory program is two years. They go to the same school. Surveyor clarified, how are V5 and V10 competent to complete assigned tasks and make acute care decisions in the respiratory setting, V7 (Regional Respiratory Director) said, V5 and V10 had 1 on 1 orientation upon hire, they have competence checks and in-services provided in the facility, and direct observation by V4 (Respiratory Therapy Director). Surveyor asked to define student appropriate respiratory tasks, V7 (Regional Respiratory Director) said, V5 and V10 are both students, are their responsibilities are done under supervision and consist of: oral and tracheal suctioning, general resident assessment that includes vital signs, oxygen levels, responding to alarms, responding emergencies, providing care to tracheal stoma, which consist of cleaning stoma site, and changing the dressing; and reporting any changes to the therapist and/or the nurse who works with them. V5 and V10 cannot do ventilator set up, testing and changes to ventilator setting. When asked why it is inappropriate for V5 and V10 do ventilator set up, testing, and changes to ventilator setting, V7 (Regional Respiratory Director) said, I know the answer to your question; however, refused to answer the question. V5's (Respiratory Technician/Student) most recent competency check done 09/23/2022 and most recent in-service done 03/16/2024. Neither training differentiates V5 as a student. V10's (Respiratory Technician/Student) most recent competency check done 01/25/2024 and most recent in-service done 03/08/2024. Neither training differentiates V10 as a student. R67's ventilator administration record dated 01/01/2025 to 01/27/2025 shows V5 (Respiratory Technician/Student) and V10 (Respiratory Technician/Student) completing respiratory assessment, treatment, and monitoring multiple times within the above time interval. R79's ventilator administration record dated 01/01/2025 to 01/30/2025 shows V5 (Respiratory Technician/Student) and V10 (Respiratory Technician/Student) completing respiratory assessment, treatment, and monitoring multiple times within the above time interval. R149's ventilator administration record dated 01/01/2025 to 01/30/2025 does not show observed tracheostomy care performed on 01/27/25 at 12:07 PM by V5 (Respiratory Technician/Student). Per electronic medical record legend, V5's initials are vc99, V10's initials are it13. R67's ventilator/aerosol flowsheets dated 01/01/2025, 01/07/2025, 01/10/2025, 01/13/2025, 01/16/2025, 01/19/2025, 01/21/2025, 01/24/2025, and 01/27/2025 show V5 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. R67's ventilator/aerosol flowsheets dated 01/10/2025, 01/11/2025, 01/18/2025, and 01/24/2025 show V10 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. R79's ventilator/aerosol flowsheets dated 01/01/2025, 01/05/2025, 01/13/2025, 01/16/2025, 01/18/2025, 01/19/2025, 01/21/2025, 01/24/2025, 01/26/2025, and 01/27/2025 show V5 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. R79's ventilator/aerosol flowsheets dated 01/10/2025, 01/11/2025, 01/18/2025, and 01/24/2025 show V10 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. R149's ventilator/aerosol flowsheets dated 01/01/2025, 01/04/2025, 01/05/2025, 01/07/2025, 01/10/2025, 01/13/2025, 01/16/2025, 01/25/2025, 01/26/2025, and 01/27/2025 show V5 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. R79's ventilator/aerosol flowsheets dated 01/11/2025, 01/18/2025, and 01/24/2025 show V10 (Respiratory Technician/Student) performing ventilator setting checks, providing tracheostomy care, completing respiratory assessment, and suctioning. August 2024 - January 2025 respiratory therapy schedule lists V5 (Respiratory Technician/Student) and V10 (Respiratory Technician/Student) as respiratory therapists with no assigned preceptor and no indication of student designation. The facility assessment Overall Staffing Needs shows, Respiratory Therapist Director 7a-7p - 1, Respiratory Therapist 7a-7p - 1, and Respiratory Therapist 7p-7a - 2. Staff list provided by the facility misrepresents, both V5 (Respiratory Technician/Student) and V10 (Respiratory Technician/Student) as Respiratory Therapists. Per record review, facility does not ensure accurate credentialed certified respiratory therapist to patient ratio by including students in the respiratory therapy schedule. V5's (Respiratory Technician/Student) healthcare worker registry lists V5 as Technical, Unlicensed Health Care personnel. V10's (Respiratory Technician/Student) healthcare worker registry lists V10 as Technical, Unlicensed Health Care personnel. The facility Respiratory Therapist job description signed by V5 (Respiratory Technician) on 01/17/2022 reads in part, Qualification: 1. Graduate of an accredited Respiratory Therapy program; 2. Respiratory Therapist certification is listed as Respiratory Care Practitioner in the State of Illinois; 3. Current License in good standing. The facility Respiratory Therapist job description signed by V10 (Respiratory Technician) on 04/27/2022 reads in part, Qualification: 1. Graduate of an accredited Respiratory Therapy program; 2. Respiratory Therapist certification is listed as Respiratory Care Practitioner in the State of Illinois; 3. Current License in good standing. Respiratory Care Practice Act reads in part, The purpose of the Act is to protect and benefit the public by setting standards of qualifications, education, training, and experience for those who seek to obtain a license and hold the title of respiratory care practitioner, to promote high standards of professional performance for those licensed to practice respiratory care in the State of Illinois, and to protect the public from unprofessional conduct by persons licensed to practice respiratory care. Licensed means that which is required to hold oneself out as a respiratory care practitioner as defined in this Act. Proximate supervision means a situation in which an individual is responsible for directing the actions of another individual in the facility and is physically close enough to be readily available, if needed, by the supervised individual. Respiratory care education program means a course of academic study leading to eligibility for registry or certification in respiratory care. The training is to be approved by an accrediting agency recognized by the Board and shall include an evaluation of competence through a standardized testing mechanism that is determined by the Board to be both valid and reliable. Sec. 20. Restrictions and limitations. (a) No person shall, without a valid license as a respiratory care practitioner (i) hold himself or herself out to the public as a respiratory care practitioner; (ii) use the title respiratory care practitioner; or (iii) perform or offer to perform the duties of a respiratory care practitioner. Sec. 50. Qualifications for a license. (a) A person is qualified to be licensed as a licensed respiratory care practitioner, and the Department may issue a license authorizing the practice of respiratory care to an applicant who: (1) has applied in writing on the prescribed form and has paid the required fee; (2) has successfully completed a respiratory care training program approved by the Department; (3) has successfully passed an examination for the practice of respiratory care authorized by the Department, within 5 years of making application; and (4) has paid the fees required by this Act. A person may practice as a respiratory care practitioner if he or she has applied in writing to the Department in form and substance satisfactory to the Department for a license as a licensed respiratory care practitioner and has complied with all the provisions under this Section except for the passing of an examination to be eligible to receive such license, until the Department has made the decision that the applicant has failed to pass the next available examination authorized by the Department or has failed, without an approved excuse, to take the next available examination authorized by the Department or until the withdrawal of the application, but not to exceed 6months. An applicant practicing professional registered respiratory care under this subsection (c) who passes the examination, however, may continue to practice under this subsection (c) until such time as he or she receives his or her license to practice or until the Department notifies him or her that the license has been denied. No applicant for licensure practicing under the provisions of this subsection (c) shall practice professional respiratory care except under the direct supervision of a licensed health care professional or authorized licensed personnel. In no instance shall any such applicant practice or be employed in any supervisory capacity. The Immediate Jeopardy that began on 01/27/2025 was removed and the deficient practice corrected on 02/03/2025 when the facility took the following actions to remove the Immediacy and correct the noncompliance. Corrective Action Taken: 1. Affected resident corrective actions. . R67, R79 and R149 were provided with respiratory care and assessment. There are no negative effects noted resulting from the alleged deficiency. The assessment and respiratory care were completed by a licensed RT (respiratory therapist) on 1/29/25. . Currently, there is a total of 18 residents identified who receive respiratory care: 12 are on ventilators and 6 residents have tracheostomy. Respiratory assessments on all current 18 residents were completed by a licensed RT. There are no concerns identified. This was completed on 1/29/2025. . The Medical Director who is also the physician of R67, R79 and R149 was notified of the alleged deficiency by the DON (director of nursing) on 1/29/25. No new order was obtained. Additionally, each ventilator residents responsible party was notified of the alleged deficiency on 1/30/25. 1. Immediate Actions and Actions to prevent recurrence. (Initiated on 1/29/2025 and will continue until all credentialed staff licenses are verified and confirmed active and current.) The facility took the following immediate actions to address the citation and prevent any residents from suffering an adverse outcome. . The two (2) unlicensed respiratory staff (Staff A and Staff B) were immediately removed from schedule and will be terminated from their role are a respiratory aide effective immediately. . Staff A's last day of schedule was 1/27/2025 . Staff B'S last day of schedule was 1/25/2025 .2. The Respiratory Program Director, The Director of Human Resources and the Administrator were provided with education by the Regional Director of to ensure that each newly hired credentialed staff meets the facility's requirements for hiring: Have a valid and active license related to their job description and responsibilities. This immediate action was initiated and completed on January 29, 2025. . The Regional Director of Operations and the [NAME] President of Clinical services checked and verified that all respiratory therapists have a valid and active license. This immediate action was initiated and completed on January 29, 2025. . Quarterly, the Human Resources Director will also review the licenses of all RT to ensure compliance. . To ensure qualified certified respiratory staff are available to complete respiratory assessment, treatment, and monitoring for residents requiring respiratory care, the Director of RT and/or Regional RT will continue to develop a biweekly schedule. In addition, an on-call schedule will also be created to ensure a licensed RT is available. Additionally, the facility has two current contracts with staffing agencies to provide supplemental licensed Respiratory Therapists to cover call in, vacations or vacancies. The RT schedule will also be reviewed with the facility Administrator. Any concern related to staffing will be reported to Director of RT and/or Regional RT and will be addressed immediately. . To ensure that the Respiratory Therapist to Patient ratio is always a sufficient ratio, the facility Administrator and Director of Nursing will review the Respiratory Therapist ratio on a daily basis at the facility's morning meeting. . The Administrator provided education to the Director of Nursing and Director of Staffing to ensure that any Nurses, CNAs, and Respiratory Therapist allowed to work in the facility from any outside agency have the appropriate valid and active license before working on the floor. (This immediate action was initiated on January 29, 2025) To ensure compliance, the Administrator will review newly hired licensed professional staff employee files to ensure that they: Have a valid and active license and credentials related to their job description. This will be completed prior to the first day of work of the employee. 3 Any identified concern will be addressed immediately and will also be discussed during the weekly Ad-hoc QAPI. . To ensure that the Respiratory Therapist licenses do not lapse, the Human Resource Director will send out communication on renewing their licenses 3 months prior to their licenses expiring. Any Respiratory Therapist that does not renew their license one (1) week prior to their expiration date will be removed from the schedule. The Administrator will monitor for overall compliance. 1. The facility will reinforce the following process. . The Director of Human Resources will conduct audits on newly hired licensed professionals to identify non-compliance. Their licenses will be reviewed and verified during the audit. (This will be initiated on 1/30/2025 and will be done for the next four weeks.) . All results of the audits will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits to determine if additional interventions are necessary to ensure compliance. . The Administrator and Director of Human resources will monitor the completion of this plan of removal. Date Facility Asserts Likelihood for Serious Harm No Longer Exists

Based on interviews and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for a resident who was experiencing a change in condition for 4 of 4 (R61, R67, R79, R149) of residents reviewed for services provided to meet professional standards in the sample of 58. This failure resulted in R61's unnecessarily prolonged physical distress and anxiety lasting until the resident made arrangements to be taken to the hospital, where she was diagnosed with pneumonia and influenza A Findings include: 1. R61 is a [AGE] year-old female with medical diagnoses listed in part, but not limited to chronic obstructive pulmonary disease (COPD); acute respiratory failure with hypoxia; asthma; influenza due to identified novel influenza A virus with other respiratory manifestations; narcolepsy; morbid obesity; and adjustment disorder with anxiety. On 01/29/2025 at 11:30 AM, R61 said that on 01/12/2025, sometime during the night, she began feeling bad, physically. R61 said she felt very drowsy and was coughing a lot of phlegm, making it hard for her to breath. R61 said she, then, decided she needed to go to the emergency room of the local hospital; so, she asked the nurse on duty to call 911 on her behalf. R61 said she did not remember the name of the nurse she spoke to, but the nurse told her she was not going to call 911 for her because there was nothing wrong with her, and she could get treated at the facility. R61 also said that the following morning, she did not feel any better; so, she asked the same nurse to call 911, and, again, she told her, No. R61 added that the nurse told her she had no coughing medicine prescribed, so, she would have to wait until the doctor ordered it for her. R61 said she, then, fell asleep, and when she woke up, she let V24 (Family Member) know that she wanted to go to the hospital because she felt bad; so, she, eventually, called 911, herself, on 01/13/2025 and was taken to the local hospital. Lastly, R61 said V24 called the facility, and spoke with V2 (Director of Nursing), adding that V24 told her V2 didn't know what to say, and that V2 told V24 V2 would speak to the nurses at the facility but the nurses did what they wanted to do. On 01/29/2025 at 1:01 PM, V2 said R61 was complaining of knee pain on 01/13/2025 and requested to go out. V2 said R61 was given pain medication. V2 said that R61 called 911 all the time, and that the facility was warned R61, and the facility would be cited and fined for line abuse in the future. V2 said that when R61 called 911 on 01/13/2025, there was no reason for her to be sent out. V2 said she did not know how long R61 stayed at the hospital but that she tested positive for the flu while there. V2 said there were no new medications prescribed for R61 while at the hospital. V2 said she was unaware of any other medical concerns for R61, other than having the flu. Lastly, V2 said the facility staff did not share with her any concerns R61 had on 01/13/2025 about her health. On 01/29/2025 at 3:18 PM, V2 said R61 called 911 because she preferred having therapy at the hospital. Per a progress note found in R61's electronic health record and dated 01/13/2025 at 7:37 PM, by V19 (LPN), R61 complained of body pain; V19 gave R61 Acetaminophen 650 mg at 6:30 PM; at approximately 6:40 PM, staff notified V19 that R61 was in her bedroom on the phone with 911; the fire department arrived at 6:50 PM; proper paperwork was given to the team lead; R61 was alert times four; R61 was being transferred to the local hospital via a stretcher; and V19 informed the nurse supervisor on duty. Per progress note found in R61's electronic health record and dated 01/14/2025 at 7:16 AM, by V25 (LPN), V25 noted to have spoken with a staff member at the local hospital where R61 was taken to the hospital, and was told R61 had been admitted with pneumonia due to infectious organisms and had tested positive for the flu. Per a progress note found in R61's electronic health record and dated 01/15/2025 at 10:36 PM, R61 arrived back to the facility in stable condition via a private ambulance and was placed on isolation precautions for influenza. Per R61's electronic health record, no documentation of a head-to-toe physical assessment performed on R61, either on 01/12/2025 or 01/13/2025 was found. Also, no documentation of R61 complaining of knee pain on 01/13/2025, as stated by V2, was found. The only documentation found of an R61 complaint was the progress note by V19 on 01/13/2025 that stated R61 complained of body pain. Per R61's hospital discharge documents dated 01/15/2025, two new medications were prescribed for R61 at the hospital; the antibiotic Cefuroxime 500 mg tablet, one tablet by mouth two times daily for five days; and Oseltamivir 75 mg capsule, one capsule by mouth every twelve hours for four days. Per R61's January 2025 medication administration record, Cefuroxime 500 mg was given to R61 twice per day from 01/16/2025 to 01/20/2025 and Oseltamivir 75 mg was given to R61 twice per day from 01/16/2025 to 01/19/2025. The facility Registered Nurse/Licensed Practical Nurse job description reads in part, Essential Duties: Recognize significant changes in the condition of residents and take necessary action. 2. R67 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure, Nontraumatic Intracranial Hemorrhage, Dysphasia following Nontraumatic Intracerebral Hemorrhage, Neurocognitive Disorder with Lewy Body; Encounter for Attention to Tracheostomy, and Quadriplegia. R67's physician order dated 10/06/2024 reads in part, Tracheostomy tube Portex 6. R67's physician order dated 12/04/2024 reads in part, Oxygen: TP/TC 40% FiO2. R79 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure with Hypoxia, Dysphasia following Cerebral Infarction, Tracheostomy Status, Dementia, Encephalopathy, Generalized Anxiety Disorder, and Anoxic Brain Damage. R79's physician order dated 12/13/2024 reads in part, TRACH: Other: Flex cuffless, SIZE: 6. R79's physician order dated 12/13/2024 reads in part, Oxygen: Trach collar 40%. R149 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Respiratory Failure, Chronic Obstructive Respiratory Disease, Heart Failure, Epilepsy, Tracheostomy Status, and Anemia. R149's physician order dated 01/24/2025 reads in part, Trach: Shiley, Size: 6 FLEX. R149's physician order dated 01/24/2025 reads in part, VENTILATOR SETTINGS: Mode: A/C, Rate: 14 Tidal Volume: 450, PEEP: 5, FIO2: 40, Continuous? Yes. On 01/27/25 at 11:43 AM V4 (Respiratory Therapy Director) said, It's me and another staff, she's a student, working today (on the respiratory unit). There are 20 residents, 19 have been assessed as needing respiratory therapist attention. V5 (Respiratory Technician/Student) is not a student, but she is not certified yet. Some of our tasks, respiratory therapist, include suctioning, tracheostomy care, ventilator checks, assessments, responding to respiratory emergencies, and transporting tracheostomy dependent residents to the dialysis. On 01/27/25 at 12:07 PM Surveyor observed V5 (Respiratory Technician/Student) independently providing tracheostomy care to R149. V5 (Respiratory Technician/Student) said upon interview, I have 10 residents assigned to me today, in rooms 310-322. As a respiratory technician, I do assessments, tracheostomy care, I check vital signs, and I also give medications. On 01/27/25 at 01:37 PM Surveyor observed V5 (Respiratory Technician/Student) gathering tracheostomy care supplies and independently going into R79's room. Shortly after, upon leaving R79's room, V5 said, I just finish R79's tracheostomy care and will be giving medications, breathing treatment, to R67 next. On 01/27/25 at 01:40 PM V5 (Respiratory Technician/Student) said in the follow up interview, I've been working in the facility since January of 2022. At first, I was shadowing respiratory therapists to get my clinical experience; however, I have been working independently since January of 2023. I've always been a full-time employee. My assignment changes, essentially, I provide care to all residents on the respiratory unit. When I was initially hired (January of 2022), I wasn't told that I have to finish respiratory program within any time period. The facility administration recently started to push me to finish the program. I am supposed to graduate in June of 2025, and then I can register for the Certified Respiratory Therapist (CRT) test that will allow me to obtain my license. Upon observation, V5's employee badge does not designate V5 as a student. On 01/27/25 at 01:45 PM Surveyor observed V5 (Respiratory Technician/Student) independently administer medications consisted of breathing treatment to R67. On 01/28/2025 10:52 AM V6 (Human Resources Director) said, I facilitate process of new hire orientation, employee relations, and corrective actions in the facility. I also run background checks and check licenses (upon hire only) to make sure to make sure new hired staff gave active licenses but don't check after the initial check. I was not here when V5 (Respiratory Technician/Student) was hired (January of 2022). V5 does not have respiratory therapy license. I've been made aware when I started in October of 2024 of it by V4 (Respiratory Therapy Director). When V4 brought it to my attention, I didn't do anything. Knowing now, that V5 doesn't have a license, I'll have to go through regulations and make sure she's not practicing respiratory therapist duties if she's not a respiratory therapist. On 01/28/2025 at 11:05 AM V7 (Regional Respiratory Program Director) said, V5 (Respiratory Technician/Student) does not have respiratory therapy license. V5 was originally hired as a student. V5 was allowed to work as she's completing her study. V5 is assigned with a licensed respiratory therapist while she's on the duty, she has not been working independently. There is never a time when she's worked solely. A licensed respiratory therapist should be available to V5 for any reference. The supervising staff should be on the same unit but does not have to have direct eyesight on the individual. V5 only does routine respiratory care. We gave V5 time to obtain her license until June of 2025. V5 has been a student since January of 2022. V5 has been passing medication, completing assessments and monitor respiratory therapy dependent residents under licensed respiratory therapist supervision since then (01/2022). We've been monitoring and supervising V5 for approximately two years now. V5's job responsibility is respiratory therapist job, but she's not allowed to do ventilator set up, testing, and changes to ventilator setting. The respiratory therapist job description doesn't differentiate specific job duties limited to respiratory technician. On 01/28/2025 at 11:24 AM V1 (Administrator) said, Respiratory department is new to me. When I started (October 2024), I was made aware we have a student working and that she should be supervised by a licensed respiratory staff. Licensed respiratory staff has to work with her on the same unit. I don't know the acceptable time frame for unlicensed personnel to complete the school and obtain their license. On 01/28/2025 at 01:56 PM V9 (Medical Director) said, All direct patient care staff have to be licensed in order to provide patient care. Unless they are students. If direct patient care staff consist of students, they should be directly supervised, in the supervisor's presence, when performing their tasks. Students cannot provide direct care by themselves. Students should identify themselves as a student. The resident safety is the number one concerns if care by unlicensed staff. Even licensed staff makes mistake, nonetheless, unlicensed. On 01/28/2025 at 2:00 PM surveyor asked V6 (Human Resources Director) to present active respiratory therapy licenses for all active respiratory therapist working in the facility. Shortly after, V6 (HR Director) brought everyone's but V10 (Respiratory Technician/Student) and said, V10 was hired under the same conditions as V5 and does not have a respiratory therapy license. On 01/29/2025 at 11:42 AM V7 (Regional Respiratory Director), V6 (Human Resource Director) and V4 (Respiratory Therapy Director) should be checking credentials every 2 years when licenses are due to be renewed, and active licenses should be in an employee file. The agreement was to have V5 and V10 obtain their credentials upon graduation, [DATE] for V10 and June 2025 for V5. Their respiratory program is three years I think, normally, the respiratory program is two years. They go to the same school. Surveyor clarified, how are V5 and V10 competent to complete assigned tasks and make acute care decisions in the respiratory setting, V7 (Regional Respiratory Director) said, V5 and V10 had 1 on 1 orientation upon hire, they have competence checks and in-services provided in the facility, and direct observation by V4 (Respiratory Therapy Director). Surveyor asked to define student appropriate respiratory tasks, V7 (Regional Respiratory Director) said, V5 and V10 are both students, are their responsibilities are done under supervision and consist of: oral and tracheal suctioning, general resident assessment that includes vital signs, oxygen levels, responding to alarms, responding emergencies, providing care to tracheal stoma, which consist of cleaning stoma site, and changing the dressing; and reporting any changes to the therapist and/or the nurse who works with them. V5 and V10 cannot do ventilator set up, testing and changes to ventilator setting. When asked why it is inappropriate for V5 and V10 do ventilator set up, testing, and changes to ventilator setting, V7 (Regional Respiratory Director) said, I know the answer to your question; however, refused to answer the question. V5's (Respiratory Technician/Student) healthcare worker registry lists V5 as Technical, Unlicensed Health Care personnel. V10's (Respiratory Technician/Student) healthcare worker registry lists V10 as Technical, Unlicensed Health Care personnel. The facility Respiratory Therapist job description signed by V5 (Respiratory Technician) on 01/17/2022 reads in part, Qualification: 1. Graduate of an accredited Respiratory Therapy program; 2. Respiratory Therapist certification is listed as Respiratory Care Practitioner in the State of Illinois; 3. Current License in good standing. The facility Respiratory Therapist job description signed by V10 (Respiratory Technician) on 04/27/2022 reads in part, Qualification: 1. Graduate of an accredited Respiratory Therapy program; 2. Respiratory Therapist certification is listed as Respiratory Care Practitioner in the State of Illinois; 3. Current License in good standing. Respiratory Care Practice Act reads in part, The purpose of the Act is to protect and benefit the public by setting standards of qualifications, education, training, and experience for those who seek to obtain a license and hold the title of respiratory care practitioner, to promote high standards of professional performance for those licensed to practice respiratory care in the State of Illinois, and to protect the public from unprofessional conduct by persons licensed to practice respiratory care. Licensed means that which is required to hold oneself out as a respiratory care practitioner as defined in this Act. Proximate supervision means a situation in which an individual is responsible for directing the actions of another individual in the facility and is physically close enough to be readily available, if needed, by the supervised individual. Respiratory care education program means a course of academic study leading to eligibility for registry or certification in respiratory care. The training is to be approved by an accrediting agency recognized by the Board and shall include an evaluation of competence through a standardized testing mechanism that is determined by the Board to be both valid and reliable. Sec. 20. Restrictions and limitations. (a) No person shall, without a valid license as a respiratory care practitioner (i) hold himself or herself out to the public as a respiratory care practitioner; (ii) use the title respiratory care practitioner; or (iii) perform or offer to perform the duties of a respiratory care practitioner. Sec. 50. Qualifications for a license. (a) A person is qualified to be licensed as a licensed respiratory care practitioner, and the Department may issue a license authorizing the practice of respiratory care to an applicant who: (1) has applied in writing on the prescribed form and has paid the required fee; (2) has successfully completed a respiratory care training program approved by the Department; (3) has successfully passed an examination for the practice of respiratory care authorized by the Department, within 5 years of making application; and (4) has paid the fees required by this Act. A person may practice as a respiratory care practitioner if he or she has applied in writing to the Department in form and substance satisfactory to the Department for a license as a licensed respiratory care practitioner and has complied with all the provisions under this Section except for the passing of an examination to be eligible to receive such license, until the Department has made the decision that the applicant has failed to pass the next available examination authorized by the Department or has failed, without an approved excuse, to take the next available examination authorized by the Department or until the withdrawal of the application, but not to exceed 6months. An applicant practicing professional registered respiratory care under this subsection (c) who passes the examination, however, may continue to practice under this subsection (c) until such time as he or she receives his or her license to practice or until the Department notifies him or her that the license has been denied. No applicant for licensure practicing under the provisions of this subsection (c) shall practice professional respiratory care except under the direct supervision of a licensed health care professional or authorized licensed personnel. In no instance shall any such applicant practice or be employed in any supervisory capacity.

Based on interview and record review, the facility failed to timely assess and respond to a significant change in condition for 1 (R61) of 1 resident reviewed for acute medical changes from the sample of 58. This failure resulted in the delay of care to send the resident to the emergency department, failure to assess the resident's medical condition after pleas for hospitalization , resulting in prolonged physical distress, pain, and anxiety for nineteen hours, after which she was admitted for pneumonia and influenza. Findings include: R61 is a [AGE] year-old female with medical diagnoses listed in part, but not limited to chronic obstructive pulmonary disease (COPD); acute respiratory failure with hypoxia; asthma; and influenza due to identified novel influenza A virus with other respiratory manifestations. On 01/29/2025, during interview, at 11:30 AM: R61 said that on 01/12/2025, at about 11:00 PM, she began feeling bad, physically. R61 said she felt very drowsy and was coughing up a lot of phlegm, making it hard for her to breath. R61 said it was then that she decided she needed to go to the emergency room of the local hospital; so, she asked the nurse on duty to call 911 on her behalf. R61 said she did not remember the name of the nurse she spoke to, but the nurse told her she was not going to call 911 for her because there was nothing wrong with her, and she could get treated at the facility. R61 also said that the following morning, she did not feel any better; so, she asked the same nurse to call 911, and, again, she told her, No. R61 added that the nurse told her she had no cough medicine prescribed, so, she would have to wait until the doctor ordered it for her. R61 said she, fell asleep, and when she woke up, she let V24 (Family Member) know that she wanted to go to the hospital because she did not feel well; so, she, eventually, called 911, herself, on 01/13/2025 and was taken to the local hospital. R61 said that V24 called the facility and spoke to V2 (DON) who told her that the facility nurses always did what they wanted to do. On 01/29/2025 at 1:01 PM, V2 said R61 was given pain medication, and that the resident called 911 all the time; so, the facility was warned by the local emergency services they would be fined for abusing 911 services. V2 added that when R61 called 911 on 01/13/2024, there was no reason for her to be sent out, and that her staff did not inform her of R61's health concerns or need for urgent medical care. Progress note dated 01/13/2025 at 7:37 PM by V19 (LPN), noted R61 complained of body pain; V19 gave R61 Acetaminophen 650 mg at 6:30 PM; at approximately 6:40 PM, staff notified V19 that R61 was in her bedroom on the phone with 911; the fire department arrived at 6:50 PM; proper paperwork was given to the team lead; R61 was alert times four; R61 was being transferred to the local hospital via a stretcher; and V19 informed the nurse supervisor on duty. Surveyor made several calls to a phone number provided by the facility to interview V19, but there was no reply. Message was also left, with no response. Progress note dated 01/14/2025 at 7:16 AM by V25 (LPN) noted V25 spoke with a staff member at the local hospital where R61 was taken and was told R61 had been admitted with pneumonia due to infectious organisms and had tested positive for the flu. Progress note dated 01/15/2025 at 10:36 PM noted R61 arrived back to the facility in stable condition via a private ambulance and was placed on isolation precautions for influenza. R61's electronic health record revealed no documentation of a head-to-toe physical assessment performed on R61, either on 01/12/2025 or 01/13/2025 by the facility staff. Also, no documentation of R61 complaining of knee pain on 01/13/2025, as stated by V2, was found. The only documentation found of an R61 complaint was the progress note by V19 on 01/13/2025 that stated R61 complained of body pain. R61's hospital discharge papers dated 01/15/2025, noted two new medications were prescribed for R61 at the hospital; the antibiotic Cefuroxime 500 mg tablet, one tablet by mouth two times daily for five days; and Oseltamivir 75 mg capsule, one capsule by mouth every twelve hours for four days. R61's January 2025 medication administration record showed Cefuroxime 500 mg was given to R61 twice per day from 01/16/2025 to 01/20/2025 and Oseltamivir 75 mg was given to R61 twice per day from 01/16/2025 to 01/19/2025. R61's care plan, dated 01/09/2025, noted one focus addressed R61's potential risk for difficulty in breathing related to COPD, asthma, and respiratory failure. The care plan goal stated respiratory symptoms would be managed through the next review. The intervention stated among other things, that the nursing staff would monitor R61 for lung sounds and assess respiratory status. No documentation of monitoring for lung sounds or assessment of respiratory status was found for 01/12/2025 or 01/13/2025 in R62's electronic health record. The facility's Change in Resident Condition policy, last reviewed October 2024, stated, Nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's physical, mental or emotional status. No documentation was found in R61's electronic health record indicating the nursing staff assessed R61 after she told them she was not feeling well on 01/12/2025 and 01/13/2025, nor was any documentation found indicating the facility notified R61's physician or nurse practitioner of her change in condition. R61's antibiotic therapy evaluation, dated 01/18/2025, stated R61's reason for antibiotic therapy was lower respiratory infection (Pneumonia, Bronchitis), with cough and congestion as the signs and symptoms. This documentation confirmed that R61 had a reasonable expectation for requesting help from the facility staff, prior to calling 911herself to be evaluated for emergent intervention on 01/13/2025. Prior calls to 911 from R61 should not deter the staff from performing a physical assessment, including monitoring R61 for lung sounds and assessing respiratory status to confirm an emergent situation; and notifying the physician regarding a change of condition as per the facility policy and R61's care plan, which provides for her present diagnosis of chronic obstructive pulmonary disease; acute respiratory failure with hypoxia; and asthma.

Based on interview and record review, the facility failed to follow their mechanical lift policy by not keeping the base in the widest/opened position when lowering/transferring a resident with the mechanical lift. This affected one of three residents (R3) reviewed for safety when using the mechanical lift for transfers. This failure resulted in R3 hitting his head hard on the floor sustaining an acute subdural hematoma . Findings include: R3 was diagnosed with morbid (severe) obesity and need for assistance with personal care. Care plan initiated on 11/15/2024 documents: R3 has inability to self-transfer related to decrease muscle tone and comorbidities. R3 is a mechanical lift for transfers. Care plan initiated on 11/18/2024 documents: R3 is at risk for falls weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/neurological deficit. Nursing note dated 12/9/24 documents R3 fell on the chair while two certified nursing assistance (CNA) put him on the chair. R3 hit his head on the floor. On 1/2/25 at 12:43PM, V4 (cna) said, R3 was removed from bed via mechanical lift. There was not enough space in R3's room to put R3 into his dialysis chair. V4 said, V5 (cna) and herself rolled R3 to the hallway on the lift in order to put R3 in his dialysis chair. R3 was in the sling on the mechanical lift with his hand in his lap. V4 said, we lowered R3 to the chair. R3 started to fidget as he was being lowered. R3 did not keep his hands inside of the sling or on his lap. R3 hands was moving around like he was nervous. R3 was top heavy. R3 and his chair fell backwards. R3 hit his head hard on the floor. The mechanical lift legs were closed when R3 was being lowered to the chair. On 1/2/25 at 1:03PM, V2 (don) said, she saw R3 was on the floor with his body inside the mechanical lift sling with the machine on his side. V2 said, she could not recall if the machine was on the left or right side of R3. R3's buttock was in dialysis chair. R3's head was on the ground maybe by three inches above the back of the chair. R3 was assessed on the ground. R3 was on his back, denied pain, reported hitting the back of his head and denied loss of consciousness. A pillow was place under R3's head for comfort. 911 was called. The emergency medical techs couldn't get R3 up off the floor. They called the fire department. It took seven people to get R3 off the ground. V2 said, the root cause of the fall was when R3 took his arms out of the sling, once his buttock hit the chair and attempted to scoot/push himself backwards while holding on to the sides of the chair. R3 was scooting left and right resulting in his chair falling backwards when staff was lowering him. On 1/2/25 at 1:55PM, V5 (cna) said, R3 was scared and nervous to go onto the mechanical lift. R3 kept jumping back. R3 was heavy. V5 said, as V4 and herself were lowering R3 down to the chair, positioning his body in the chair, R3 jumped a few times and R3 fell . The mechanical lift fell with R3. R3 hit the floor. V5 said, she can't recall if the legs on the lift were opened or closed. On 1/7/25 at 3:16pm, V2 (don) said, she expect her staff to follow the mechanical lift policy. Hospital paperwork dated 12/10/24 documents R3 presents after a fall with closed head trauma and has an acute subdural hematoma. Mechanical lift owner's manual documents: During lifting or lowering, whenever possible, always keep the base off the lift in the widest position. Mechanical lift policy dated 10/2024 documents: Spread the legs of the machine around the chair or under the bed.

Based on interview and record review, the facility failed to prevent and protect a resident (R1) from resident-to-resident physical abuse. This failure affected one (R1) resident out of four residents reviewed for abuse. As a result of this failure, R2 hit R1 in the face with a remote control resulting in R1 sustaining facial lacerations with bleeding, requiring medical attention. Findings include: Facility reported incident (FRI) dated 12/2/2024 documents: R1 reported to staff that he was involved in a physical altercation with his roommate R2. R1's face sheet dated 12/23/2024 documents that R1 is an [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, anxiety disorder, depression, and suicidal ideations. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 10, which suggests R1 is moderately cognitively impaired. On 12/23/2024, at 10:50 AM, R1 stated, I argued with someone here, one of the residents. We did not hit each other but we argued. He came in my room, and he takes things. We did not hit each other. A lady came when we were arguing and stopped it from getting physical. It almost did get physical. I did not hit him, and he did not hit me. Since then, he has not come in my room when I am here. I do not know if he has come in when I am not here. I just want him to respect me and my room and my things. Resident was clean and well groomed. Resident was up walking in room. No foul odors noted. R1's nurses note dated 12/2/2024 documents: This resident came to the nurse's station and said his roommate was next to bed and was holding the remote control. There was a skin issue noted to bridge of nose and under chin. Area cleaned and bacitracin applied. Family notified. R2's face sheet dated 12/23/2024 documents that R2 is a [AGE] year-old resident with diagnoses including but not limited to: Wernicke's encephalopathy, unspecified dementia, anxiety disorder, and alcohol abuse. R2's Minimum Data Set (MDS) dated [DATE] documents that R2 has a Brief Interview for Mental Status (BIMS) score of 8, which suggests R1 is moderately cognitively impaired. R2's nursing progress note dated 12/2/2024 documents: Note Text: The resident had an exchange of words that allegedly ended in a physical altercation with co-peer as evidenced by the co-peer resident---- stating that the resident hit him in the face with the remote controller. -----Nurse practitioner notified. New order to send the resident to hospital for psychiatric evaluation. Orders placed in electronic medical record and carried out. Transport services called to escort the resident. Family notified. Director of nursing aware. R2's social service progress note dated 12/2/2024 documents: Note Text: WELL-BEING CHECK 1/3: Social Services met with R2, following an altercation with a co-peer. R2 stated that he was upset because his co-peer (R1) unplugged his television. Social services offered to refer the resident (R2) for one-on-one counseling services; resident (R2) declined. Resident (R2) stated that they feel safe in the facility. Social Services will follow-up. R2's Petition for involuntary/judicial admitted d 12/2/2024 documents: R2 is a [AGE] year-old male who exhibited physical aggression towards another resident. It included striking the other resident with a remote resulting in medical intervention. Resident has a MHdx (mental health diagnosis) including dementia, anxiety disorder and alcohol abuse. Due to the mention behaviors resident is placing himself in harm's way and others and requires involuntary psy (psychiatric) admission. On 12/23/2024, at 11:11 AM, V7 Certified Nursing Assistant (CNA) stated, I was here when R1 and R2 got into an argument. R1 had blood on his face. R2 had a remote control in his hand. I was at the nurse's station when that happened. The nurse assessed him, management came up here. R2 had the remote control in his hand and said he didn't do it. R2 got sent out to the hospital. I don't remember who the nurse was or when it was. It was probably a couple weeks ago. I am not sure if that was the only time they got into it. The rooms got changed that day. Social services, Director of Nursing, and Administrator all came up here. On 12/23/2024, at 11:24 AM V10 Psychiatric rehabilitation services coordinator stated, I was in the building when R2 and R1 got into an argument. Based off what both individuals stated, it was ultimately an argument over the TV in their bedroom. R2 stated, R1 unplugged the television. R1 stated, R2 unplugged the television. It ultimately got physical. There was an altercation and one resident got sent out to hospital. R2 used the remote to hit R1. R1 had blood on his face, it was cleaned up by the time I seen R1. R2 got sent out. Wound care nurse took care of R1's face. I had to have V3 (Social Service Director) here to translate for R1. On 12/23/2024, at 11:32 AM, V11 Licensed Practical Nurse (LPN)/wound care nurse stated, when R1 and R2 got in an altercation, I assisted with wound care on R1's face. R1 was bleeding from the nose. R1 had two small marks one on bridge of nose and one above left eyebrow. I just cleaned it up. It stopped bleeding right away. There was no need for a dressing. There was no need to send R1 out to the hospital. R1 did not tell me what happened. R1 told me the guy (R2) was upset about the tv but did not describe how R1 was bleeding. I have never observed any altercations between R1 and R2 before. On 12/23/2024, at 11:44 AM, V12 Licensed Practical Nurse (LPN) stated, I was here on floor orientation the day R1 and R2 had an altercation. I recall that R1 came to the desk and had blood on his face. He really didn't say anything at first. We got the interpreter V3 (Social Service Director) and encouraged R1 to speak about it, and R1 said his roommate (R2) hit him in the face with the remote control. We kept them away from each other, notified the Director of Nursing (DON) who came right up, and treatment nurse came up and cleaned up R1's face. R2 got sent out to the hospital. On 12/23/2024, at 11:49 AM, V3 Social Service Director stated, I was here the day R1 and R2 got into an argument. It did go from verbal argument to altercation with a remote control. R1 got hit in the face with a TV remote from R2. I did interpret for R1. R1 said he got hit by a microphone. I was not present when R1 was bleeding from the face. We sent R2 out for psychiatric evaluation. On 12/23/2024, at 2:18 PM V2 Director of Nursing (DON) stated, Regarding R2 and R1, I was in the building the day of altercation. My understanding of what happened is that the TV was too loud and one of the residents was trying to get the remote from the other resident to turn the TV down. The certified nursing assistant or nurse heard it and broke it up immediately. Social services were notified and did an immediate petition for R2. I think R2 was trying to get the remote away from R1 and remote hit R1 in the face. R1 had a little scratch on his face, we called the wound care down and she cleaned R1's face and she put bacitracin on it. When surveyor asked V2 if there was anything that could have been done to prevent this from happening V2 stated, we encourage residents to come out to activities. Sometimes they like to take a nap in the afternoons. Sometimes they refuse so we try to do person centered care. I mean education could have been done regarding TV's to possibly prevent this. Education on TV volume level. I think education was done, maybe reinforcement of education could have been done. I know we always encourage them to come out of room for activities. Abuse policy and prevention program 2022 dated 10-22 documents: Abuse policy This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: - Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. - Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines)

Based on interview and record review the facility failed to prevent an incident of staff to resident mental abuse. This affected one of three residents (R5) reviewed for mental abuse. This resulted in V9 (Activity Aide) pulling a wig off R5's head after a disagreement. R5 said she felt humiliated and embarrassed. Findings include: R5's MDS dated [DATE] denotes BIMS score of 15. On 8/6/24 at 2:20 pm, R5 observed alert and oriented to person, place, and time and situation. R5 said that V9 (Activity Aide) snatched her wig off. R5 said V9 was upset because she (R5) had borrowed a portable speaker from a friend that V9 wanted to borrow. R5 said V9 told her (R5) that she (R5) was selfish and an inconsiderate person for borrowing the speaker. R5 said this happened in the hall and there was staff in the area. R5 said her and V9 exchanged words, R5 said V9 said to her ( R5) to go get some teeth and R5 responded by saying go get a body, you're shaped like sponge [NAME], R5 said V9 then said I will pull your wig off, R5 responded by saying what wig, not this this wig, well do it then, and V9 snatched her (R5) wig off. R5 said she then threw a cup at V9 and grabbed V9 shirt. R5 said she was embarrassed that V9 pulled her wig off her head, R5 said she doesn't have hair, just a few strings of hair. R5 said V9 knows her (R5) family and she thought V9 was like family, but no one in her family would have ever pulled her wig off her head. R5's statement gathered during facility investigation denotes in-part, R5 stated that V9 pulled her (R5) wig off and it embarrassed her (R5). 8/6/24 at 3:26 pm, V7 (Administrator) said she interviewed the nurse that was on duty when the incident occurred with R5 and V9. V7 read the statement from the nurse denoting that R5 told the nurse that V9 pulled her wig off. V7 said, V9's actions were not willful. V7 said, the nurse stated that she (V37) doesn't think the activity aide had ill intent. V7 was asked, how can the nurse speak for a resident that is alert and oriented, who stated that she was embarrassed by V9's actions. V37's (Nurse) interview from facility investigation denotes in-part V37 said she heard commotion and when she turned around R5 was throwing cups at V9. V37 immediately went to separate R5 and V9 because R5 had a hold of V9's shirt and did not let want to let go. V37 stated that R5 did not want to let go of V9's shirt because R5 stated V9 pulled her wig off. V37 stated that V38 from therapy came out of the therapy room and was able to get R5 to let go of V9's shirt. V37 (Nurse) denies seeing V9 pull off R5's wig. V37 states, that what she did witness she did not feel like V9 was intentionally trying to hurt R5 in anyway. On 8/9/24 at 4:09 pm, V38 (Occupational Therapist) said he heard the commotion, he observed V9 and R5 arguing, R5 grabbed V9. V38 said he separated V9 and R5 and left the facility for the day. Facility Abuse prevention policy dated 2/2017 denotes in-part this facility affirms the right to our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property or mistreatment by anyone but not limited to facility staff, other residents, consultants, volunteer, staff from other agencies providing services to the individual, family members or legal guardian, friends, or any other individuals. The Resident's Rights for the people living in the long-term care facilities denotes in-part your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually.

Based on interview and record review, the facility nursing staff failed to respond to a resident requiring respiratory care and the nursing staff failed to provide needed suctioning for a resident in potential hypoxia (lack of oxygen); for one (R2) of three residents reviewed for respiratory care in the sample of four. Findings include: R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia or Hypercapnia; Dysphagia; Chronic Obstructive Pulmonary Disease; Systolic (Congestive) Heart Failure; Hypertension; and Gastrostomy and Tracheostomy Status. According to R2's face sheet, R2's code status: Full Code. According to R2's MDS (Minimum Data Set) assessment dated [DATE] and [DATE] under section E, R2 had no behaviors that impacted care. R2's care plan dated [DATE] (revised on [DATE]) reads in part, (R2) is Ventilator dependent related to Respiratory Failure. Patient is refusing to turn to ventilator at night. Goal: Will actively participate in the weaning process. Resident will have appropriate ventilator alarm settings. Disconnect Alarm: High Pressure Alarm: Date Initiated: [DATE] Revision on: [DATE]. Resident will maintain a patent airway. [DATE] Revision on: [DATE]. Trach type: Trach size: Will be maintained on the lowest Fi02/PEEP/PS to support an adequate oxygenation level of: (Specify) through the review date. [DATE] Revision on: [DATE]. Interventions: Assess for s/sx of hypoxia: altered level of consciousness, irritability, listlessness, educate resident/family/caregivers purpose/mode/and all treatments; encourage resident to relax and breath with the ventilator; explain alarms; teach importance of deep breathing; Keep call bell within reach. Keep head of bed elevated above 30 degrees unless providing care or resident request. Patient and family educated on the importance of return to ventilator during night. All parties all aware of this behavior. A review of R2's care plan showed revisions made on [DATE] to goals and interventions for R2 on the same day of the resident's death with no explanation. R2's Call Light Ability Screen dated [DATE] reads in part, (R2) is unable to use a call light due to cognitive status. R2's order dated [DATE] reads in part, Ventilator Settings: Mode: AC, Rate: 12, Tidal Volume: 400, PEEP: 5, FiO2: 40%; Ventilator: noc. Every night shift. R2's order dated [DATE] reads in part, Weaning orders: TC 40% dayshift. No oxygen saturation level monitoring nor acceptable oxygen saturation level order noticed among R2's orders. On [DATE] at 12:31 PM, Surveyor interviewed V4 (Respiratory Therapist) who stated in summary: The company is trying to cut down on respiratory therapists. There is only 1 respiratory therapist from 07:00 AM to 07:00 PM for over 20 residents with tracheostomy needs. Our manager is on the floor today because you are here. My respiratory therapy duties are to check vital signs for residents with tracheostomies, make sure all residents with tracheostomy status are connected to ventilators, make sure there is water present for humidity, make sure tracheostomy site is clean and secured, and give breathing treatments. Additionally, majority of alarms sounding in this unit, are for suctioning needs, so I need to respond to those. On Mondays, Wednesdays, and Fridays, we have to assist with transport to dialysis and check on residents while they're in the dialysis. I was here on [DATE], I started at 7:00 AM. I provided R2 with routine morning tracheostomy care, which included suctioning, around 9:25 AM - 9:30 AM. I don't remember being called by the nurse for additional suctioning needs for R2 at any time before or after that. R2 was agitated before, during, and after tracheostomy care that morning ([DATE]). Then the code blue was called, and, when I came in to R2's room, I noticed his tracheostomy tube was dislodged. R2's tracheostomy would not initiate unit alarms because he was not connected to the ventilator during day shift, and only ventilators trigger unit alarm. [DATE] at 2:19 PM, Surveyor interviewed V5 (Licensed Practical Nurse) who stated in summary: I remember R2, he suffered cardiac arrest on [DATE] while in the facility. Earlier in the day ([DATE]), around 9:00 AM, I checked on R2's roommate and noticed R2 gesturing and pointing to his tracheostomy, which meant, that he needed to be suctioned. I told V4 (RT) right away. I'm not sure when or whether she went back to provide suctioning for R2. When I was finishing medication pass, around 10:30 AM, a CNA came out of R2's room and said that R2 doesn't look right and asked me to check on him. I went in right away, checked for pulse, didn't feel it, and yelled out to the CNA to call code blue. The code blue protocol was initiated, staff rushed in with emergency cart, and started chest compressions. I could not tell if R2's tracheostomy tube was dislodged at that time, but when V6 (Respiratory Therapy Director) attempted to bag (oxygenate) R2, she realized, that R2's tracheostomy tube was dislodged. R2 was paralyzed on the right side but had some strength in the left arm and leg. I've never witnessed R2 pulling on his tracheostomy tube. On [DATE] at 1:20 PM, Surveyor re-interviewed V5 (LPN) to clarify how did V5 know R2 was not in distress despite being agitated and repetitively pointing to his tracheostomy, V5 said, I knew R2 was not in respiratory distress, respiratory distress can be recognized by resident's inability to communicate. R2 just needed to be suctioned and respiratory therapist was next door, so I just told her to go into R2's room. He did not appear to be in respiratory distress because he was able to communicate. Surveyor reiterated that R2 was agitated and was unable to speak. Surveyor asked who and when can suction resident's air way, V5 (LPN) responded, Respiratory therapists will always suction, as it is their primary job. The only event when nurses would be required to suction resident's airway is, if a resident was in any sort of distress. On [DATE] at 10:23 AM, Surveyor interviewed V6 (Respiratory Therapy Director) who stated in summary: On [DATE], at the time of the incident, I was in the morning meeting. The code blue was called, and everyone left the morning meeting immediately and headed out to R2's room. When I got to the room, staff were doing chest compressions. When I looked, I noticed, staff bagging (oxygenating) R2 without noticing that his tracheostomy tube was dislodged. I immediately placed a spare tracheostomy tube and continued oxygenating R2. A little later, EMS arrived and took over resuscitation efforts. R2 was under V4's (RT) care that day. Based on R2's orders, he was supposed to be on ventilator at night, and tracheostomy collar throughout the day. We don't have alarm system on residents who are connected to tracheostomy collars, we are supposed to do physical rounds and look at the resident, between nurses, CNAs, and respiratory therapists. Frequency of monitoring is based on secretion load and resident's comfort. R2 fluctuated, there were times when he was calm, but he was combative and aggressive other times. Surveyor clarified who is allowed to suction resident's air way, V6 (RT Director) stated, Nurses and respiratory therapists can suction resident's airway, whether the nurse is a Licensed Practical Nurse or a Registered Nurse. Surveyor asked why was R2's ventilator dependency care plan revised on the day of his death, V6 (RT Director stated), I don't know why somebody would revise his care plan after he passed away, but it wasn't me making those changes. On [DATE] at 11:29 AM, Surveyor interviewed V2 (Director of Nursing) who stated in summary: Based on nurses' assessment, they can suction any resident in need of suctioning. My expectation for nurses and respiratory therapists is to suction all residents in need for suction. V5 (Licensed Practical Nurse) assessed R2 on the morning of [DATE] and concluded that there was no immediate need for suctioning, so she left the room, saw V4 (RT) and asked her to go in and suction R2. V4 (Respiratory Therapist) who was making morning rounds on [DATE], said that she suctioned R2's air way, but there was not much secretions, and R2's agitation was more so anxiety driven. Surveyor clarified, if a resident remains agitated regardless of suctioning needs, what should the nurse do, V2 (DON) said, If a resident remains agitated, they should be assessed, maybe checked for repositioning or pain needs, and go forward from there. I rounded on R2 that morning, around 9:20 AM, but he looked like he was at his baseline, did not appear to be in distress. On [DATE] at 12:20 PM Surveyor interviewed V3 (Licensed Practical Nurse) who stated in summary: Since I've been working here (5 months), respiratory therapists are ones who suction residents; however, nurses should be able to suction if they have skills and training to do so. In a critical moment, nurse should suction the resident. Seeing an agitated resident who is pointing to his tracheotomy, nurse should stay and attend resident's needs until, at least, until respiratory therapist arrives. There is no documentation that the facility monitored or provided any follow-up assessment to R2 for an hour after suctioning even though he showed signs of agitation, which is outside of his baseline per his MDS Section E:Behavioral assessment. On [DATE] at 1:55 PM, Surveyor interviewed V7 (Medical Director) who stated in summary: R2 was a [AGE] year old with chronic respiratory failure, tracheotomy, and congestive heart failure with ejection fraction of 35%. R2 had cardiac arrest followed by intracranial bleeding and stroke before his admission into the facility. R2 was stable on tracheostomy, his main problem, was cardiomyopathy. On [DATE], R2 requested suctioning around 9:15 AM from V5 (LPN), V5 (LPN) asked V4 (RT) to suction R2, who suctioned R2 at 9:30 AM. R2 had minimal secretions. At 10:30 AM, CNA found him unresponsive, and CPR was started. If R2 was in respiratory failure related to mucus plug, they would be cyanotic, their oxygen saturation would drop, they would be unable to talk, and their respiratory rate would be elevated. Surveyor clarified that R2 was unable to talk, was agitated, and was pointing to his tracheostomy site, communicating that his tracheostomy needs to be addressed, V7 (MD) said, Respiratory distress and agitation are completely different. Surveyor further clarified if dislodged tracheostomy could cause respiratory distress, V7 (MD) stated, Tracheostomy dislodgement would not have impact on R2's respiratory status. Based on his vital signs at the time (last known vital signs documented at 09:30 AM), it is very unlikely R2 was in respiratory distress. If resident is in respiratory distress, nurse have to make a clinical judgment, to see if it's appropriate to suction or call for respiratory therapist. I think the nurse did the right thing by looking at the timeline of this incident. On [DATE] at 3:18 PM, Surveyor interviewed V8 (Respiratory Program Director) who stated in summary: We have respiratory therapists whose primary duty is to care for residents' air way. Nurses are cross trained to care for an air way, but it's their secondary duty. If there is a resident in respiratory distress, both respiratory therapist and nurse can address the issue. It is not written in the policy but assumed that nurses are expected to address air way issues. V2 has noted prior to that statement that there is no policy regarding suctioning, monitoring or ratios for ventilated residents. On [DATE] at 10:03 AM Surveyor interviewed V9 (Respiratory Therapist) who stated in summary: Residents who are not connected to the ventilator are not connected to the unit alarm, so, if they were in respiratory distress, we would not know. We check resident's oxygen saturation with pulse oximeter twice a shift, on a 12 hour shift. We also do frequent checks, or we are notified by nurses if any resident needs respiratory therapist attention. There is no camera or any kind of alarm for residents with tracheotomies who are not connected to the ventilator. We wouldn't know if anybody's tracheotomy would be dislodged, so you don't always know if they are breathing ok. I'm not aware of any specific expectation as far as resident monitoring. 3. According to National Library of Medicine article Respiratory Failure in Adults dated [DATE], Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia. Type 2 respiratory failure occurs when the respiratory system cannot sufficiently remove carbon dioxide from the body, leading to hypercapnia. If either type of respiratory failure is not identified and addressed early, it will become life-threatening and lead to respiratory arrest, coma, and death. Signs of respiratory failure may be present throughout the body. Physical examination findings by region appear below: General inspection: Accessory muscle use, altered mental status, cachectic, conversational dyspnea, diaphoresis, fever, respiratory distress (i.e., at rest or with exertion), obesity, and purse-lipped breathing No comprehensive assessment documented in R2's electronic medical record related to R2's ongoing distress on [DATE]. Altered mental status documented prominently by V4 (Respiratory Therapist) in R2's last known assessment on [DATE] at 09:30 AM. According to National Library of Medicine article Pain, agitation and delirium in acute respiratory failure dated [DATE], Since pain, agitation and delirium compromise respiratory function they should also be regarded during noninvasive ventilation and during ventilator weaning. Progress Noted dated [DATE] at 9:15 AM, written by V5 (Licensed Practical Nurse) reads in part, While caring for (R2) in bed, alert, and gesturing for respiratory. RT (V4, respiratory therapist) informed that (R2) is in need of suctioning. RT (V4) states, she is on her way to (R2's) room. R2's Ventilator/Aerosol Flowsheet assessment dated [DATE] at 09:30 AM written by V4 (Respiratory Therapist) reads in part, Breath sounds Left: rhonchi. Breath sounds Right: rhonchi. Upon entry, (R2) seemed to be irritated and turned combative while assessing him. Trach care done - trach ties changed, trach secured and intact - (R2) was very aggressive with RT, (R2) was alert and responsive. VS (vital signs): 88 HR (heart rate), 16 RR (respiratory rate), 96% suctioning small amount of thick, yellow secretions from trach, BS rhonchi bilaterally, HOB 35% throughout the entire procedure and after will continue to monitor. Progress note dated [DATE] at 10:30 AM written by V5 (Licensed Practical Nurse) reads in part, (V5) called to (R2's) room via CNA to check on resident. (R2) vs (vital signs) absent at this time with no pulse present. 10:32 am (V5) called for CNA to call code blue, code blue called and 911 called, all available staff on scene 10:34 am Chest Compressions initiated, trach observed dislodged 10:35 am RT (V6, respiratory therapy director) at bedside, trach immediately replaced via RT without difficulty,02 applied 10:37am AED applied, no shock advised 10:41am Peripheral IV line placed and 0.9 NACL infusing 10:45 am Paramedics arrived and continue with CPR 10:50 am 1 round of epi (epinephrin) given, (R2) remains asystole, CPR continues 10:55 am 2nd round of epi (epinephrin) given, (R2) remains asystole, CPR continues 11:07am Code called to end, (R2) declared deceased at this time. Ambulance run sheet dated [DATE] 01:37 PM reads in part, Dispatched to above location for a reported cardiac arrest. U/a (upon arrival) found (R2) lying supine in bed, nursing staff doing CPR and ventilating (R2) via BVM (bag valve mask) to trach. Per staff, (R2) was last seen alive 30 minutes ago. AED (automated external defibrillator) was applied (R2) with no shock advised. Crew placed (R2) on monitor and asystole noted, IO (intraosseous) established in right leg. CPR (cardiopulmonary) continued by crew throughout duration of call, only pausing for rhythm checks, asystole noted on all rhythm checks. Pupils noted to be fixed and dilated. (Local hospital) contacted and orders to terminate resuscitation given. Facility's policy Oxygen Therapy dated ,d+[DATE] reads in part, Oxygen therapy may be provided through various types of supply and delivery systems. Equipment may include trans-tracheal oxygen catheters. Residents who require O2 therapy will have an ongoing assessment of respiratory status and response to respiratory therapy; Monitoring of SPO2 levels and/vital signs as ordered will be documented in medical record.

Based on interview and record review, the facility nursing staff failed to provide timely respiratory care to a resident with a tracheostomy and failed to provide documentation of monitoring for an agitated resident for an hour after suctioning. These failures affected one (R2) of three residents reviewed for respiratory care in the sample of four. This failure resulted in R2 left being agitated with no follow up for one hour after trach care from RT, found with this trach out and in respiratory arrest. The Immediate Jeopardy began on [DATE] when R2 gestured and pointed to his trach, was not immediately suctioned by nursing staff, but later was by respiratory who admitted R2 was agitated before, during, and after trach care. V1 (Administrator), V2 (Director of Nursing), V10 (Regional Consultant), and V11 (Regional Director of Operations) were notified on [DATE] at 11:29 AM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia or Hypercapnia; Dysphagia; Chronic Obstructive Pulmonary Disease; Systolic (Congestive) Heart Failure; Hypertension; and Gastrostomy and Tracheostomy Status. According to R2's face sheet, R2's code status: Full Code. According to R2's MDS (Minimum Data Set) assessment dated [DATE] and [DATE] under section E, R2 had no behaviors that impacted care. R2's care plan dated [DATE] (revised on [DATE]) reads in part, (R2) is Ventilator dependent related to Respiratory Failure. Patient is refusing to turn to ventilator at night. Goal: Will actively participate in the weaning process. Resident will have appropriate ventilator alarm settings. Disconnect Alarm: High Pressure Alarm: Date Initiated: [DATE] Revision on: [DATE]. Resident will maintain a patent airway. [DATE] Revision on: [DATE]. Trach type: Trach size: Will be maintained on the lowest Fi02/PEEP/PS to support an adequate oxygenation level of: (Specify) through the review date. [DATE] Revision on: [DATE]. Interventions: Assess for s/sx of hypoxia: altered level of consciousness, irritability, listlessness, educate resident/family/caregivers purpose/mode/and all treatments; encourage resident to relax and breath with the ventilator; explain alarms; teach importance of deep breathing; Keep call bell within reach. Keep head of bed elevated above 30 degrees unless providing care or resident request. Patient and family educated on the importance of return to ventilator during night. All parties all aware of this behavior. A review of R2's plan showed revisions made on [DATE] to goals and interventions for R2 on the same day of the resident's death with no explanation. R2's Call Light Ability Screen dated [DATE] reads in part, (R2) is unable to use a call light due to cognitive status. R2's order dated [DATE] reads in part, Ventilator Settings: Mode: AC, Rate: 12, Tidal Volume: 400, PEEP: 5, FiO2: 40%; Ventilator: noc. Every night shift. R2's order dated [DATE] reads in part, Weaning orders: TC 40% dayshift. No oxygen saturation level monitoring nor acceptable oxygen saturation level order noticed among R2's orders. On [DATE] at 12:31 PM, Surveyor interviewed V4 (Respiratory Therapist) who stated in summary: My respiratory therapy duties are to: check vital signs for residents with tracheostomies, make sure all residents with tracheostomy status are connected to ventilators, make sure there is water present for humidity, make sure tracheostomy site is clean and secured, and give breathing treatments. Additionally, majority of alarms sounding in this unit, are for suctioning, so I need to respond to those. On Mondays, Wednesdays, and Fridays, we have to assist with transport to dialysis and check on residents while they're in the dialysis. I was here on [DATE]. I started at 7:00 AM, I provided R2 with routine morning tracheostomy care, which included suctioning, around 9:25 AM - 9:30 AM. Then code blue was called, and when I came in to R2's room, I noticed his tracheostomy tube was dislodged. R2's tracheostomy would not initiate unit alarms because he was not connected to the ventilator at the time of the incident, and only ventilators trigger unit alarm. [DATE] at 2:19 PM, Surveyor interviewed V5 (Licensed Practical Nurse) who stated in summary: Earlier in the day ([DATE]), around 9:00 AM, I checked on R2's roommate and noticed R2 gesturing and pointing to his tracheostomy, which meant, that he needed to be suctioned. I told V4 (RT) right away. I'm not sure when or whether she went back to provide suctioning for R2. When I was finishing medication pass, around 10:30 AM, a CNA came out of R2's room and said that R2 doesn't look right and asked me to check on him. I went in right away, checked for pulse, didn't feel it, and yelled out to the CNA to call code blue. Code blue protocol was initiated, staff rushed in with emergency cart, and started chest compressions. I could not tell if R2's tracheostomy tube was dislodged at that time, but when V6 (Respiratory Therapy Director) attempted to bag (deliver oxygen) R2, she realized, that R2's tracheostomy tube was dislodged. On [DATE] at 1:20 PM, Surveyor re-interviewed V5 (LPN). Surveyor asked who is qualified to suction resident's air way, V5 (LPN) responded, Respiratory therapy will always suction resident's air way, as it is their primary job. The only event when nurses would be required to suction resident's air way is, if a resident was in any sort of distress. On [DATE] at 10:23 AM, Surveyor interviewed V6 (Respiratory Therapy Director) who stated in summary: On [DATE], during the incident, I was in the morning meeting. The code blue was called, and everyone left the morning meeting immediately and headed out to R2's room. When I got to the room, staff was doing chest compressions. When I looked, I noticed staff bagging (oxygenating) R2 without noticing that his tracheostomy tube was dislodged. I immediately placed a spare tracheostomy tube and continued oxygenating R2. A little later, EMS arrived and took over resuscitation. R2 was under V4's (RT) care that day. Based on R2's orders, he was supposed to be on ventilator at night, and tracheostomy collar throughout the day. We don't have alarm system on residents who are connected to tracheostomy collars, we are supposed to do physical rounds and look at the resident, between nurses, CNAs, and respiratory therapists. Frequency of monitoring is based on secretion load and resident's comfort. R2 fluctuated, there were times when he was calm, but he was combative and aggressive other times. Surveyor clarified who is allowed to suction residents' air way, V6 (RT Director) stated, Nurses and respiratory therapists can suction the residents' air way, whether the nurse is a Licensed Practical Nurse or a Registered Nurse. On [DATE] at 11:29 AM, Surveyor interviewed V2 (Director of Nursing) who stated in summary: Based on nurse's assessment, they can suction any resident in need of suctioning. My expectation for nurses and respiratory therapist is to suction all residents in need for suction. V5 (Licensed Practical Nurse) assessed R2 on the morning of [DATE] and concluded that there was no immediate need for suctioning, so she left the room, saw V4 (RT) and asked her to go in and suction R2. V4 (Respiratory Therapist) who was making morning rounds on [DATE], said that she suctioned R2, but there was not much secretions, and R2's agitation was more so anxiety driven. Surveyor clarified, if a resident remains agitated regardless of suctioning needs, what should the nurse do, V2 (DON) said, If a resident remains agitated, they should be assessed, maybe checked for repositioning or pain needs, and go forward from there. I rounded on R2 that morning, around 9:20 AM, but he looked like he was at his baseline, did not appear to be in distress. Review of R2's MDS section E:Behavior did not show that R2 had any assessed behaviors related to agitation. On [DATE] at 12:20 PM, Surveyor interviewed V3 (Licensed Practical Nurse) who stated in summary: Since I've been working here (5 months), respiratory therapists are ones who suction residents; however, nurses should be able to suction if they have skills and training to do so. In a critical moment, nurse should suction the resident. Seeing an agitated resident who is pointing to his tracheotomy, nurse should stay and attend resident's needs until, at least, when respiratory therapist arrives. Even though R2 presented with agitation, there was follow-up or increased monitoring provided by the facility. On [DATE] at 1:55 PM, Surveyor interviewed V7 (Medical Director) who stated in summary: On [DATE], R2 requested suctioning around 9:15 AM from V5 (LPN), V5 (LPN) asked V4 (RT) to suction R2, who suctioned R2 at 9:30 AM. R2 had minimal secretions. At 10:30 AM, CNA found him unresponsive, and CPR was started. There was no documentation or report on interviews that any other contact was made with R2 between 9:30 AM and 10:30AM. V7 continued, if R2 was in respiratory failure related to mucus plug, they would be cyanotic, their oxygen saturation would drop, they would be unable to talk, and their respiratory rate would be elevated. Surveyor clarified that R2 was unable to talk, was agitated, and was pointing to his tracheostomy site, communicating that his tracheostomy needs to be addressed, V7 (MD) said, Respiratory distress and agitation are completely different. Surveyor further clarified if dislodged tracheostomy could cause respiratory distress, V7 (MD) stated, Tracheostomy dislodgement would not have impact on R2's respiratory status. Based on his vital signs at the time (last known vital signs documented at 09:30 AM), it is very unlikely R2 was in respiratory distress. If resident is in respiratory distress, the nurse has to make a clinical judgment, to see if it's appropriate to suction or call for respiratory therapist. I think the nurse did the right thing by looking at the timeline of this incident. On [DATE] at 3:18 PM, Surveyor interviewed V8 (Respiratory Program Director) who stated in summary: We have respiratory therapists whose primary duty is to care for residents' air way. Nurses are cross trained to care for an air way, but it's their secondary duty. If there is a resident in respiratory distress, both respiratory therapist and nurse can address the issue. It is not written in the policy but assumed that nurses are expected to address air way issues. On [DATE] at 10:03 AM Surveyor interviewed V9 (Respiratory Therapist) who stated in summary: Residents who are not connected to the ventilator are not connected to the unit alarm, so, if they were in respiratory distress, we would not know. We check resident's oxygen saturation with pulse oximeter twice a shift, on a 12 hour shift. We also do frequent checks, or we are notified by nurses if any resident needs respiratory therapist attention. There is no camera or any kind of alarm for residents with tracheotomies who are not connected to the ventilator. We wouldn't know if anybody's tracheotomy would be dislodged, so you don't always know if they are breathing ok. I'm not aware of any specific expectation as far as resident monitoring. According to National Library of Medicine article Pain, agitation and delirium in acute respiratory failure dated [DATE], Since pain, agitation and delirium compromise respiratory function they should also be regarded during noninvasive ventilation and during ventilator weaning. Progress Noted dated [DATE] at 9:15 AM, written by V5 (Licensed Practical Nurse) reads in part, While caring for (R2) in bed, alert, and gesturing for respiratory. RT (V4, respiratory therapist) informed that (R2) is in need of suctioning. RT (V4) states, she is on her way to (R2's) room. R2's Ventilator/Aerosol Flowsheet assessment dated [DATE] at 09:30 AM by V4 (Respiratory Therapist) reads in part, (R2) in no respiratory distress. Upon entry, (R2) seemed to be irritated and turned combative while assessing him. Trach care done - trach ties changed, trach secured and intact - (R2) was very aggressive with RT, (R2) was alert and responsive. VS (vital signs): 88 HR (heart rate), 16 RR (respiratory rate), 96% suctioning small amount of thick, yellow secretions from trach, BS rhonchi bilaterally, HOB 35% throughout the entire procedure and after will continue to monitor. Progress note dated [DATE] at 10:30 AM written by V5 (Licensed Practical Nurse) reads in part, (V5) called to (R2's) room via CNA to check on resident. (R2) vs (vital signs) absent at this time with no pulse present. 10:32 am (V5) called for CNA to call code blue, code blue called and 911 called, all available staff on scene 10:34 am Chest Compressions initiated, trach observed dislodged 10:35 am RT (V6, respiratory therapy director) at bedside, trach immediately replaced via RT without difficulty,02 applied 10:37am AED applied, no shock advised 10:41am Peripheral IV line placed and 0.9 NACL infusing 10:45 am Paramedics arrived and continue with CPR 10:50 am 1 round of epi (epinephrin) given, (R2) remains asystole, CPR continues 10:55 am 2nd round of epi (epinephrin) given, (R2) remains asystole, CPR continues 11:07am Code called to end, (R2) declared deceased at this time. Ambulance run sheet dated [DATE] 01:37 PM reads in part, Dispatched to above location for a reported cardiac arrest. U/a (upon arrival) found (R2) lying supine in bed, nursing staff doing CPR and ventilating (R2) via BVM (bag valve mask) to trach. Per staff, (R2) was last seen alive 30 minutes ago. AED (automated external defibrillator) was applied (R2) with no shock advised. Crew placed (R2) on monitor and asystole noted, IO (intraosseous) established in right leg. CPR (cardiopulmonary) continued by crew throughout duration of call, only pausing for rhythm checks, asystole noted on all rhythm checks. Pupils noted to be fixed and dilated. (Local hospital) contacted and orders to terminate resuscitation given. From the National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK593189/ After completing suctioning, the outcomes from the procedure should be evaluated and documented, including the following: Improvement of lung sounds Removal of secretions Improvement of pulse oximetry Decreased work of breathing Stabilized respiratory rate Decreased dyspnea Facility's policy Oxygen Therapy dated ,d+[DATE] reads in part, Oxygen therapy may be provided through various types of supply and delivery systems. Equipment may include trans-tracheal oxygen catheters. Residents who require O2 therapy will have an ongoing assessment of respiratory status and response to respiratory therapy; Monitoring of SPO2 levels and/vital signs as ordered will be documented in medical record. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Affected resident corrective actions. A. Resident #1 - Resident 1 is no longer a resident in the facility. 2. Immediate Actions and Actions to prevent recurrence. (Initiated on [DATE] at 12:00 noon and will continue until all staff are in-serviced and trained prior to the start of their shift.) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. The Respiratory Program Director checked and verified proper function of all ventilator alarm system. There was no concern identified. (This immediate action was initiated and completed on [DATE], 12:30pm) B. Respiratory assessment was completed for all residents requiring respiratory care - on ventilators and tracheostomy. There was no concern identified. (This immediate action was initiated and will be completed on [DATE], 2:30pm) C. All Nurses and respiratory staff were provided with education by the DON/ Respiratory Program Director. The training will include but is not limited to appropriate assessments to recognize potential respiratory distress on residents on ventilators and tracheostomy and identifying appropriate interventions to address any identified respiratory problem. (This immediate action was initiated and will be completed on [DATE], 3:30pm) D. All Nurses and Respiratory Therapists were educated by the DON/ Respiratory Program Director on timely response to the ventilator alarm system and appropriately address any identified safety concerns. (This immediate action was initiated and will be completed on [DATE], 3:30pm) E. The Medical Director, Administrator, Director of Respiratory Program and DON reviewed the facility's policies which includes but are not limited to: a. Respiratory Care b. Suctioning c. Ventilator alarm There was no revision necessary. This was initiated and completed on [DATE]. F. The DON/Respiratory Program Director provided all nurses and respiratory therapists with training related to the above-mentioned policies, focusing on appropriate respiratory assessment, hypoxia and appropriate interventions. (This immediate action was initiated and will be completed on [DATE], 3:30pm) G. New hires will be trained by the DON, ADON or RT Director. All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials. H. The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. (This immediate action was initiated and will be completed on [DATE], 3:30pm) Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first. I. The DON/ADON/RT Director will conduct daily rounds to identify any potential concerns related to this plan of removal. (This immediate action was initiated on [DATE]) J. The DON/ADON/RT Director will also conduct staff (nurses & respiratory therapists) interview, with at least five employees, daily to gauge knowledge retention and determine if additional training is required. (This immediate action will be initiated on [DATE]) K. During the weekends, the assigned Nursing Supervisor/Respiratory Therapist will conduct unit rounds to identify any concern related to Ventilator/tracheostomy residents' respiratory status. Any identified concern will be addressed immediately. L. Residents are monitored every two hours by respiratory therapists or nursing staff. a. Staff make rounds every two hours. b. Any change in the resident's condition will be identified such as difficulty breathing, changes in color, change in mental status, or other changes that may signal further evaluation is needed. c. The nurse or respiratory therapist will assess the resident whenever changes are identified. d. If the change requires immediate intervention (resident is in distress, having difficulty breathing, etc.), the assessment will be completed and appropriate interventions implemented. M. During the Q2H rounds, a. if there is any change of condition observed which includes but not limited to: i. change in vitals signs including Respiratory Rate ii. signs of dyspnea iii. cyanosis, iv. coughing, v. change of characteristics of sputum,signs of potential infection, or vi. presence of behavioral changes that may reflect hypoxia including anxiety, apprehension, level of consciousness b. the RT will do the following: i. Notify the MD. ii. Increase the respiratory monitoring from Q2 hours to either q15, Q30, or QH based on the RT's discretion and MD orders iii. The increased respiratory monitoring by RT will be continued for a minimum of 24 hours. iv. The RT will notify the MD after 24 hours to report results of the increased respiratory monitoring. v. The RT will notify the MD to obtain order to downgrade the respiratory monitoring based on the collected information for 24 hours. (Downgrade maybe done as follows: Q15 minutes to Q30 minutes, or Q30 minutes to Q-hour rounds.) vi. To ensure resident safety, the same frequency of increased monitoring will not be used for less than 24 hours. vii. The MD will order to discontinue the increased respiratory monitoring, based on the RT's assessment. viii. The RT will resume the Q2H rounds after receiving a discontinuation order of the increasing respiratory monitoring from the MD. ix. Care plan will be revised accordingly. x. The resident will be sent to the hospital for further evaluation is deemed necessary. N. To ensure compliance, the result of the flowsheet will be reviewed daily during the meeting which is attended by the Director of Respiratory Therapy and clinical leadership which includes but is not limited to the: DON, ADON, MDS, IP, Restorative, and the Administrator. O. Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI. P. The current flowsheet which are being used already includes the Q15, Q30, Qh and Q2 and PRN. Q. The facility will ensure that the staffing ratio will be followed as indicated in the facility staffing grid: Vent Residents RT Comments ,d+[DATE] 1 RT on-site ,d+[DATE] 2 RT on-site ,d+[DATE] 3 RT on-site 3. The facility will reinforce the following process. A. The DON/ADON/RT Director will conduct clinical rounding and observations to identify non-compliance. Staff shall be randomly evaluated by the DON/ADON/RT Director on their knowledge of the facility's policy and procedure on respiratory care and suctioning. (This will be initiated on [DATE] and will continue for 4 weeks.) B. All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. C. The Administrator and Director of Respiratory Program will monitor completion of this plan of removal.

Based on interview and record review the facility failed to protect a resident from sexual abuse from another resident when both residents were found engaging in inappropriate behavior in bed earlier that same day. This failure resulted in R13 found with her breast exposed and R6 poking R13's genitals through R13's clothes. This failure affected 1 resident (R13) of 2 residents reviewed for sexual abuse in a total sample of 21. Findings include: On 2-8-24 at 9:02 AM, V1 (Admin) said staff reported the incident and V1 was on duty at that time. V1 said CNA found both residents fully clothed in bed and R13's leg was resting over R6's hand. V1 said CNA removed R13 from the room and brought to dining room. R13 was brought to dining room for closer observation. V1 said R6 and R13 are non-decisional and unable to give consent. V1 said she is unsure if R6 was being monitored. V1 said this was before mealtime and staff was passing trays. Minutes later, CNA found R6 and R13 sitting in R6's bed, R6 was poking R13's genitals through her clothes. On 2-7-24 at 10:46 AM, V2 (Director of Nursing) said CNA reported both residents were found in R6's room around 3:30 or 4:00 PM. V2 said CNA said R6 was on top of R13 and both were fully clothed. V2 said the CNA immediately separated the two residents and both placed in dining room at opposite sides for monitoring and during the process of a room change. V2 said CNA broke the couple up because both residents are confused and both residents could not consent to this. At 4:30 PM, both residents walked to R6's room. V2 said CNA observed both residents on the bed and CNA reported that she saw R6 poking his fingers between R13's legs with her pants on. On 2-8-24 at 10:30 AM, V29 (LPN) said around the beginning of shift (3:30 PM) the CNA called V29. V29 said she came to R6's room and saw R6 and R13 sitting on R6's bed. R6 was sitting close to R13. Both R6 and R13 were clothed however, R13's shirt was slightly up and a breast was exposed. V29 said R13's legs were open but clothes were on. On 2-7-24 at 9:03 AM, V15 (CNA) said around 6:00 PM, she made rounds and saw R6's door slightly open. V15 said she went into R6's room and saw R13 (fully clothed) in R6's bed. R6 was sitting at the foot of the bed. V15 saw R6 poking R13's genital area with her pants on. V15 saw R13 refusing and saying No. V15 said R6 stopped when he saw V15 enter the room. Initial State Reportable (dated 1-10-24) documents: At approximately 5pm staff reported that (R6) and (R13) both confused residents were in (R6's) room laying on his bed. (R13's) shirt was up exposing her breasts and his hand was placed on her genital area on top of her clothes. Both residents were immediately separated and placed on 1:1. Final State Reportable (dated 1-18-24) documents: after a thorough investigation of residents medical records, staff, and resident interviews it has been determined this allegation is unfounded. Both residents have a cognitive impairment, are confused, and has a diagnosis of Dementia. Neither resident was able to recall any interactions with the other resident. Staff interviews conducted and staff deny seeing any inappropriate or sexual behaviors noted for either resident. ER report for (R13) states a full body assessment was completed and there were no clinical signs for physical or sexual trauma and was cleared to return to facility. At the time of alleged incident (R6) was immediately moved to another unit and residents remain separated. Both residents immediately placed on enhanced supervision (1:1) and will continue until further orders from physician. Care plans have been reviewed and revised as necessary. R13's Hospital Record dated 1-10-24 documents: Assessment/Plan/MDM: [AGE] year-old who presents for wellness examination. Afebrile, hemodynamically stable, nontoxic in NAD, saturating well on RA. Full body exam without clinical signs for physical or sexual trauma. Pt cleared for discharge to NH in stable condition. Subjective: (R13) is a 77y female who presents for wellness check. Pt with hx of advanced dementia, coming from (Facility), Per staff, pt was found in another male patient's room. Staff reports that they found pt on top of male but reports both of their clothes were on. EMS reports clothes were on both of them when they arrived, did note that part of pt's depends diaper was ripped on the side, but sweatpants were still on fully. sent to ER for evaluation. Pt pleasantly demented, difficult to follow pt's train of thought, but she did not mention any concerns for sexual or physical assault. Pt repeatedly requesting that she wants to go home. Police Report (dated 1-10-24) documents: Narrative: V2 (Director of Nursing) related at appropriately 1545, that a female resident later identified as R13 and a male resident later identified as R6 were caught possibly trying to have sexual relations twice today (1-10-24) and when they were separated R13 was blowing kisses at R6. Both times they were stopped by two different CNAs. V2 further related that both of the above listed residents have dementia and do not recall what occurred. A CNA related she was making rounds checking on the residents and walked into R6's room at approximately 1545hrs and observed R6 on top of R13 in between her legs. CNA further related that both residents had their clothes on. CNA then requested help from other staff member and was able to separate both residents. V15 (CNA) related she was making her rounds checking in on the residents when she observed the door on (R6's) room opened slightly and the bathroom door opened as well blocking her view in to the actual room at approximately 1645. V15 entered and observed R13 and R6 were in the bed together. R13 had one of her breasts exposed and R6's hand was rubbing his fingers on the outside of R13's pants near her vagina. V15 asked what they were doing and R6 replied She's bothering me V15 requested for other staff members to separate R13 and R6. R6 was then relocated to the fourth floor. V17 (Social Services Director) related that both residents R13 and R6 were both considered non-consenting adults because they are both diagnosed with dementia. R6's MDS (ARD 1-4-24) documents: BIMS summary score = 6. Active Diagnoses (not limited to): Non-Alzheimer's Dementia, Altered Mental Status, unspecified. R13's MDS (ARD 12-5-23) documents: BIMS summary score = 9, Active Diagnoses (not limited to): Non-Alzheimer's Dementia, Psychotic Disorder, and Altered Mental Status, unspecified. Abuse Prevention Program (dated 2-2017) documents: Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. 41156

Based on interview and record review, the facility failed to follow their abuse policy by not ensuring one resident (R11) social security checks were returned to the office of social security after being discharged from the facility for four months. This affected one of three residents (R11) reviewed for misappropriation of funds. This failure resulted in R11's family not receiving two months of social security payments for daily expenses. Findings include: R11 was admitted to the facility on [DATE]. R11 was discharged from the facility on 10/20/23. R11's resident statement documents on 11/3/23 Social security administration payment of 2030.00 deposited ; on 11/3/23 1800.64 removed from account for care costs. On 12/1/23 social security payment of 2030.00 deposited; on 12/1/23 1800.64 removed from account for care costs. Under status: closed 12/29/23. On 2/7/24 at 3:12pm, V9 (Business Office Manager) said R11's family came to speak to her some time last week about concerns related to R11's social security checks not being received. V9 said she instructed the family to speak to social security because the check had been returned. V9 said she thought the family was only asking about January social security funds which were already returned and was not aware of the November or December checks not being received by R11. On 2/6/24 at 4:08PM, V23 (Medicaid specialist) said resident accounts are supposed to be closed when the resident discharges from the facility. The November and December social security income checks for R11 were deposited into the facility account and have not been returned to social security at this time. V23 said the account should have been closed timely to prevent those checks/funds social security from being directly deposited into the account. On 2/7/24 at 12:45PM, V22 (R11's family) said she spoke to V9 about concerns related to R11's November and December social security checks and she was referred to go to the social security office because V9 (business office) said the income had been returned. V9 said she reached out to social security office who said the checks had not been returned by the facility. V22 said R11 was living with her and that money was needed to assist with bills and food. V22 said R11 had passed away this week and that money would be needed to help pay for the cost of funeral services. V22 said she is trying to borrow money from other family members to help pay for the services. Facility abuse prevention program dated 2/2017 documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, interviews, and record reviews, the facility failed to implement effective pressure prevention interventions. This affected one of three residents (R7) reviewed for pressure sores. This failure resulted in R7 stage 4 pressure ulcer progressing to develop osteomyelitis (an inflammation or swelling of bone tissue this is usually the result of an infection.) Findings include: On 2/6/24 at 12:05 PM, V28 (Wound Care Nurse) was observed performing wound care treatment for R7's sacral pressure ulcer. R7's sacral dressing was observed to be nonocclusive on the distal half of dressing. There was bowel movement on top and under R7's dressing. Bowel movement was also observed in R7's wound. R7 was observed to have a flat sheet folded in half twice under R7's buttocks. On 2/7/24 at 9:30 AM, V28 was observed performing wound care treatment for R7 with V20 (Wound Care Physician). R7 was observed to have a blanket folded twice underneath R7. R7's sacral dressing was covered in old bowel movement. On 2/7/24 at 9:50 AM, V20 (Wound Care Physician) stated that the residents on low air loss mattresses can have one flat sheet and one draw sheet under the resident. V20 stated that blankets and flat sheets folded twice should not be placed underneath the resident. V20 stated that the nurse should change R7's dressing if dressing becomes nonocclusive or soiled after R7 has a bowel movement. V20 stated that R7's ESR (sedimentation rate) and CRP (C-reactive protein) levels are elevated suggesting osteomyelitis (infection in bone) of sacral bone. On 2/7/24 at 10:45 AM, V2 DON (Director of Nursing) stated that the nurse is expected to change wound dressing if it becomes nonocclusive or soiled. V2 stated that the nurse should document in the resident's electronic medical record if the dressing is changed. On 2/8/24 at 2:45 PM, V3 LPN (Licensed Practical Nurse) stated that some CNAs (Certified Nurse Aides) will notify V3 if R7's sacral dressing becomes soiled and needs dressing changed. R7's POS (Physician Order Sheet), notes an order, dated 1/7/24, for sacrum - stage 4 pressure wound, clean with normal saline, dry with gauze, apply alginate calcium with silver, cover with ABD pad and tape, change dressing daily and as needed. This order was discontinued on 1/15/24. Upon R7's re-admission on 1/16/24, there were no orders for wound care treatments obtained until 1/18/24 at 4:00 PM. On 1/18, sacrum - stage 4 pressure wound, clean with normal saline, dry with gauze, apply alginate calcium with silver, cover with ABD pad and tape, change dressing daily and as needed was ordered. This order was discontinued on 1/27; re-ordered on 1/28; and discontinued again on 1/30. R7's POS, dated 1/19/24, notes an order for sacrum - stage 4 pressure wound, clean with normal saline, dry with gauze, apply dakins soaked gauze, cover with ABD pad and tape, change dressing daily and as needed. This order was discontinued on 1/27 and re-ordered on 1/30. R7's POS, dated 2/7/24, notes an order for Levofloxacin (antibiotic) 750mg (milligrams) via gastrostomy tube daily x 14 days for osteomyelitis. R7's TAR (Treatment Administration Record), dated January and February 2024, notes R7's sacrum stage 4 pressure ulcer did not receive wound care treatment on 1/7, 1/9, 1/13, 1/17, 1/18, 1/29, 2/2, 2/3, 2/4, or 2/5. R7's medical record, dated 1/13/24, notes R7 was transported to the hospital at 3:54 PM. R7 was readmitted to this facility on 1/16/24 at 5:50pm. V20 (Wound Care Physician) note, dated 1/31/24, notes R7 with a stage 4 sacral pressure ulcer, measuring 14cm (centimeters) x 12cm x 2.4cm, moderate serosanguinous (clear blood tinged yellow fluid) drainage, 100% granulation tissue. A factor affecting wound healing is fecal incontinence. V20 (Wound Care Physician) note, dated 2/7/24, notes R7 with a stage 4 sacral pressure ulcer, measuring 14cm x 10.5cm x 2.4cm, heavy serous (clear yellow fluid) drainage, thick adherent devitalized necrotic (dead) tissue 10%, granulation tissue 80%, fascia (band of connective tissue) 10%. ESR (sedimentation rate) was very elevated (134) and CRP (C-reactive protein) was also elevated suggestive of underlying osteomyelitis. Plan: start antibiotics to treat osteomyelitis. R7's laboratory test results, dated 2/1/24, notes CRP 1.6 (normal range 0.1-0.9) and ESR 134 (normal range 0-20). R7's MDS, (Minimum Data Set), dated 10/16/23, notes R7's cognition is severely impaired and R7 is dependent on staff for all ADLs (activities of daily living). R7 is always incontinent of bowel. R7's skin care plan, initiated 7/14/23, notes R7 is at risk for skin breakdown due to limited mobility. R7 also has a pressure ulcer to sacrum. R7 does not have a care plan related to bowel incontinence.

Based on interview and record review the facility failed to monitor and supervise a resident with a diagnosis of dementia and a history of wandering. This failure affected two of three residents (R6, R13) reviewed for supervision. This failure resulted in R13 being able to wander into R6 room, and being found by facility staff with R6 inappropriately touching and groping R13 while exposing R13's breast. Findings include: On 2-8-24 at 9:02 AM, V1 (Admin) said staff reported the incident and V1 was on duty at that time. V1 said CNA found both residents fully clothed in bed and R13's leg was resting over R6's hand. V1 said CNA removed R13 from the room and brought to dining room. R13 was brought to dining room for closer observation. V1 said R6 and R13 are non-decisional and unable to give consent. V1 said she is unsure if R6 was being monitored. V1 said this was before mealtime and staff was passing trays. Minutes later, CNA found R6 and R13 sitting in R6's bed with R6 was poking R13's genitals through her clothes. On 2-7-24 at 10:46 AM, V2 (Director of Nursing) said CNA reported both residents were found in R6's room around 3:30 or 4:00 PM. V2 said CNA said R6 was on top of R13 and both were fully clothed. V2 said the CNA immediately separated the two residents and both placed in dining room at opposite sides for monitoring and during the process of a room change. V2 said CNA broke the couple up because both residents are confused and both residents could not consent to this. At 4:30 PM, both residents walked to R6's room. V2 said CNA observed both residents on the bed and CNA reported that she saw R6 poking his fingers between R13's legs with her pants on. V2 said the staff placed the residents in the dining room for monitoring however the staff was not able to prevent the residents from going back to his room the 2nd time. On 2-8-24 at 10:30 AM, V29 (LPN) said around the beginning of shift (3:30 PM) the CNA called V29. V29 said she came to R6's room and saw R6 and R13 sitting on R6's bed. R6 was sitting close to R13. Both R6 and R13 were clothed however, R13's shirt was slightly up and a breast was exposed. V29 said R13's legs were open but clothes were on. V29 said she was not aware of previous incident when R6 and R13 were found in R6's bed. On 2-7-24 at 9:03 AM, V15 (CNA) said she last saw R13 in dining room around 4:00 PM. V15 said around 6:00 PM, she made rounds and saw R6's door slightly open. V15 said she went into R6's room and saw R13 (fully clothed) in R6's bed. R6 was sitting at the foot of the bed. V15 saw R6 poking R13's genital area with her pants on. V15 saw R13 refusing and saying No. V15 said R6 stopped when he saw V15 enter the room. V15 said she took V13 from the room and notified the nurse on duty. Initial State Reportable (dated 1-10-24) documents: At approximately 5pm staff reported that (R6) and (R13) both confused residents were in (R6's) room laying on his bed. (R13's) shirt was up exposing her breasts and his hand was placed on her genital area on top of her clothes. Both residents were immediately separated and placed on 1:1. Final State Reportable (dated 1-18-24) documents: after a thorough investigation residents medical records, staff, and resident interviews it has been determined this allegation is unfounded. Both residents have a cognitive impairment, are confused, and has a diagnosis of Dementia. Neither resident was able to recall any interactions with the other resident. Staff interviews conducted and staff deny seeing any inappropriate or sexual behaviors noted for either resident. ER report for (R13) states a full body assessment was completed and there were no clinical signs for physical or sexual trauma and was cleared to return to facility. At the time of alleged incident (R6) was immediately moved to another unit and residents remain separated. Both residents immediately placed on enhanced supervision (1:1) and will continue until further orders from physician. Care plans have been reviewed and revised as necessary. R13's Hospital Record dated 1-10-24 documents: Assessment/Plan/MDM: [AGE] year-old who presents for wellness examination. Afebrile, hemodynamically stable, nontoxic in NAD, saturating well on RA. Full body exam without clinical signs for physical or sexual trauma. Pt cleared for discharge to NH in stable condition. Subjective: (R13) is a 77y female who presents for wellness check. Pt with hx of advanced dementia, coming from (Facility), Per staff, pt was found in another male patient's room. Staff reports that they found pt on top of male but reports both of their clothes were on. EMS reports clothes were on both of them when they arrived, did note that part of pt's depends diaper was ripped on the side, but sweatpants were still on fully. sent to ER for evaluation. Pt pleasantly demented, difficult to follow pt's train of thought, but she did not mention any concerns for sexual or physical assault. Pt repeatedly requesting that she wants to go home. Police Report (dated 1-10-24) documents: Narrative: V2 (Director of Nursing) related at appropriately 1545, that a female resident later identified as R13 and a male resident later identified as R6 were caught possibly trying to have sexual relations twice today (1-10-24) and when they were separated R13 was blowing kisses at R6. Both times they were stopped by two different CNAs. V2 further related that both of the above listed residents have dementia and do not recall what occurred. A CNA related she was making rounds checking on the residents and walked into R6's room at approximately 1545hrs and observed R6 on top of R13 in between her legs. CNA further related that both residents had their clothes on. CNA then requested help from other staff member and was able to separate both residents. V15 (CNA) related she was making her rounds checking in on the residents when she observed the door on (R6's) room opened slightly and the bathroom door opened as well blocking her view in to the actual room at approximately 1645. V15 entered and observed R13 and R6 were in the bed together. R13 had one of her breasts exposed and R6's hand was rubbing his fingers on the outside of R13's pants near her vagina. V15 asked what they were doing and R6 replied She's bothering me V15 requested for other staff members to separate R13 and R6. R6 was then relocated to the fourth floor. V17 (Social Services Director) related that both residents R13 and R6 were both considered non-consenting adults because they are both diagnosed with dementia. R6's MDS (ARD 1-4-24) documents: BIMS summary score = 6. Active Diagnoses (not limited to): Non-Alzheimer's Dementia, Altered Mental Status, unspecified. R13's MDS (ARD 12-5-23) documents: BIMS summary score = 9, Active Diagnoses (not limited to): Non-Alzheimer's Dementia, Psychotic Disorder, and Altered Mental Status, unspecified.

Based on interviews and record reviews, the facility failed to notify the physician of abnormal laboratory test results for one resident (R7) out of three reviewed for physician notification in a sample of 18. R7's elevated sodium level (sodium 151, normal range is 135-145) was reported to this facility on 1/17/24 at 4:02pm and not reviewed by nursing staff until 1/18/24 at 2:54 AM. This result was not communicated to R7's physician prior to R7 being admitted to the hospital on 1/19/24 at 9:20pm with diagnoses including dehydration and elevated sodium level (sodium 158). Findings include: On 2/8/24 at 1:50 PM, V35 NP (Nurse Practitioner) stated that V35 would expect the nurse to notify her of all abnormal laboratory results. V35 denied being made aware that R7's sodium level was elevated (151) on 1/17/24. V35 stated that she would have given the nurse an order to start intravenous fluids to reduce R7's sodium level to within normal range. V35 stated that V35 also would have ordered follow up laboratory testing to monitor R7's sodium level. On 2/8/24 at 1:55 PM, V34 NP stated that V34 expects the nurse to call with all abnormal laboratory results. On 2/8/24 at 2:45 PM, V3 LPN (Licensed Practical Nurse) stated that every nurse should check the dashboard in assigned residents' electronic medical record to see if any laboratory results have been reported and if any are abnormal. V3 stated that the nurse should note any test results reviewed and relay results to the NP or Physician. V3 stated that there is no way to know if test results have been reviewed by the nurse and relayed to the NP/Physician, if the nurse does not document this has been done. V3 stated that R7 has a gastrostomy tube and receives water flushes for hydration. V3 stated that he does not recall seeing R7's laboratory results from 1/17/24. V3 stated that V3 was not aware R7's sodium level was elevated. V3 stated that the nurse should call all abnormal laboratory results. R7's laboratory test results, dated 1/17/24, were reported/uploaded into R7's electronic medical record at 4:02 PM and were flagged with a yellow triangle symbol noting abnormal test results. R7's sodium level was 151 (normal range is 135-148). On 1/13/24, R7's sodium level was 141. R7's hospital record, dated 1/19/24 - 1/28/24, notes R7's sodium level was 158. R7 was admitted to the intensive care unit with diagnoses dehydration and elevated sodium level. R7 was treated with intravenous fluids and increased water flushes via gastrostomy tube to decrease R7's sodium level.

Based on observation, interview, and record review, the facility failed to follow their abuse prevention policy and procedures by failing to protect 1 of 3 residents (R1) in the sample from abuse by a staff member. This failure resulted in R1 being pushed to the bed, forcibly restrained, and roughly suctioned by a respiratory therapist (V3) after a physical struggle. This failure also led to R1 expressing fear, anger, and frustration with facility for not preventing further contact with this staff member after the resident reported the incident to his nurse and family member. This resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on 12/25/2023 when V3 (Respiratory Therapist) physically abused R1 and satisfied interventions were not implemented to prevent it from happening again. The immediacy was removed on 01/07/2024. On 01/09/2024 the Administrator (V1) was notified of the Immediate Jeopardy and provided the IJ template. The facility presented an initial removal plan on 1/09/2024. After a modification of the plan was done and resubmitted the removal plan was approved on 01/10/2024. Although, the immediacy was removed the facility remains out of compliance at a level 2 until the facility has an opportunity to evaluate the effectiveness of the removal plan. Findings include: R1 is an alert and oriented [AGE] year-old with diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. On 1/5/24 at 11:45 AM, R1 was observed in bed watching television, appeared alert and oriented, able to recall events of an incident, and able to respond to questions appropriately when asked. R1 stated that he was slapped by a respiratory therapist while he was being suctioned around Christmas time and that it happened on two separate occasions. R1 indicated he ignored the first time it had occurred but could not ignore the second time because he realized it was now done on purpose. R1 then appeared distraught and became emotional when describing the events that occurred and added that the respiratory therapist pushed him on the bed and fought with him to get a tube down his throat. Surveyor tried to calm the resident and asked the resident if he was able to write the events down on paper, so he didn't have to struggle to talk through his trachea. R1 wrote on a piece of paper a similar statement he made with the surveyor that the respiratory therapist slapped him for coughing two times and that he told a nurse supervisor the next day. R1 added on this statement that he saw the respiratory therapist the next day and proceeding days thereafter and that he did not feel safe when he saw him. 1/5/24 at 12:30 PM, V1 Administrator stated, The incident was reported to me on Christmas day around 3 PM but the incident happened on Christmas eve. I interviewed V3 (Respiratory Therapist) on Christmas day over the phone and I suspended him that day. It was reported that V3-respiratory therapist was standing on the left-hand side of the bed and the resident coughed and mucus came out and that the respiratory therapist slapped him on the face. I asked him to describe the employee and R1 said he was tall with long straight white hair. He did identify him as V3. Every time I spoke with (R1) he told me the same story, so it was consistent. The only thing that changed was that was that it was the left side of the face, not the right. I spoke with his sister, and she requested that he (V3) not take care of the resident again, but I explained to her that if something happened, and that the resident needed care, that two people would come in just in case if it was an emergency. Surveyor asked why nurses or other staff couldn't respond to the emergency, V1 had no response except to say, We always have two respiratory therapists at night. Surveyor asked how she ensured that V3 never came into R1's room at night since there is no supervisor at night and the respiratory office is on the same floor close to R1's room, V1 stated, To my knowledge V3 has not come in to service (R1). On 1/5/24 at 2:20 PM, V3-Respiratory Therapist came to the facility to be interviewed by the surveyor. The VP of Clinical Operations (V 4) was requested to be present in the room. V3 stated, Everybody knows that since he has been here (referring to the resident) he's been giving a hard time to all the staff, nurses, staff CNA's. He is refusing everything as far as respiratory care is concerned. He is totally refusing suctioning and in short, he doesn't like to be bothered. Sometimes he's in good mood then he will let you suction him. Everybody knows this. I reported to V11(Respiratory Director) and when I reported it to her, she said try to make the best and don't force him. Also, he just doesn't cooperate. He fights and wants me to suction him while you are standing. That's not easy and he wants to lie down in bed. It has happened 2-3 times. I tried to get him in bed. He was standing so I had to push him to the bed. I struggled with him to put him in bed for his safety. I pushed him to bed and struggled and he still wanted to get up, so I had to hold him down and check his saturation. Surveyor asked if he asked for any assistance, V3 stated, I did not get any help. I suctioned him a little bit, he was very mad, and he was pulling my gown repeatedly and he was trying to push me away. I was trying to hold his hand and I pushed his hand away from my lab coat. I finished suctioning and tried to check his oxygen saturation. He coughed when he was lying down and when he coughed out his phlegm, I turned my face. I never touched his face when he coughed. Surveyor asked if he should have returned later when the resident calmed down, V3 stated, No, I struggled with him and he's stronger than me. I even told the administrator that I struggled with the man and that I was upset about the whole thing. Surveyor asked V3 how upset it made him, V3 stated, I was a little upset, but then I got very upset because I couldn't suction him thoroughly. He constantly fought me. I told the patient care tech and the nurse at the station as soon as I left the room, I told them to watch for that guy, he is out of control. Surveyor asked if at any point he had to manipulate the resident's face during suctioning that could have been construed as a slap, V3 stated, No I never touched his face. (V3 became argumentative with surveyor and began lecturing surveyor of the location of the trachea). V3 stated, If you knew where his trachea is then you'd know his trachea doesn't move so I didn't do anything to him like that. Surveyor asked V3 to go through the events again for clarity in case anything was missed, V3 stated, The resident coughed two to three times. At no time did his cough hit me. Because of the struggle and I suctioned him real hard, and I was upset, not frustrated. I had to press his hands down so I could suction him. I was moving his hand away and I did not stabilize his face. The trachea remains the same and I don't need to touch his face. I had to restrain his hands. There was another respiratory therapist on duty there but she was busy, so I did not get any help. During and after the interview, V3 affirmed and repeated his statements to the surveyor and to V4. On 1/6/24 at 12:45 PM, R1 was observed seated in a chair in an upright position and was asked how he was doing, R1 stated that he was still upset about the situation that happened to him on Christmas and that V3 was still around after that occurred. R1 became upset and stated that no one did anything to V3 after he was slapped by him and indicated that he felt the facility chose not to believe him when he reported it to the nurse of what happened. R1 stated, I told my sister, and she told me she would take care of it. On 1/6/24 at 1:15 PM, R1's sister V15 requested to meet with surveyor. V15 stated, I was informed by the facility you were here. I just got back from the police station. I've been telling the administrator (V1) that I did not want V3 to ever come in to take care of my brother, but she kept giving me excuses as if they didn't believe my brother. V1 told me that in case of an emergency that V3 needed to go into my brother's room, but he would take someone with him. I was like, why couldn't anyone else do that in an emergency, the guy slapped my brother! I told her (V1) why can't you just call 911? On 1/6/24 at 2:30 PM, V4 (VP of Clinical Operations) stated, I told the administrator and director of nursing to take V3 off the schedule and we walked him out. Our plan is to terminate V3 and train our staff. I thought that there's a language barrier with V3, but he speaks good English. The administrator should've brought him in to conduct an in-person for interview. We're changing that process moving forward. At 3:00 PM, V4 returned to surveyor and stated, We terminated him. I'm going to refer the administrator (V1) and DON (V2) for training on how to conduct a thorough investigation including calling the police for any physical abuse, investigate alleged perpetrators in person, and in service when a resident indicates that they do not want to be taken care of by particular staff. We have to consider that to prevent psychosocial effect on a resident. I will have the Assistant DON (V12) conduct the in services for the whole staff on behavioral management. On 1/6/24 at 1:55 PM, V9 (Social Service Director) stated, I met with the resident last night and checked on him on his well-being and how he was doing. I checked to see if he felt safe and felt comfortable in the building and he said he did. He mouthed words and it was very brief, and he didn't want to elaborate too much and said he was ok. He seemed calm and seemed comfortable and didn't see any distress that I saw. I was prompted to see him due to the investigation. The administrator told me to do this. Surveyor asked if it was her role to conduct a psychosocial assessment during these types of incidents and V9 affirmed that it was. Surveyor asked why no such assessment was conducted during the first alleged incident that was reported by R1 on 12/25/23, V9 stated, I was on vacation the whole week, so I was not aware of it. I have an assistant V13 but from my knowledge no one directed him to be seen after the initial allegation. Surveyor asked what type of abuse training she received, V9 stated, As directed by the administrator our procedure is to follow up after any alleged abuse. I was not informed of the one that happened on Christmas day. On 1/9/24 at 2:10 PM, V14 (Medical Director) stated, I've been discussing this incident the last few days and am very aware of what happened. I was told by administration about this RT (respiratory therapist-V4) and about his history. That is a pattern. I did discuss with facility with the abuse situation on our aspect that has to be answered. Sometimes this therapist or any staff they are not children and should know how to respond to abuse. They all know abuse and should know how respond. When the new company took over the operations, they let this facility go down and didn't pay any attention. After this new operation, I took medical directorship about a month ago, so I have been working with management including abuse prevention. protecting residents is what I am working with the facility, and I am working closely with the facility. I have scheduled a meeting next Thursday. Abuse will be included in the QAPI meeting. On 1/11/24 at 11:15 AM, V14 Medical Director met with surveyor and stated, I am working closely with administration to improve their function. This incident should not have happened and even though the resident and the respiratory therapist stories don't match we still know that some abuse occurred. Surveyor asked whether administration acted effectively and efficiently to maintain the safety and psychosocial well-being of the resident, V14 stated, Well in hindsight not for this instance, that is why I am here as part of quality assurance meeting to discuss changes moving forward. Surveyor asked since the original incident occurred last year on 12/24/23, whether a doctor should have examined him by then, V14 stated, I have not seen him, yet, but I am on my way to see R1 after this meeting. Facility policy on abuse preventions dated 2/2017 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. On 01/11/2024, the surveyor confirmed via observation, record review and interview that the facility did the following to remove the immediacy: 1. Affected resident corrective actions. A. Resident #1 - resident was immediately assessed by the ADON and the DON to identify signs of injury. There was no sign of injury identified resulting from the deficiency. Per assessment completed by the ADON and DON on 1/5 at 5:46 pm the resident did not exhibit changes in speaking, no changes in voice, no sign of noisy breathing, no bruising or swelling in the neck area and denies any pain on the neck area. (Initiated and completed on 1/5/2024 at 5:46 pm) B. Resident #1 - Psychosocial well-being of the resident was assessed by the Social worker to identify the need for additional interventions. The resident was calm, cooperative at the time. Resident reports he feels safe and comfortable in the facility. (Initiated on 1/6/2024 at 10:43 am and completed on 1/8/2024 at 2:27 pm). C. The resident was immediately notified by the administrator of the corrective actions in place. (Initiated and completed on 1/5/2024 at 6 pm) D. The resident's responsible party was immediately notified by the Administrator of the additional information gathered during IDPH investigation and the facility's corrective action. (Initiated and Completed on 1/5/2024 at 5:45pm) E. Alleged Perpetrator was escorted out of the facility by the Administrator and the DON on 1/5/2024 at 2:30 pm. F. Local Police Department was immediately notified by the Administrator of the additional information collected by the facility during IDPH investigation. (Completed on 1/5/2024 at 2:35 pm) G. A new investigation was immediately initiated to include interview of all staff who worked when the incident occurred. (Initiated on 1/5/2024 at 2:30 pm and expected date of completion will on or before 1/12/2024). An initial Abuse Reportable was submitted to the Illinois Department of Public Health on 1/5/2024 at 4:29 pm. 2. Immediate Actions and Actions to prevent recurrence. (Initiated on 1/5/2024 at 5:46 pm and will continue until all staff are in-serviced and trained prior to the start of their shift.) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. All residents who received care from the alleged perpetrator who are cognitively intact and interviewable were interviewed by the Administrator to identify for Abuse. If any of the residents who is cognitively intact and interviewable reports any allegation against the alleged perpetrator or any staff or resident, the facility's abuse policy will immediately be enacted. (Initiated on 1/5/2024 at 5:45 pm and Completed on 1/9/2024 at 1:30 pm) B. Skin assessments were completed by the Director of Nursing and the Assistant Director of Nursing to all residents who are cognitively impaired and/or not interviewable and who received care from the alleged perpetrator to identify any signs of injury. (Initiated on 1/6/2024 at 10 am and Completed on 1/9/2024 at 1:30 pm) C. All residents who received care from the alleged perpetrator will be monitored for adverse effects three (3) times a week for two (2) weeks. (Initiated on 1/5/2024 at 5:45 pm and will be completed on 1/19/2024) D. Based on the results of both assessments, the IDT (interdisciplinary team) which includes the DON, ADON, Social Service Director, Administrator, MDS (minimum data set) nurse, will determine the appropriate intervention to protect the residents. (Initiated on 1/5/2024 at 10:44 pm and Completed on 1/9/2024 at 12:00 noon). E. All staff who worked during the shift (including Agency staff) when the alleged incident occurred were interviewed by the administrator. (Initiated on 1/5/2024 at 5:45 pm and Completed on 1/7/2024 at 5:00 pm) F. All staff who worked in the unit (including Agency staff) were interviewed by the administrator. (Initiated on 1/5/2024 5:45 pm and completed on 1/7/2024 at 1:00 pm) G. The VP of Policies & Staff education/VP of Regulatory Compliance & Clinical Services will provide the Administrator/DON/SSD (social service director)/ADON/RT Director with education related to the above-mentioned Policies. (Initiated and completed on 1/5/2024 at 4 pm) H. The Administrator and DON reviewed the facility's policies which includes but not limited to: a. Abuse b. Behavior Management c. Suctioning There was no revision necessary. This was initiated and completed on 1/5/2024 at 4:30 pm. I. After the training, DON/ADON will provide all nurses with training related to the above-mentioned policies, focusing on Behavior Management, Abuse and Neglect, Burn out Prevention and Management. The training will include posttests and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from a trained department head, DON, ADON, RT Director or Administrator. (Initiated on 1/6/2024 at 10 am and will continue until all nurses have been trained and in-serviced.) J. After the training, RT Director will provide all Respiratory Therapists with training related to the above-mentioned policies, focusing on Behavior Management, Abuse and Neglect, Burn out Prevention and Management. The training will include posttests and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from a trained department head, DON, ADON, RT Director or Administrator. (Initiated on 1/6/2024 at 10 am and will continue until all Respiratory Therapist has been trained and in-serviced.) K. New hires will be trained by the DON, ADON, SSD, RT Director or Administrator. To validate retention of knowledge, posttests will also be used, and the acceptable score is 100%. All staff members who are currently on vacation will also receive the same education via telephone and complete the post test. The staff members were also provided with the same educational materials. Upon their return to work, the Administrator/DON/ADON/SSD will also provide a review of the training provided. L. The facility will utilize the same process of providing the education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. An agency staff will not start the shift without finishing the training first. M. The VP for Regulatory Compliance and Clinical Services/VP of Education and Policy will provide training to the Administrator, DON/ADON on the following but not limited to: a. Abuse & Neglect, b. Law enforcement notification c. Thorough investigation d. Best practice interview - interview alleged perpetrator in person if possible. e. Interview all staff when an alleged event occurs. N. The social workers will conduct an assessment on all residents to identify: a. Residents who are vulnerable for abuse, b. Identify residents with aggressive behavior. (Completed on 1/5/2024) O. The Social workers will review and revise, if necessary, all care plans of residents who are identified as: a. High risk for abuse, b. Noted with aggressive behavior (Completed on 1/5/2024) P. The DON/ADON/SS/Administrator will train all staff the interventions as indicated in the resident's plan of care. (Completed 1/6/2024) Q. The DON/ADON will review the process of communicating care plan interventions with the staff. (Completed 1/6/2024) There is no revision necessary at this time. R. The Administrator/DON/ADON/RT Director/SSD will conduct daily rounds and interview at least five employees daily to gauge knowledge retention and determine if additional training is required. S. During the weekends, the assigned MOD (manager on duty) will conduct unit rounds to identify any concern related to resident's safety. Any identified concern will be addressed immediately. 3. The facility will reinforce the following process. A. The IDT will review behavior monitoring tracking to ensure completion. An Audit Tool was started on 1/8/2024. B. The HR Director will review all personnel files to ensure background checks and orientation are complete. (Initiated on 1/7/2024 at 8 am and will continue until all employees files have been completely reviewed) C. An audit will be conducted weekly by Social Services Director/Administrator to ensure that current residents, and new admissions identified to be at risk for abuse have appropriate care plans and care plans are implemented to protect the residents. (This will be initiated on 1/6/2024 and will continue for 4 weeks. D. The DON/Administrator/Social Services staff will conduct clinical rounding and observations to identify non-compliance. Staff shall be randomly evaluated by the Administrator/DON/Social Services on their knowledge of the facility's policy on abuse and management of aggressive/violent behavior. (This will be initiated on 1/6/2024 and will continue for 4 weeks.) E. All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. F. The Administrator will monitor completion of this plan of removal.

Based on observation, interview, and record review, the facility failed to follow their abuse prevention investigation procedures by failing to conduct a thorough investigation of an alleged abuse by a staff member; Failed to remove access by the alleged perpetrator to the victim; and failed to provide ongoing assurances of protection after appeals from the resident and family member to disallow alleged staff member access to the resident. This failure affects 1 of 3 residents (R1) in the sample and led to R1 being physically abused, restrained, and roughly suctioned by a staff person, and continued fearfulness of staff person's return. Findings include: On 1/5/24 at 12:30 PM, V1 Administrator and designated abuse prohibition designee stated, An incident of abuse was reported to me on Christmas day around 3 PM about a staff person slapping R1 but the incident happened on Christmas eve. I interviewed V3 (Respiratory Therapist) on Christmas day over the phone and I suspended him that day. It was reported that V3 was standing on the left-hand side of the bed and the resident coughed and mucus came out and that the therapist slapped him on the face. I asked him to describe the employee and R1 said he was tall man with long straight white hair. He did identify him as (V3). Every time I spoke with (R1) he told me the same story, so it was consistent. The only thing that changed was that it was the left side of the face, not the right. I spoke with his sister, and she requested that he (V3) not take care of the resident again, but I explained to her that if something happened and that the resident needed care, that two people would come in just in case if it was an emergency. Surveyor asked why nurses or other staff couldn't respond to the emergency, V1 had no response except to say, We always have two respiratory therapists at night. Surveyor asked how she ensured that V3 would never come into R1's room at night since there is no supervisor at night and the respiratory office is on the same floor close to R1's room, V1 stated, To my knowledge (V3) has not come in to service (R1). R1 is an alert and oriented [AGE] year-old with diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. On 1/5/24 at 11:45 AM, R1 was observed in bed watching television, appeared alert and oriented, able to recall events of the incident, and able to respond to questions appropriately when asked. R1 stated that he was slapped by a respiratory therapist while he was being suctioned around Christmas time and that it happened on two separate occasions. R1 indicated he ignored the first time it had occurred but could not ignore the second time because he realized it was now done on purpose. R1 then appeared distraught and became emotional when describing the events that occurred and added that the respiratory therapist pushed him on the bed and fought with him to get a tube down his throat. Surveyor tried to calm the resident and asked the resident if he was able to write the events down on paper, so he didn't have to struggle to talk through his trachea. R1 wrote on a piece of paper a similar statement he made with the surveyor that the respiratory therapist slapped him for coughing two times, and that he told a nurse supervisor the next day. R1 added on this statement that he saw the respiratory therapist the next day and on following days thereafter, and that he did not feel safe when he saw him. On 1/5/24 at 11:45 AM, surveyor affirmed R1's room to be on the same floor and in close proximity to the respiratory therapist office. On 1/5/24 at 2:20 PM, V3 (RT/ Respiratory Therapist) came to the facility to be interviewed by surveyor with V4 (VP of Clinical Operations) present during the interview. During this interview, V3 indicated that R1 was a difficult resident for all staff to contend with and that he struggled with the resident during care. V3 stated that he pushed the resident to the bed, struggled with the resident throughout in an effort to suction the resident but did not obtain any assistance from anyone or return at a different time to conduct care. V3 added that during the struggle with the resident he had to forcibly restrain R1's hands and that the resident became mad. V3 went on to say that he became upset to the extent he had to suction the resident in a hard manner. On 1/6/24 at 1:15 PM, R1's sister V15 requested to meet with surveyor. V15 stated, I was informed by the facility you were here. I just got back from the police station. I've been telling the administrator (V1) that I did not want V3 to ever come in to take care of my brother, but she kept giving me excuses as if they didn't believe my brother. V1 told me that in case of an emergency that V3 needed to go into my brothers room, but he would take someone with him. I was like, why couldn't anyone else do that in an emergency, the guy slapped my brother! I told her (V1) why can't you just call 911? On 1/5/24 at 11:45 AM surveyor affirmed R1's room to be on the same floor and in close proximity to the respiratory therapist office. Reviews of respiratory ventilator flow sheets showed V3 returned on duty 12/31/23 with easy access to the resident. Review of V3's employee file showed one abuse Inservice training upon hire in 2022 and no other abuse prohibition training provided throughout 2023, and no abuse training immediately after the alleged incident occurrence on 12/25/23 or upon V3's return to duty. On 1/6/24 at 1:55 PM, V9 (Social Service Director) stated, I met with the resident last night and checked on him on his well-being and how he was doing. I checked to see if he felt safe and felt comfortable in the building and he said he did. He mouthed words and it was very brief, and he didn't want to elaborate too much and said he was ok. He seemed calm and seemed comfortable and didn't see any distress that I saw. I was prompted to see him due to the investigation. The administrator told me to do this. Surveyor asked if it was her role to conduct a psychosocial assessment during these types of incidents and V9 affirmed that it was. Surveyor asked why no such assessment was conducted during the first alleged incident that was reported by R1 on 12/25/23, V9 stated, I was on vacation the whole week, so I was not aware of it. I have an assistant V13 but from my knowledge no one directed him to be seen after the initial allegation. Surveyor asked what type of abuse training she received, V9 stated, As directed by the administrator our procedure is to follow up after any alleged abuse. I was not informed of the one that happened on Christmas day. On 1/6/24 at 2:30 PM, V4 (VP of Clinical Operations) stated, I told the Administrator and Director of Nursing to take V3 off the schedule and we walked him out. Our plan is to terminate V3 and train our staff. The administrator should've brought him in to conduct an in-person for interview. We're changing that process moving forward. At 3:00 PM, V4 returned to surveyor and stated, We terminated him. I'm going to refer the Administrator (V1) and DON (V2) for training on how to conduct a thorough investigation including calling the police for any physical abuse, investigate alleged perpetrators in person, and Inservice when a resident indicates that they do not want to be taken care of by particular staff. We have to consider that to prevent psychosocial effect on a resident. I will have the Assistant DON (V12) conduct the in-services for the whole staff on behavioral management. On 1/9/24 at 2:10 PM, V14 (Medical Director) stated, I've been discussing this incident the last few days and am very aware of what happened. I was told by administration about this RT (respiratory therapist-V4) and about his history. That is a pattern. I did discuss with facility with the abuse situation on our aspect that has to be answered. Sometimes this therapist or any staff they are not children and should know how to respond to abuse. They all know abuse and should know how respond. When the new company took over the operations, they let this facility go down and didn't pay any attention. After this new operation, I took medical directorship about a month ago, so I have been working with management including abuse prevention. protecting residents is what I am working with the facility, and I am working closely with the facility. I have scheduled a meeting next Thursday. Abuse will be included in the QAPI meeting. On 1/11/24 at 11:15 AM, V14 Medical Director met with surveyor and stated, I am working closely with administration to improve their function. This incident should not have happened and even though the resident and the respiratory therapist stories don't match we still know that some abuse occurred. Surveyor asked whether administration acted effectively and efficiently to maintain the safety and psychosocial well-being of the resident, V14 stated, Well in hindsight not for this instance, that is why I am here as part of quality assurance meeting to discuss changes moving forward. Surveyor asked since the original incident occurred last year on 12/24/23, whether a doctor should have examined him by then, V14 stated, I have not seen him yet, but I am on my way to see R1 after this meeting. Facility policy on abuse preventions dated 2/2017 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Investigation Procedures: a review of the initial written reports; completion of a written report on the status of the investigation within 24 hours of the occurrence; An interview with the persons reporting the incident; Interviews with any witnesses to the incident; Where appropriate, an interview with the resident's attending physician or psychiatrist; A review of the medical records of any residents involved in the occurrence, including care plans and medications; If the accused individual is an employee, a review of the personnel file to check for references, background check, and documentation of orientation and training; Interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; interviews with other residents to which the accused individual has regular contact; An interview with the accused individual; A review of all circumstances surrounding the incident.

Based on observation, interview, and record review, the facility failed to monitor and implement a treatment plan for one resident who was at moderate risk for skin breakdown and readmitted to the facility with a stage two pressure sore.This affected one of three residents (R11) reviewed for pressure sore prevention. This failure resulted in R11's wound worsening and progressing to a stage 4. Findings include: R11 was admitted to the facility on [DATE] with a diagnosis of dysphagia, respiratory failure, hemiplegia, cerebral infarction, need for assistance with personal care, tracheostomy status, and lack of coordination. R11 had no documented wounds on admission. R11's Braden scale dated 9/13/23 documents a score of 13 which indicates moderate at risk. R11's progress note dated 10/17/23 documents: R11 was readmitted to facility from local hospital by ambulance via stretcher accompanied by husband. Resident is full code, has left side weakness with right sided contraction, trach collar and wound on the sacrum area. R11's treatment administration record and physician order sheets for October 2023 does not document any wound treatments or orders for R11's sacrum. Facility shower sheets dated 10/19/23 and 10/23/23 document an open area on the sacrum. R11's progress note dated 11/1/23 documents: writer informed by CNA that resident has open wound on buttocks, shower sheet sent to wound care to follow up. R11's wound evaluation dated 11/2/23 documents: new wound sacrum measuring 8.7 cm length x 8.18 cm width. On 12/5/23 at 12:12 PM, V2 (Wound Care Nurse) said all resident's skin is assessed upon admission/readmission within a day. A progress note would be documented in the medical record and if any skin breakdown a skin assessment would be completed. V2 said they do not always know when residents return form hospital stay and was unaware of any skin concerns with R11 until 11/2/23. V2 said 11/2/23 is the first skin assessment documented on R11. On 12/1/23 at 2:19 PM, V12 (Director of Nursing, DON) said wound care should conduct an assessment by the next day of any new admission or readmission. R11's initial Wound Doctor visit dated 11/8/23 documents unstageable necrotic wound has revealed underlying deep tissue at muscle. This wound has revealed itself to be a Stage 4 pressure injury. Wound measurements 8.0 x 10.0 x not measurable due to necrosis. R11's wound evaluation dated 11/27/23 documents: length 9.86 x 8.59 cm width. R11's Wound Care Doctor note dated 11/29/23 documents: Stage 4 pressure ulcer measuring 9.1 x 9.7 x 2.2 cm. R11's skin plan of care dated 9/18/23 documents: assess and document of progress areas weekly; observe and assess regularly. On 11/30/23 at 12:52 PM, on third floor unit, R11 was observed on her back in the middle of the bed with hands crossed at her wrist on her stomach. Brace observed to her right hand and lower arm. A wedge pillow was observed under her left side of her upper body from her waist to her shoulder. Observations were conducted on R11 every 15 minutes with no staff observed providing any repositioning to the resident and resident remained in same position. On 11/30/23 at 3:23 PM, V9 (CNA) said, she repositioned R11 around 1:00 PM. V9 said, she is getting ready to reposition R11 now, and R11 was in the same position from when she repositioned her around 1:00 PM. R11 needs to be repositioned every two to three hours. On 12/1/23 at 2:19 PM, V12 (Director of Nursing, DON) said turning and reposition should be conducted at least every two hours. On 12/1/23 at 12:18 PM, V15 (Wound Care Nurse) said R11 should be turned and repositioned every 2 hours to relieve pressure from the wound. R11's plan of care for pressure sore dated 11/2/23 documents following interventions: administrator treatments as ordered; remind/assist to change position at least every two hours. R11's skin plan of care dated 9/18/23 documents: assess and document of progress areas weekly; observe and assess regularly. Facility skin management policy reviewed, dated 6/2023 document under treatment guideline for stage two pressure injuries: turn and reposition every two hours, pressure redistribution devices for bed and/or chair, hydrocolloid dressing; transparent film dressing, hydrogel, thin foam or composite dressing. On 11/30/23 at 3:35 PM, R11 was observed with a bordered dressing over her sacrum with blood noted on dressing. The adhesive border was observed to be on the wound bed. R11 was observed on top sheet, mattress pad and incontinence brief on air mattress which was set to weight of between 210 and 250 pounds. On 12/1/23 at 12:05 PM, R11's wound care was performed by V15 (Wound Care Nurse). R11 was observed on air mattress with sheet, mattress pad soiled with dried serosanguinous rings, and incontinence product. R11 had bed sheet indentations to her upper back confirmed by V15. R11 had a bordered gauze dressing that was undated and adhesive tape on the wound bed. It appeared to be the same dressing observed on 11/30/23. The dressing was removed with no packing noted with in the wound. Dressing had moderate amount of serosanguinous drainage. Area cleaned and packed and orders followed. On 12/1/23 at 12:18 PM, V15 (Wound Care Nurse) said, The air mattress should only contain a sheet and/or a pad or incontinence brief. The air mattress should not have all three layers of linen because it will not restrict the airflow. V15 verified the weight setting on R11's air mattress that was set between 210 and 250 pounds . V15 verified R11's weight in her medical record and said it was on the wrong weight which causes the mattress to be more firm not beneficial wound healing. V15 said the old dressing that was removed was not the correct dressing and there was no packing within the wound. On 12/1/23 at 2:19 PM, V12 (Director of Nursing, DON) stated, Floor nurses are expected to follow the physician orders for wound care and have access to all the supplies. Wound care is responsible for ensuring the air mattress are set appropriately. On 12/6/23 at 1:10 PM, V16 (Wound Doctor) said he would expect his wound orders to be followed as written. V16 said the wound should be packed with saline gauze if topical antiseptic (Dakins) solution not available to keep the wound moist and clean. Topical antiseptic (Dakin's) solution is an antimicrobial to help clean out bacteria and he would expect to be informed of any treatments missed for more than 24 hours. V16 would expect staff to follow facility protocols for turning and repositioning and mattress settings. R11's weight summary documents weight on 11/14/23 163.6 pounds R11's Physician Order Sheet dated 11/24/23 documents: sacrum, clean with dakins, dry with gauze, apply metro gel, insert dakin gauze sponge and cover with abdominal pad (ABD) secure with tape. R11's plan of care for pressure sore dated 11/2/23 documents following interventions: administrator treatments as ordered; remind/assist to change position at least every two hours. R11's skin plan of care dated 9/18/23 documents: assess and document of progress areas weekly; observe and assess regularly. Facility skin management policy dated 6/2023 documents under treatment guideline for stage two pressure injuries: turn and reposition every two hours, pressure redistribution devices for bed and/or chair, hydrocolloid dressing; transparent film dressing, hydrogel, thin foam or composite dressing. Facility skin care prevention policy dated 1/2023 documents: nursing department will review all new admission/readmissions to put a plan in place for prevention based on residents activity level, comorbidities, mental status and other pertinent information, all residents will be evaluated for changes in skin condition weekly. All residents unable to reposition them selves will be repositioned as needed

Based on interviews and record reviews, the facility failed to provide appropriate and sufficient supervision to prevent avoidable accidents for two residents (R2 and R19) out of three residents reviewed for falls in a sample of 34. This failure resulted in R19 sustaining a right pelvic fracture. Findings include: 1. On 9/5/23 at 4:15 pm, V11 (Nurse) stated that V11 recalls R19's fall incident, but does not recall the date it occurred. V11 stated that the CNA (Certified Nurse Aide) found R19 on the floor in R19's room. V11 stated that R19 is alert with confusion. V11 stated that V11 performed a head to toe assessment and assessed R19's range of motion. V11 stated that V11 did not note any injuries. V11 stated that R19 was sent to the hospital for evaluation because it was an unwitnessed fall. On 9/6/23 at 12:25 pm, V39 (Restorative Aide) stated that R19's fall precaution intervention is bed in lowest position. V39 stated that R19 is non-ambulatory. V39 stated that V39 has not seen R19 try to walk on own. V39 stated that the restorative nurse informed the aides what interventions needed to be put in place after a resident falls. V39 stated that the restorative nurse's last day was 9/1/23 and at this time, there isn't a restorative nurse. On 9/6/23 at 12:40 pm, V4 (Restorative Aide) stated that R19 is non-ambulatory. V4 stated that staff pivot R19 from bed to wheelchair. V4 stated that R19 does not attempt to self propel wheelchair or attempt to ambulate on own. R19's medical record notes R19 with diagnoses including, but not limited to, dementia, generalized muscle weakness, unsteadiness on feet, and falls. R19's medical record notes on 8/11/23, V11 RN noted R19 found on the floor by CNA as she was doing her rounds, unwitnessed, and V11 was notified. V11 went immediately to R19's room and saw R19 on the floor on her bottom by her bed. No injuries noted, vital signs taken, within normal limits, and range of motion within baseline. R19 stable, no complaints of pain, not in any distress. R19 transferred back onto bed, made clean and comfortable. Nurse practitioner made aware and ordered to send R19 to the hospital for evaluation. R19's fall care plan, dated 5/9/23, notes R19 is at high risk for falls related to poor safety awareness. R19's MDS (Minimum Data Set), dated 8/2/23, notes R19's cognition is moderately impaired for daily decision making. R19 requires extensive assistance with bed mobility. R19 is totally dependent on two staff members for all transfers. R19 is totally dependent on one staff member for toileting/incontinence care. This facility's investigation of R19's fall incident notes R19 is alert and oriented x 1 with confusion. R19 has poor safety awareness and impulsivity due to dementia. The agency CNA assigned to provide care for R19 on 8/11/23 was interviewed by facility staff at the time of the incident. Per the CNA's interview, R19's bed was in the lowest position, call light was within reach, and R19's bedside table was by R19's bed where R19 could easily reach her stuff. There is no documentation found in R19's medical record or care plan noting R19 has a behavior of being impulsive. R19's behavior charting, dated 8/6/2023 at 12:23 pm noted R19 in the common room area where lunch is being served where she is closely supervised. R19 is seen sliding off her wheelchair onto the floor. Actions taken by staff: Reposition R19. R19 was placed on a 1:1 for feeding. Where she continued to attempt to slide off her wheelchair. The nurse re-positioned R19 x2. After lunch R19 was then placed back to her bed. Continuously rounding by staff and fall precautions in place. Where R19 was noted to be calm and resting. Any new treatment or interventions initiated: Monitor R19 closely. Continuously rounding by staff. Continue with fall precautions in place. R19's behavior charting, dated 8/10/23 at 2:42 pm, noted R19 in the common room area where she is closely supervised. R19 is seen sliding off her wheelchair onto the floor. Actions taken by staff: Reposition R19. R19 was placed on a 1:1 for feeding. Where she continued to attempt to slide off her wheelchair. The nurse re-positioned R19 x 2. After lunch R19 was then placed back to her bed. Continuously rounding done by staff and fall precautions in place. Where R19 was noted to be calm and resting. Any new treatment or interventions initiated: No. 2. On 9/6/23 at 10:50 am, V36 CNA stated that R2 requires two person assist for all care. V36 stated that all residents that are totally dependent for care should have two CNAs present during care. V36 stated that when R2 coughs, his legs will move towards the sides of bed. V36 stated that staff should use pillows and wedges to prevent R2 from falling out of bed. On 9/6/23 at 3:00 pm, V28 (Wound Care Nurse) stated that R2 has a history of moving legs to the sides of bed. V28 stated that these are not purposeful movements. V28 stated that when R2 coughs, R2's legs will sometimes move. Review of R2's medical record notes R2 with diagnoses including chronic respiratory failure with hypoxia (lack of oxygen), gastrostomy, anoxic brain damage, and tracheostomy-ventilator dependent. R2's MDS, dated [DATE] notes R2 with severely impaired cognition . R2 is totally dependent on two staff members for bed mobility, transfers, and toileting. R2 has impairment in range of motion to all extremities. Review of R2's medical record, dated 9/1/23 at 8:10 pm, notes the CNA reported that during resident care, the CNA turned R2 to the left side to clean R2. R2 started to move leg and fell on floor. R2 sustained a small scratch on right eyebrow and was transported to the hospital for evaluation. R2 returned from hospital by ambulance via stretcher. R2 came back with no new orders and discharge papers. R2 has a laceration to the right eyebrow with a bandage over eyebrow. R2's fall care plan notes R2 is at risk for falling related to dependent with ADLs (activity of daily living) and transfers. R2 requires staff anticipation with ADLs. This facility's fall prevention and management policy, dated 09/2022, notes a fall risk evaluation will be completed on admission, re-admission, quarterly, significant change, and after each fall. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interview and record review, the facility failed to adequately monitor a gastrostomy stoma site for placement and signs/symptoms of infection. This affected one of three residents (R14) reviewed for Gastrostomy tube care. This failure resulted in R14's gastrostomy tube requiring hospitalization and requiring abdominal surgery. Findings include: On 9/5/23 at 2:45 pm, V5 (Nurse) stated that V5 was the one that documented first about R14's abdomen feeling hard on palpation, G-tube (gastrostomy tube) area warm to touch. V5 denied any redness to abdomen. V5 stated that when she attempted to flush R14's G-tube, it was a little tighter (difficult to flush) and R14 appeared to be in pain. V5 stated that she notified V52 NP (Nurse Practitioner), R14's enteral feeding held, an urgent abdominal x-ray was ordered, and intravenous fluids started. V5 stated that when she checked the G-tube for any residual, she did not get any. V5 stated that it was difficult to pull back on syringe. V5 stated that R14's G-tube looked like what appeared to be curdled milk. On 9/7/23 at 12:25 pm, V25 (Nurse) stated that V25 endorsed to oncoming nurse that R14's abdomen was distended, abdominal x-ray ordered. V25 stated that R14's feedings held while waiting for x-ray to be done. V25 stated that V25 did not hold R14's medications or water flushes via gastrostomy tube because only the enteral feedings were held. V25 stated that V25 did not clarify order with nurse practitioner. V25 stated that R14's abdomen was reddened and firm. V25 stated that there was resistance with instilling water and medications via gastrostomy tube. V25 stated that abdominal ultrasound results were obtained on 7/5/23 and the nurse practitioner was notified. Order received to resume G-tube feedings. On 9/13/23 at 9:45 am V2 DON (Director of Nursing)stated that when staff receive order for an urgent x-ray, the nurse is expected to call the outside diagnostic imaging company, and then staff wait for technician to come to facility to complete the testing. V2 stated that depending on the situation, may have to send resident to the hospital if testing cannot be done within 24 hours. V2 stated that if the order is for an urgent abdominal x-ray and the resident is a diabetic, do not want resident to be without feeding for 24 hours, so would send resident to hospital for testing to be done. V2 stated that typically routine testing should be completed within 24 hours, urgent orders should be completed much sooner and the same day. V2 was informed that V52 NP ordered to hold R14's feedings until results known, staff continued to use G-tube (gastrostomy tube) for water flushes and administration of medications. V2 acknowledged that staff should have clarified order with physician/NP regarding water flushes and medications as well as delay in x-ray being done. V2 stated that there is a lack of communication between nurses, between physician/NP and nurses due to the use of a lot of agency nurses. V2 was informed that on 7/7/23, R14 was sent to the hospital due to abnormal vital signs and had a CT (computerized tomography) scan of abdomen that showed R14's G-tube was dislodged and there was fluid collection in the abdominal subcutaneous tissue requiring surgical incision and drainage and debridement. V2 is unsure why abdominal x-ray was changed to abdominal ultrasound as there is no order for an ultrasound. On 9/13/23 at 11:00 am V58 (attending physician) stated that if R14 would have had an abscess, the abdominal ultrasound should have shown fluid collection or abscess. V58 stated that at the time of the ultrasound, there may not have been enough fluid collecting in R14's abdomen to show up. V58 stated that the physician can only order testing based on the information the nurse provides. If the nurse does not let the physician know of any difficulty with flushing G-tube, he will not know. If he had known that, he would have ordered a abdominal x-ray with gastrografin to check G-tube placement. V58 stated that based on the information provided, abdomen hard, reddened, V58 would suspect skin infection. V58 stated that there was a lack of communication between the nurse and V52 NP regarding what was going on with R14. R19's hospital medical record, dated 7/7/23 at 2:12pm, notes R19 presented to the hospital with fever, low blood pressure, and diaphoresis (sweating). The physician's physical assessment noted dry mucus membranes in mouth, rapid heart rate - 148 beats per minute, coarse breath sounds, G-tube with surrounding redness, tenderness, and cellulitis (inflammation), and skin hot. R19's G-tube was flushed with water and the water was coming out of G-tube site. Physician notified. WBC (white blood cell) count 16.2 (normal range is 3.5-10.5). CT (computerized tomography) scan of R19's abdomen noted gastrostomy tube dislodged with the distal tip now positioned in the subcutaneous (under the skin) tissues; large amount of abdominal wall subcutaneous emphysema (air in the tissues under the skin); and diffuse abdominal wall inflammatory fat stranding (thickened fat tissue indicating inflammation or infection in the surrounding tissues) suggesting abscess or instillation of feeding material. R19 was transferred to another hospital due to need for a bed in an intensive care unit. R19 diagnosed with G-tube infection from dislodged G-tube. R19's G-tube was removed and abdomen surgically debrided. R19's abdomen with large subcutaneous fluid collection and displacement of G-tube into the subcutaneous tissue. Review of R14's medical record notes: On 7/3, V5 (nurse) noted g-tube area site is hard to palpate and with abscess. V52 NP notified with order to hold feeding and do urgent abdominal x-ray. On 7/4 at 2:12pm, V25 (nurse) noted abdominal x-ray not done yet, informed V52, ordered to start intravenous fluids and discontinue once abdominal ultrasound result is in, orders carried out. On 7/5 at 6:44 am, V53 (nurse) noted V53 called the outside diagnostic imaging company and spoke with representative in regards to R14's abdominal x-ray. Representative stated someone will be in facility when they have someone available. Endorsed to oncoming shift nurse. On 7/5 at 2:32pm, V25 noted x-ray not done yet, followed up outside company, V25 was informed that somebody will come and do it this afternoon, endorsed accordingly. On 7/6, V52 NP made rounds, informed about redness and tenderness at R14's abdominal wall, V52 noted abdominal ultrasound negative for abscess, but showed some abdominal wall edematous changes. Site is red and painful. area superior and right of g-tube with erythema, edema, warmth, and tenderness. On 7/7, V32 (nurse) noted at 7:40 am noted by respiratory therapist on duty that R14's heart rate is 140 beats/minute. Vital sign checked and blood pressure 100/56, respirations 23 breaths per minute, temperature 97.7, oxygen saturation level 93%. V52 NP notified with order to send R14 to the hospital. All due medication given. R14 left facility at 11:00 am by private ambulance. On 7/7, R14 admitted with diagnosis sepsis. R14 was to be transferred to another hospital for a higher level of care. On 8/29/23, R14 was readmitted status post surgery for infected G-tube site. This facility's tube feeding policy, dated 09/2022, notes to check for G-tube placement using auscultation prior to flushing.

Based on interview and record review the facility failed to follow their antibiotic stewardship policy to ensure one resident was receiving the correct treatment for a urinary tract infection and wound infection, and failed to track the duration of antibiotic therapy, in order to monitor the effectiveness of antibiotic therapy. This affected two of three residents (R9, R12) reviewed for antibiotic therapies. This failure resulted in R9 being hospitalized with a white blood count of 79.1(normal range 3.5-10.5) and diagnosed with septic shock related to sacrococcygeal osteomyelitis and urinary tract infection/cystitis. Findings include: 1. R9 was admitted to the facility on [DATE] with a diagnosis including hemiplegia affecting right side, unspecified dementia with behavioral disturbance, urinary tract infection, vitamin D deficiency, transient ischemic attack and cerebral infarction, hypertension, chronic obstructive pulmonary disease, osteoarthritis right knee, pain in right foot and rhabdomyolysis. R9's wound evaluation and management summary dated 6/28/23 documents: skin tear left buttocks 16 x 19 x 2.0cm, heavy purulent exudate. Wound progress: deteriorated due to infection, patient non complaint with wound care, generalized decline of patient. Deep undermining cavity with purulence expressed. Culture taken and sent by MD for rapid culture and sensitivity. Nurse practitioner started doxycycline on 6/27/23. Will adjust based on sensitivity. On 9/6/23 at 11:04 AM, V37 (Wound MD) said R9's wounds had declined, resulting in the right and left wounds on buttocks merging into one wound. V37 said he ordered a rapid culture for R9's buttocks wound due to purulent drainage and possible abscess. V37 said R9 was being treated with doxycycline and was awaiting culture results. V37 said he received the results but said it was on him for the delay in relaying culture result and changing the antibiotics due to the holiday. V37 said the culture results showed that doxycycline was resistant to wound pathogens identified in R9's wound. R9's wound culture report collection date 6/28/23 and reported date of 6/30/23 documents pathogens detected: peptostreptococcus 76%, Escherichia coli 7.6%, prevoteela 7.6%, staphylococcus aureus enterotoxins A/B 7.6%, peptoniphilusharei ivorii 0.76%, Acinetobacter baumannii 0.076%, enterococcus faecalis 0.076%, kiebsiella 0.076%, pseudomonas aeruginosa 0.076%, serratia marcescens 0.076%. Under resistance genes detected and potential medication class affected: methicillin, Bactrim, tetracycline, and quinolones. The bacteria identified in this patient carries same gene that confers potential resistance to methicillin. Due to the potential seriousness of methicillin resistance, this infection should be treated aggressively and with close and vigilant monitoring of treatment effectiveness. R9's wound evaluation and management summary dated 7/5/23 documents: skin tear left buttocks size 17 x 20 x 2.0 cm. under additional wound details: culture grew multiple organism with resistance . Will switch antibiotics. Under recommendations: discontinue doxycycline. Start Augmentin and Bactrim. R9's physician order sheet dated 7/6/23 documents new orders for Bactrim and Augmentin. R9's urine culture collected date 5/19/23, specimen received 5/23/23, specimen reported 5/25/23 documents positive for kiebsiella greater than 100,000. Documents resistance to cipro. R9's physician order sheet dated 5/22/23 documents new orders Cipro. R9's progress notes dated 5/23/23 documents: relayed urinalysis results to Nurse Practitioner and ordered to continue Cipro. On 9/7/23 at 4:55 PM, V2 (DON) said the nurses are responsible for informing the doctor or nurse practitioner of culture results to ensure residents are treated with the correct medication. V2 said they are unable to provide any documentation of antibiotic stewardship prior to end of June. R9's hospital record dated 7/5/23 documents: admitted with acute hypoxic respiratory failure, acute encephalopathy, hypotension, possible sepsis, severe leukocytosis and thrombocytosis. Labs white blood count of 79.1 (normal 3.5-10.5. CT scan under impression documents: multifocal pneumonia in left lung, collection of gas and fluid in left hip joint and areas of osseous erosion. Findings consistent with osteomyelitis and septic arthritis; prominent decubitus ulcer in sacrococcygeal region with erosion of the coccygeal segments consistent with osteomyelitis's, thickening of bladder wall possibility of cystitis. Facility antibiotic stewardship revised 9/2022 documents: It is the policy of facility to maintain an antibiotic stewardship program with mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse event associated with antibiotic use. Tracking we will monitor antibiotic use and outcome from antibiotic use. Reporting we will provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff 41758 2. R12's lab results dated 3/21/23, 4/10/23 and 6/15/23 documents: Positive C-difficile Toxin. On 9/1/23 at 10:30 AM, V31 (Pharmacy Personnel) said, it appears that R12's original dose of vancomycin in March was not effective which is why it was restarted in April at a higher dose. On 9/7/23 at 3:03 pm, V51 (Nurse Practitioner) refused to answer any questions. On 9/7/23 at 4:55 PM, V2 (DON) said, R12 was not followed by an infectious diseases doctor. It was not customary to have R12 on vancomycin for four months. I wasn't aware until now. V2 said, they are unable to provide any documentation of antibiotic stewardship prior to end of June. On 9/12/23 at 11:00 AM, V41 (IP Nurse) said, he did not have any other tracking information for R12's antibiotic use. Facility antibiotic tracking log documents: R12; 6/20/23; C-Diff, KPC; Vancomycin; 6/30 -7/20. Pharmacy dispense record documents: Vancomycin was dispensed on 3/21/23, In April, on 5/22/23, on 6/20/23, a three day supply was sent 6/23 and 6/26 with a request for the facility to check the stop date. This order was cancelled by the facility on 7/5 and they sent the following update on 7/5 (which is in line with the previous taper dose from 6/20) and on 7/18 until 7/20 (still in line with the original taper dose). On 3/21/23 - Vancomycin oral capsules 125 milligram (mg) - one capsule every six hours times (x) ten (10) days In April, Vancomycin oral caps restarted at higher dose and tapered down - 4/12-4/22/23: 250mg by mouth four times a day. - Starting 4/23: 250mg by mouth three times a day x 10 days - Starting 5/3: 250mg by mouth twice a day x 10 days - Starting 5/13: 250mg by mouth every day x 10 days (end of therapy 5/22/23). Nursing note dated 4/15/23 documents: no loose stools, (4/18/23)-no loose stools two bowel movements semi-formed, (4/22/23, 4/24/23, 5/8/23) - no loose stool. On 5/22/23, Vancomycin was restarted: 250 mg by mouth twice a day x 10 days, then 250mg by mouth every day x 10 days. Nurse Practitioner note dated 5/22/23 documents: Pt was to complete treatment for C-difficile today, however, continues to have soft stools with mucus. (6/15/23)- CNA stating patient (R12) with diarrhea, loose stools again today, recently completed long vancomycin taper for c-difficile. Nursing note dated 6/7/23 documents no loose stools. (6/14/23)- per nurse practitioner resident can come off isolation, no foul smell, diarrhea or other symptoms, (6/15/23) - R12 was observed by nurse and CNA to have loose stool, stool collected to rule out c-difficile, (6/16/23) - normal bowel movement, (6/20/23) - R12's stool results were positive for c-difficile and (6/26/23) R12 has a small formed stool. On 6/20/23, oral vancomycin solution 25mg/ml was ordered: - Sent stat 6/21/23 - 10ml (250mg) PO QID (stop date 6/30/23) - 7/1 - 10ml (250mg) by mouth three times a day x 10 days - 7/11 - 10ml (250mg) by mouth twice a day x 10 days - 7/21 - 10ml (250mg) by mouth every day x 10 days On 6/23 we received an updated order (label change) stating to take 10ml (250mg) QID with no stop date. A three day supply was sent 6/23 and 6/26 with a request for the facility to check the stop date. (Nursing note dated 6/26/23 documents: R12 had a small formed stool.) This order was cancelled by the facility on 7/5 and they sent the following update on 7/5 (which is in line with the previous taper dose from 6/20): - 7/5 - 7/10: 10ml (250mg) by mouth three times a day - 7/11 - 7/20: 10ml (250mg) by mouth twice a day - 7/21 - 7/29: 10ml (250mg) by mouth every day On 7/18 - received new order for Vancomycin oral solution 25mg/1ml - give 10ml (250mg) PO BID until 7/20 (still in line with the original taper.) Physician order sheet dated 3/22/23- 7/21/23 documents: R12 had vancomycin ordered. Medication administration record dated 4/11/23 - 5/11/23, 5/12/23 - 6/11/23, 6/12/23 -7/11/23 documents: R12 was given vancomycin. Facility antibiotic stewardship revised 9/2022 documents: It is the policy of facility to maintain an antibiotic stewardship program with mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse event associated with antibiotic use. Tracking we will monitor antibiotic use and outcome from antibiotic use. Reporting we will provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers for two residents (R72, R246) of five residents reviewed for pressure ulcer in a sample of 30. This failure resulted in R246 developing a stage 3 pressure ulcer to the right bunion. Findings Include: 1. On 2/1/2023 at 12:53 PM, surveyor observed R72 laying in his bed with V4 - Registered Nurse (RN). R72 did not have a heel protector on. On 2/1/2023 at 12:55 PM, V4 said that the heel protector should have been on. On 2/2/2023 at 10:45 AM, surveyor observed R72 laying in his bed with V10 - (Wound Care Nurse). R72 did not have a heel protector on. On 2/2/2023 at 10:47 AM, V10 said that the heel protector should have been on. On 2/2/2023 at 4:00 PM, V2 (Director of Nursing) said, R72 should have his heel protector on when resting in bed. R72 is admitted with a diagnosis not limited to chronic respiratory failure, major depressive disorder, peripheral vascular disease, and unspecified-arterial insufficiency. Review of R72 physician order dated 3/31/2020 documents, Bilateral Heel protectors q shift. Review of R72 care plan dated 3/21/2019 documents: R72 is at a very high risk of skin breakdown related to Braden Score of below 12, level of dependence, incontinence, immobility, impaired cognition, decreased tissue perfusion, impaired circulation, poor nutritional status, presence of non-removable devices (trach, gastric tube), presence of scar tissue, hx of wounds, decreased sensory of perception, and presence of severe contractures to bilateral lower extremities. 2. R246 has a diagnosis not limited to hereditary and idiopathic neuropathy, hypertension, and type 2 diabetes. Review of progress note dated 12/1/2022 at 02:13 PM documents that R246 was assessed, stage 3 pressure ulcer noted to right outer foot measuring 2cm x 1.5cm. New orders noted. On 2/1/2023 at 4:45 PM, V20 (Nurse) said that she was the one that sent R246 to the hospital due to x-ray result that showed dislocation of the right foot. V20 said that she usually works on a different floor. V20 said that she does weekly skin checks but cannot remember if she did skin check on R246 when she took care of her. V20 said that R246's wound should have been observed before it advanced to stage 3. On 2/2/2023, V10 stated she saw R246 for right metatarsal location for wound treatment and noticed a dislocation and the wound for the first time on 12/1/2023, and it was at stage 3. V10 said that wound should have been observed before it advanced to stage 3. V10 said that R246 had heel protectors in place but R246 kicks them off. V10 said that she always calls the nurses to medicate R246 before her wound treatment, and also assess her pain before, during and after providing wound care treatment. On 2/2/2023 at 5:10 PM, V21(CNA) said that she took care of R246 and that she gave R246 bed baths when she took care of her. V21 said that R246 started getting red at the ankle bone and pillows were used to separate her legs. V21 does not recall if R246 had a heel protector. V21 said that R246 was admitted and the metatarsal was red. V21 noticed the wound and notified the nurse and wound care nurse was notified. On 2/2/2023 at 3:54 PM V2 said that she expects CNA'S to inspect the skin and notify the nurse and wound care nurse of any skin care alteration, and also document in the observation sheet. V2 said that the wound should have been discovered before it advanced to stage 3. On 2/2/2023 at 4:42 PM, V19 (Wound Doctor) said that when she assessed R246's wound on 12/6/2023, she staged the wound at stage 4. V19 said that the wound should have been discovered before it got to stage 3, which was when it was first noticed by the facility staff. Reviewed Care plan dated 12/15/2022 Reviewed Braden scale for initial assessment document R246 at score of 13. Facility unable provide weekly skin assessment. Policy: Pressure Ulcer Prevention Protocol Objective: 1. Residents will be assessed to determine their risk factor(s) for pressure ulcer development. Procedure: 4. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. 6. Residents will have their skin checked and documented utilizing Treatment Administration Record. This skin check will be performed at minimum of weekly.

Based on interviews and record reviews, the facility failed to follow their policy for respiratory care program for mechanical ventilation. Facility failed to ensure that a Respiratory Therapist is present in their mechanical ventilation unit to monitor residents on mechanical ventilation. This practice failure affects one resident (R3) of three residents reviewed for Respiratory Care. R3 had an acute change in condition resulting in difficulty breathing and low oxygen saturation. R3 was transferred to local hospital via emergency response for hypoxemia. Findings Include: On 7/28/2022 at 1:00pm, V21 (EMT/Fire Department) stated that V21 observed R3 to be a [CONDITION(S)] and vent patient. R3 was in the room, and vent machine alarming. Nurse on duty reported to V21 that there is no Respiratory Therapist (RT) in the unit all day. We asked for RT to bring us vent set up for the resident and disconnect the resident, the nurse stated they did not have a RT in the vent unit all day. On 7/28/22 at 12pm, V1 (Administrator) stated that they don't have an RT on 6/28/22. Their RT director had resigned couple of days before the incident of 6/28/22. V1 stated that V1 was made aware that there is no licensed respiratory therapist on the third floor (vent unit) around 11am that day. Reported that they tried to look for RT to come in and there was no on willing to pick up shift. The agency RT also did not show up that day. On 7/29/22 at 11:05am, V24 (RN) stated On the 28th, there was no RT on the third floor, vent unit. There was no RT aide in the unit also. I am the assigned nurse to R3 on 6/28/22. Around 10 am, I noticed that there were no RT in the unit, I called the scheduler (nursing staff). They told me they are working on finding a RT to come in. R3 moves a lot and the machine would beep but it would stop, I was not worried because R3 was not in distress at that time. However I remember at least one time that I suctioned R3 on 6/28/22 due to gurgling sound and that R3 was in need of suctioning. I do not recall calling any RT over the phone at that time. I don't even know where to find their numbers. R3 was stable at the time I was R3's nurse. On 7/29/22 at 12:35pm, V25 (Agency Nurse) stated that V25 worked on 6/28/22. We are not allowed to disconnect or change the setting of the vent machine. I remember I called 911 for R3 on 6/28/22. I called 911 because R3's vent machine was beeping non-stop and I know that when the machine beeps there is something wrong and the machine needed to be checked. R3 was saturating below 80's at the time but not tachypneic. There was no one from Respiratory Department to troubleshoot the vent machine. I suctioned R3 and the machine would stop for a short moment and then would start beeping again, so I know something was wrong. I started at 3pm, I checked the RT's office and I did not see anybody. I asked the other nurse that was schedule double that day, and she said that there was no one from RT department all day. I remember going down stairs and talked to a gentlemen, V1 (Administrator). I asked V1 if there is a respiratory therapist coming to help us out on the 3rd floor (vent unit). V1 said there will be someone coming but not until 7pm. I mentioned to V1 that I have at least 14 to 15 residents on my side and majority of them has [CONDITION(S)] and mechanical ventilation residents. I called 911 maybe an hour or two after my shift started at 3pm that day (6/28/22). Emergency responder asked for a respiratory therapist to help unhook R3 from the mechanical ventilator. I reported to the emergency responder that we did not have a RT at the time and that one will come but not until 7pm. On 7/27/22 at 1:30pm, V15 (Director of Respiratory Therapist) stated that it is the facility policy to have a licensed RT at all times in the vent unit. Also stated that nurses are allowed to suction a vent resident but not allowed to touch or manipulate the ventilator machine. RT needs to be present when giving care to a resident for airway protection. Fire Department Runsheet reviewed (6/28/22) reads in part: Found R3 in care of nursing staff. Per staff, R3's oxygen saturation is dropping and they are unable to suction R3. Staff states there is no respiratory therapist currently on duty. R3 in obvious respiratory distress. Crew attempted to vent R3 via BVM to [CONDITION(S)], unable due to resistance. Crew place mask over R3's mouth and was able to ventilate via BVM to mouth. Crew attempted to suction R3 with French Catheter [CONDITION(S)], unable to advance catheter due to hard [MEDICATION(S)]. Crew was able to use saline to loosen [MEDICATION(S)] and crew able to suction R3. BVM via [CONDITION(S)] attempted again and less resistance noted with better ventilation achieved. Oxygen saturation (SP02) noted at 96% while crew ventilating R3 via [CONDITION(S)] after suctioning. R3 continued to be ventilated via BVM to [CONDITION(S)]. Care to emergency room 13. Hospital record: Documented on 6/28/22 at 1823: Upon arrival in the ED (Emergency Department), R3 appears to be in respiratory distress. RT at bedside, suctioned R3. A lot of secretions have been suctioned. R3 not in respiratory distress at this time. Resting comfortably and tolerating vent appropriately. Per EMS, nurse at nursing home (NH) attempted to suction patient, as well as EMS, unsuccessful. Per EMS, NH does not have respiratory therapist at nursing home. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes reviewed from admission to present. There is no Respiratory Therapy notes for Day shift on 6/28/22. Staffing Schedule reviewed, There was an agency RT scheduled for day shift (7am to 7pm) and Agency RT per V1 was a no show that day. Facility Job Description for Respiratory Therapist shows a qualification for an RT are: graduate of an accredited Respiratory Therapy program, Respiratory Therapist certification listed as Respiratory Care Practitioner in the State of Illinois, and current License in good standing. Respiratory Care Program policy updated on 6/30/21 reads in part: The goal is to provide the highest quality physician ordered Respiratory Care services in a timely effective, safe, and efficient manner. This facility will accomplish this through: Timely and thorough assessment of resident needs, Administer care in a manner that ensures the health and safety of the residents, and maintain compliance with the state and federal regulations relating to Respiratory Care. Mechanical ventilation updated 6/30/21, reads in part: Ventilation and respiratory equipment will be monitored and maintained by respiratory therapist with each[OBSCENITY]and as needed check. Respiratory therapist will ensure that the ventilator and all respiratory equipment s operating according to manufacturer recommendation and that there are no warning light indicating equipment failure or impending equipment failure. Respiratory therapist will complete all required documentation for residents on mechanical ventilation every shift and as needed. Respiratory therapist will complete every shift assessment for all residents on mechanical ventilation.

Based on interviews and record reviews, the facility failed to have a Licensed respiratory therapist assined to the mechanical ventilation on 6/28/22. This failure affects one resident (R3) of 3 residents reviewed for Respiratory care: sufficient staffing. R3 had difficulty breathing, and low oxygen saturation. R3 was transferred to local hospital via emergency response for hypoxemia. Findings Include: On 7/29/22 at 11:05am, V24 (RN) stated On the 28th, there was no respiratory therapist (RT) on the third floor, vent unit. There was no RT aide in the unit also. I am the assigned nurse to R3 on 6/28/22. Around 10 am, I noticed that there were no RT in the unit, I called the scheduler (nursing staff). They told me they are working on finding a RT to come in. R3 moves a lot and the machine would beep but it would stop, I was not worried because R3 was not in distress at that time. However I remember at least one time that I suctioned R3 on 6/28/22 due to gurgling sound and that R3 was in need of suctioning. I do not recall calling any RT over the phone at that time. I don't even know where to find their numbers. R3 was stable at the time I was R3's nurse. On 7/29/22 at 12:35pm, V25 (Agency Nurse) stated that V25 worked on 6/28/22. We are not allowed to disconnect or change the setting of the vent machine. I remember I called 911 for R3 on 6/28/22. I called 911 because R3's vent machine was beeping non-stop and I know that when the machine beeps there is something wrong and the machine needed to be checked. R3 was saturating below 80's at the time but not tachypneic. There was no one from Respiratory Department to troubleshoot the vent machine. I suctioned R3 and the machine would stop for a short moment and then would start beeping again, so I know something was wrong. I started at 3pm, I checked the RT's office and I did not see anybody. I asked the other nurse that was schedule double that day, and she said that there was no one from RT department all day. I remember going down stairs and talked to a gentlemen, V1 (Administrator). I asked V1 if there is a respiratory therapist coming to help us out on the 3rd floor (vent unit). V1 said there will be someone coming but not until 7pm. I mentioned to V1 that I have at least 14 to 15 residents on my side and majority of them has [CONDITION(S)] and mechanical ventilation residents. I called 911 maybe an hour or two after my shift started at 3pm that day (6/28/22). Emergency responder asked for a respiratory therapist to help unhook R3 from the mechanical ventilator. I reported to the emergency responder that we did not have a RT at the time and that one will come but not until 7pm. On 7/28/2022 at 1:00pm, V21 (EMT/Fire Department) stated that the nurse on duty reported to V21 that there is no Respiratory Therapist (RT) in the unit all day. We asked for RT to bring us vent set up for the resident and disconnect the resident, the nurse stated they did not have a RT in the vent unit all day. On 7/27/22 at 1:30pm, V15 (Director of Respiratory Therapist) stated that it is the facility policy to have a licensed RT at all times in the vent unit. Also stated that nurses are allowed to suction a vent resident but not allowed to touch or manipulate the ventilator machine. RT needs to be present when giving care to a resident for airway protection. On 7/28/22 at 11:30am, V19 (CNA) stated that V19 remember the incident on 6/28/22. R3 was having breathing problem. Also stated V19 did not see any respiratory therapist starting her shift at 3pm until R3 was sent out in the hospital via 911 that day. On 7/28/22 at 11:55am, V20 (CNA) stated I remember one incident when there was no respiratory therapist or respiratory aide. I remember it was just the nursing staff, 2 CNAs and 2 nurses. One incident (6/28/22) in morning shift I noticed after breakfast that there were no one from respiratory department. Staffing Schedule reviewed, There was an agency RT scheduled for day shift (7am to 7pm) on 6/28/22 and Agency RT per V1 was a no show that day. Hospital record: Documented on 6/28/22 at 1823: Upon arrival in the ED (Emergency Department), R3 appears to be in respiratory distress. RT at bedside, suctioned R3. A lot of secretions have been suctioned. R3 not in respiratory distress at this time. Resting comfortably and tolerating vent appropriately. Per EMS, nurse at nursing home (NH) attempted to suction patient, as well as EMS, unsuccessful. Per EMS, NH does not have respiratory therapist at nursing home. Facility Job Description for Respiratory Therapist shows a qualification for an RT are: graduate of an accredited Respiratory Therapy program, Respiratory Therapist certification listed as Respiratory Care Practitioner in the State of Illinois, and current License in good standing. Respiratory Care Program policy updated on 6/30/21 reads in part: The goal is to provide the highest quality physician ordered Respiratory Care services in a timely effective, safe, and efficient manner. This facility will accomplish this through: Timely and thorough assessment of resident needs, Administer care in a manner that ensures the health and safety of the residents, and maintain compliance with the state and federal regulations relating to Respiratory Care. Mechanical ventilation updated 6/30/21, reads in part: Ventilation and respiratory equipment will be monitored and maintained by respiratory therapist with each[OBSCENITY]and as needed check. Respiratory therapist will ensure that the ventilator and all respiratory equipment s operating according to manufacturer recommendation and that there are no warning light indicating equipment failure or impending equipment failure. Respiratory therapist will complete all required documentation for residents on mechanical ventilation every shift and as needed. Respiratory therapist will complete every shift assessment for all residents on mechanical ventilation.

Based on interviews and record reviews, this facility failed to accurately assess a resident's impaired nutritional status, implement, monitor, and evaluate the effectiveness of interventions for one resident (R1) out of three reviewed for receiving enteral nutrition via a gastrostomy tube and hydration in a sample of 3. R1 has had 17% weight loss in 3 months without any nutritional intervention. R1 was also admitted to the hospital on 3/31/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of R1's medical record notes R1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 10:00am, V6 NP (nurse practitioner) stated that V7 RD (registered dietitian) should have read the hospital record on 3/31/22 to see if there were any changes to R1's enteral feedings. On 5/2/2022 at 11:40am, V7 RD (registered dietitian) stated that V7 is familiar with R1. V7 stated that V7 is aware of R1's significant weight loss of 17%. V7 stated that V7 reviewed R1's enteral nutrition and it meets 100% of R1's needs. V7 stated that V7 would recommend more frequent weighing of admissions/re-admissions weekly x 4 weeks to identify residents with changes in weight, otherwise continue monthly weights. When questioned if R1's enteral nutrition should have been adjusted to address weight loss, V7 responded that R1's enteral feedings meet R1's needs 100%. V7 stated that V7 reviewed R1's current weight and enteral feeding order. When questioned if V7 reviewed the dietitian consultation note in R1's hospital medical record, V7 did not respond. V7 stated that R1's enteral feeding order for glucerna 1.5 at 65ml (milliliters) per hour x 20 hours daily and 250ml of water every 6 hours daily provides 1950 kcal (kilocalories) which meets 100% of R1's needs. Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinued 3/25/2022. On 3/25/22, an order to increase R1's enteral feeding to 65ml per hour x 20 hours was noted. Review of R1's weights since December 2021: 12/5/21, R1 weighed 139 pounds. 1/11/22, R1 weighed 131.2 pounds. This is a 5.8% weight loss in one month. 2/7, R1 weighed 128.8 pounds. 2/10, R1 weighed 126.4 pounds. 3/5, R1 weighed 118.8 pounds. This is a 17% weight loss in three months. Upon returning from hospital, R1 weighed 121 pounds. This is a 1.81% increase in R1's weight while in hospital. Review of R1's hospital medical record, dated 3/31/22-4/11/22, notes R1 was admitted to the hospital with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Per dietitian's observations, R1 with severe temporal, clavicular, thigh/knee muscle depletion. Nutritional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions implemented in hospital include: glucerna 1.2 at 70ml per hour x 24 hours and 110ml free water flushes every 4 hours would provide 2016 kcals, 100 grams of protein, and 2012ml water, which meets 100% of R1's needs. On 4/11/22, review of R1's laboratory results completed on 4/11 note sodium level 137. BUN (blood urea nitrogen) 7 (normal range 5-28) and creatinine 0.61 (normal range 0.5-1.4) measure of kidney function. R1 without any low blood sugar episodes, laboratory results within normal limits, and R1 is tolerating tube feeding at goal. Review of the nephrologist's assessment and plan in hospital, dated 4/1/22, notes: high sodium levels (155-158) due to free water deficit/dehydration due to high blood sugar level. On 3/31, BUN 36 and creatinine 0.83. Continue enteral feeding, increase the free water flush to 300ml every 4 hours. Review of V7's documentation, dated 12/26/21, notes R1's weight 139 pounds, R1's BMI 18.34. Enteral feedings provide 100% of estimated needs. Continue with current diet: enteral feeding glucerna 1.5 at 60ml per hour x 20 hours daily with water flush 250ml every 6 hours. Review of V7's documentation, dated 1/30/22, notes R1's weight 131.2 pounds, -5.8% weight loss. Current weight shows significant weight loss in 1, 3 months. Weight loss unplanned. Enteral feedings provide 100% of estimated needs. Continue with current diet: enteral feeding glucerna 1.5 at 60ml per hour x 20 hours daily with water flush 250ml every 6 hours. Review of V7's re-admission assessment, dated 4/13/22, notes R1's weight 121 pounds. Enteral feeding glucerna 1.5 at 65ml per hour x 20 hours daily with water flush 250ml every 6 hours. Current feeding provides 100% of estimated needs. Review of R1's laboratory results note: on 4/14/22, R1's sodium level was 139, BUN 20, and creatinine level 0.7. On 4/18/22, R1's blood sugar was 409, sodium level was 144, BUN 35, and creatinine level 0.99. On 4/24/22, R1's blood sugar was 506, sodium level was 150, BUN 74, and creatinine level 1.3. There is no documentation found noting any interventions were implemented related to elevated laboratory results. Review of this facility's weight maintenance policy, revised 03/2022, notes the facility will follow the current professional standards of practice which recommends weighing each resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as slow and progressive weight loss. All significant, unplanned, or trending weight changes must be investigated by the facility. Suggested parameters for evaluating significance of unplanned and weight loss include in part: severe weight loss of greater than 7.5% in 3 months. In the case of a significant or trending weight change the following steps will be taken: determine the possible cause, determine the plan of action, and notify the physician and responsible party. The Registered Dietitian will assess each resident with a significant weight change and make appropriate recommendations to the physician.

Based on interviews and record reviews, this facility failed adequately monitor one resident's blood sugar level prior to the administration of insulin to ensure the insulin dosage was appropriate to prevent high blood sugar levels for one resident (R1) out of three reviewed for change in condition due to high blood sugar levels in a sample of 3. This failure resulted in R1 being transported to the hospital on 3/31/22 and 4/27/22 due to blood sugar results greater than 400. Findings include: On 5/2/22 at 10:00am, V6 NP (nurse practitioner) stated that V6 is not involved with R1's care. V6 stated that V6 will get called in to see a resident if there is an urgent need; reason V6 saw R1 on 4/27. V6 stated that R1's nurse informed her that R1 had change in condition. V6 stated that when the nurse checked R1's blood sugar, the glucometer reading noted high. V6 stated that indicated that R1's blood sugar was greater than 400. V6 stated that V6 called R1's attending physician because while reviewing R1's medical record she was unable to see any blood sugar results documented. V6 stated that the nurses were not checking R1's blood sugar level prior to administering insulin. V6 stated that the nurses did not use critical thinking skills and recognize if entering order for insulin need to enter order for blood sugar monitoring. V6 stated that insulin should not be administered without first checking a resident's blood sugar. Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's medical record does not note R1's blood sugar level was checked prior to the administration of the insulin NPH from 4/14 at 5:00pm until 4/27 when R1 experienced a change in condition and blood sugar reading was high. Review of R1's medical record, dated 4/1/22, notes R1 was sent to the hospital due to high blood sugar and displayed signs of lethargy. R1 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R1's medical record, dated 4/27/22, notes R1 noted to have blank stare. Pulse within normal rate, afebrile, oxygen saturation can't be read through the pulse oximeter, blood sugar taken result is High and was having rapid breathing. R1 sent out to hospital. R1 was admitted to the hospital with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's hospital medical record, dated 3/31/22-4/11/22, notes R1 was admitted to the hospital with diagnosis, in part: high blood sugar (blood sugar greater than 400, normal range is 70-99). The nephrologist's assessment and plan in hospital, dated 4/1/22, notes: high sodium levels (155-158) due to free water deficit/dehydration due to high blood sugar level.

Based on interviews and record reviews, the facility failed to accurately assess and evaluate pressure ulcer wounds; failed to notify physician and implement necessary treatment orders and interventions in preventing the development and or worsening of pressure ulcers for four (R28, R36, R55 and R133) of nine residents in a sample of 47 reviewed for pressure ulcers. These deficiencies resulted in R28 who was admitted in the facility with intact skin but developed a facility acquired Stage 3 pressure ulcer on the sacrum; R36's Stage 3 pressure ulcer on the coccyx increased in size and became Unstageable; R55's surgical wound in the abdomen developed into Stage 3 pressure ulcer; and R133's left hip and left elbow wounds worsened into Stage 4 pressure ulcers. Findings include: R36 is a [AGE] year old, female, admitted in the facility on 12/16/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R36's physician wound notes, the following were documented: 12/21/21: Initial Wound Evaluation and Management Summary Stage 3 pressure ulcer (PU) wound coccyx - measurement: 4 cm (centimeters) x 0.5 cm x 0.1 cm, admitted with. Low air loss mattress was one of the recommendations. 01/11/22: Wound Evaluation Management Summary Stage 3 PU coccyx - 9 cm x 9 cm x 0.2 cm 02/24/22: Wound Evaluation and Management Summary Stage 3 PU coccyx - 3.5 cm x 3 cm x 0.1 cm R36's census reports recorded: 12/16/21 - admission 02/14/22 - hospital due to difficulty in swallowing 02/22/22 - readmission to facility Per R36 progress notes dated 03/01/22, time stamped 9 AM, she went to the hospital for an evaluation due to inability to open mouth during medication pass and unable to move hands. She went back into the facility on the same day at 12 PM. There was no assessment documented on 03/01/22 but on 03/03/22, Wound Evaluation and Management Summary indicated that she now has Unstageable PU on the coccyx with measurements of 10 cm x 12 cm x 0.1 cm. On 03/07/22, R36 was observed in bed, lying on her back, on a regular mattress. V7 (Certified Nurse Assistant, CNA) was observed providing morning care and incontinence care on R36. As V7 turned R36 to the left side to clean the back, it was observed that there was a very soiled dressing covering her (R36) coccygeal area, which was about to come off. Surveyor asked V7 to verify the date on the wound dressing. The date was 03/05, meaning March 05. V7 removed the soiled wound dressing, stating that she will notify the wound care nurse. V7 took some gauze, put some barrier cream on the gauze and placed it in the wound to cover it. POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/07/22 at 12:14 PM, V3 (Treatment Nurse/Licensed Practical Nurse, LPN) was asked regarding wound treatment and R36. V3 stated, I am the wound care nurse in the building. I work Mondays through Fridays from 7 AM to 3 PM. On weekends, I work every Saturday just to do the daily dressing. Sundays, there is no wound care on Sundays. Floor nurses are the one doing the wound care. Her coccygeal wound is a daily dressing. It needs to be clean and dress every day. I was the one who did the March 05 dressing. It was not done on March 06. I don't think it is okay, it should be daily. At 1:35 PM, wound care was observed on R36 performed by V3 assisted by Wound Technicians V10 and V11. V10 stated, When we came, there was no dressing on the wound. It came off. During wound dressing, a new skin redness was noticed on the upper right portion above R36's coccygeal wound. V3 verbalized, There is a new DTI (deep tissue injury) on the side of the wound. It is new, did not see it last time. The resident (R36) is not being turned and repositioned. She (R36) has a pillow wedge. We have to follow doctor's order for a daily dressing treatment. If the dressing gets soiled and I'm not here, the nurse on the floor needs to change it. We cannot put any medicine on the pressure ulcer wound, barrier cream is fine. I will cover the new DTI with a foam dressing and I will notify V9. The DTI is measured 1.5 cm x 2 cm. Now the coccyx PU is measured 14 cm (centimeters) x 8.5 cm. Progress notes dated 03/09/22 documented: Resident (R36) wound was measured at 14 x 8.5 on 03/07/22. Resident (R36) also has a new DTI on her right buttock, 1.5 x 2. R36's Care Plan on Pressure Ulcer dated 12/21/21 documented: Approach 12/26/21 - Provide treatment as ordered; Conduct a systematic skin inspection daily and weekly. Pay particular attention to the bony prominences; Report any signs of skin irritation and/or breakdown (sore, tender, red, or broken areas). R36's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE]-31, 2022: Missing signatures on 13, 14, 15, 16, 17, 18, 21, 24, 25, 26, 27, 28, 31 February 1-28, 2022: Missing signatures on February 1, 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 23, 25, 26, 27, 28 March 2022: Missing signatures on 2, 3, 5, 6 V3(Treatment Nurse/LPN) was asked regarding missing signatures on R36's MAR. V3 replied, If it is not sign, then it is not done. On 03/08/22 at 10:15 AM, R36 was observed asleep in bed, lying on her back on a regular mattress. V3(LPN) was asked regarding R36's bed. V3 stated, She is using a regular mattress. She has Unstageable PU. When she came back last 02/22/22, I asked V2 (Director of Nursing) for a low air loss mattress (LAL). She said she is going to order it. From 02/22/22 to now, she is using a regular mattress. She is supposed to use LAL mattress. With this regular mattress, there is no air flow to the mattress to shift the pressure to wound on the back that needs to be relieved. V3 was also asked if V9 (Wound Physician) was notified of the new DTI on R36's lower back. V3 replied, I did not call him (V9) for the DTI because he (V9) had a death in the family. I just covered it with a foam dressing, no medication treatment yet. He (V9) is the only wound care doctor. V2 (Director of Nursing) was also asked on 03/08/22 at 3:23 PM regarding wound care and R36. V2 verbalized, She was admitted on [DATE] with sacral PU Stage 3 on the coccyx. She went out on 02/14/22 and returned 02/22. She has Stage 3 PU and should be on a LAL mattress. Today is the first time I heard that she was not on LAL mattress. If the order is daily dressing, we need to do treatment as ordered. The wound care nurse is not here on Sundays, the nurses on the floor do the wound care treatment. The floor nurses are also expected to change the dressing when needed. Staff will observe for skin breakdown and wound care nurse should be notified. If there is a new skin issue and wound doctor (V9) is not available, we can always text him (V9) and he will give orders or will call for orders. Residents, when they come back from the hospital should be assessed for any skin problem. On 03/09/22 at 1:48 PM: V9 was interviewed regarding R36 and pressure ulcer. V9 stated, On R36, I have been seeing her since December. 2021. She had a Stage 3 pressure ulcer on the coccyx. She was last seen on 03/03/22, her wound measures 10 cm x 12 cm x 0.14 cm and the wound is Unstageable. In general, treatment orders need to be followed consistently. She has a Stage 3 pressure ulcer, a low air loss mattress should be provided. I need to be notified when there is a new skin issue on a resident. On her (R36), I was not notified regarding her new deep tissue injury on the lower back. Yes, if treatment orders are not administered and followed consistently, along with other interventions and notification, everything combined could be attributed to the worsening of a pressure ulcer. Facility's policy titled Wound Care revised date 05/17 documented in part but not limited to the following: Objective: To protect the wound from contamination and control bleeding. E. Wound Care Documentation 1. Follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Documentation of wound care must be completed each time the treatment is done. This documentation will be done on the Treatment Administration Record (TAR). 7. The physician must be notified of change in the wound status. Facility's policy titled Wound Management Protocol documented in part but not limited to the following: Pressure Ulcer Prevention Control Guidelines: 2. All beds in facility will have pressure reducing mattresses unless pressure relieving mattresses are required according to the resident's needs. 4. Residents who are assessed as being at high risk will have a plan of care that will include: A. Daily skin checks conducted by either the CNA or Licensed Nurse to ensure early identification of potential problem areas. Facility's policy titled Management of Wounds stated in part but not limited to the following: Policy: Our mission is to facilitate resident independence, promote resident comfort, and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective wound management program, allowing our residents a means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. 1. Assessing the resident Daily skin assessment - to be done by RN (Registered Nurse)/LPN) or CNA daily for all at high risk residents. R28 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) dated 9/15/21 showed R28 assessed as at-risk for skin breakdown and with no current pressure ulcers. A facility wound summary report provided to surveyors on 3/8/22 showed R28 on the list of facility-acquired pressure ulcers. Wound note dated 1/11/22 written by V9 (wound doctor) showed, Patient presents with a wound on her sacrum. She has a stage 3 pressure wound sacrum for at least 1 days duration. Wound Size (L x W x D): 3 x 10 x 0.2 cm. There is light serous exudate. MDS 3.0 Stage 3. Santyl apply once daily for 30 days; Alginate calcium apply once daily for 30 days. Off-load wound; Reposition per facility protocol. On 3/9/22 at 10:40 AM, wound observation with V3 (wound nurse/LPN). Surveyor asked V3 to describe the wound as she conducted the treatment. V3 stated, R28 has a stage 2 wound and It measures around 4.5 centimeters x 15 centimeters and I can't tell you the depth because I don't really know what it is. It was necrotic (dead tissue) at one point and it was open but I don't know how it was before I got here. I just took over the wound care last month because the previous wound person just walked out during the shift so she couldn't really train me. Surveyor asked whether the sound was facility-acquired, V3 stated, I don't know. I wasn't trained to do the assessments. I just do the treatments. Surveyor asked if the increase in measurements would indicate a decline in the wound, V3 stated, Like I said, I don't know anything about wounds, I was just thrown in this position to do the treatments until they found a wound nurse. Asked how long the facility was without a wound nurse, V3 stated, Probably around February 14. I just remember it was around Valentines day when the previous wound nurse walked out. Surveyor asked who conducts the wound treatments in the facility, V3 stated, I work six days a week and on my off days, the nurses should be doing them. Facility treatment records provided to the survey team on 3/9/22 show from 1/1/22 to 3/9/22 a total 20 missed treatments for R28. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 03/09/22 01:07 PM Surveyor asked V3 What is the cause of why the surface area of a wound increased, V3 stated, Because she wasn't being turned and repositioned is why it increased. At 2:45 PM during an interview with V9 (wound doctor), V9 stated, I was told that the current wound nurse (V3) was trained. I'm not aware she wasn't. Surveyor asked who communicated to him about which residents to see for wounds, V9 stated, The DON (V2) will touch base with me once and awhile but she does not tell me who to see, it is the wound nurse V3. Asked the importance of following doctor's orders, V9 stated, When I give a recommendation it is an doctor's order and I expect them to be followed. It is not acceptable for treatments to be ignored or not followed. R133 is a [AGE] year old female with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R133 was originally admitted on [DATE] and considered at risk for skin breakdown per MDS Minimum Data Set (Comprehensive Assessment) dated 08/12/2021. Review of the facility wound report indicates: 2 facility acquired wounds - Left hip was identified on 5/14/21 and Left elbow was identified 6/28/21. On 03/08/22 at 2:16 PM, V12 RN stated, R133 was sent to the hospital, I can call the hospital. V12 placed a call to the hospital. V12 stated, R133 was admitted to the ICU intensive care unit with [CONDITION(S)]. Progress notes indicate: V12 RN documented: 03/08/2022 02:22 PM, Called hospital, resident admitted in the ICU for [CONDITION(S)]. On 03/09/22 at 11:50 AM, V3 Treatment Nurse was inquired of R133's wound care. V3 said, In the beginning of February we still had a wound coordinator. She was in charge of who the wound doctor would see. She quit sometime in February. No one has taught me the computer system or told me how often V9 Wound Physician was supposed to see the patients. I asked V9 and he said R133's wounds were stable. I never went through the documentation of R133's wounds, the stages. I never read up on it. The last time she was seen was on January 27th. She was on the list for March 1st, but she got bumped because of all the new patients' wounds were so bad. I needed him to see those patients. I wasn't told what patients need to be seen by V9 and how often. R133's treatments are silver alginate and a dry dressing since January 27th. V9 comes on Tuesdays and Thursdays. I can only account for when I took over in February. If V9 didn't see R133, he didn't write anything. If I had known the frequency of when the patients should have been seen, then V9 would have known. R133's wounds haven't been measured since January because she wasn't seen by V9. R133's dressings are done 3 times a week. I'm the only treatment nurse. I'm here Monday through Saturday. Review of the physician wound evaluation and management summary indicates: 1/27/22 Stage 4 pressure wound of the left hip. Wound size: L x W x D (0.7x0.5x0.2 cm), Surface area: 0.35cm squared, Exudate- Moderate Serous. Primary dressing: Alginate calcium with silver apply three times per week for 14 days. Secondary dressings: Gauze island with border, apply three times per week for 14 days. Recommendations: off-load wound; Reposition per facility protocol. Wound progress: No change. Stage 4 pressure wound of the left elbow. Wound Size (L x W x D): 2.5 x 2.5 x 0.1 cm). Surface area: 6.25 cm squared. Exudate: Moderate Serous. Slough 10%. Wound change: Deteriorated. Primary dressings: Alginate calcium with silver apply three times per week for 14 days. Secondary dressings: ABD pad sterile apply three times per week for 14 days. Recommendations: Off-load wound: Reposition per facility protocol. Site 3 left elbow- Procedure: Surgical excisional debridement was performed today on this wound. Follow-up indicates: Evaluation by wound care specialist in 8-14 day(s) with further intervention as indicated. At 12:40 PM, review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Extra Ag (silver-calcium alginate) [OTC] bandage; 4 X 4 3/4 ; amount: 1 application; topical Special Instructions: Wound Care: Site 2 - left hip - Cleanse with NSS, apply calcium alginate with silver, cover with a dry dressing. Once A Day on Mon, Wed, Fri 07:00 AM - 03:00 PM. [MEDICATION(S)] Extra Ag (silver-calcium alginate) [OTC] bandage; 4 X 4 3/4 ; amt: 1 sheet; topical Special Instructions: Wound Care: Site 3 -left elbow- Cleanse with NSS, apply silver alginate, cover with a dry dressing. Once A Day on Mon, Wed, Fri 07:00 AM - 03:00 PM. At 2:07 PM, V9 Wound Physician was inquired of R133 being transferred to the hospital related to [CONDITION(S)]. V9 stated, I was not informed, didn't know she was sent. When was this? At 3:12 PM, V9 Wound Physician was inquired of R133's facility acquired wounds to the left hip and elbow. V9 stated, The last time I saw R133 was 1/27/22 according to my notes. I'm not sure exactly why, her wounds were stable the last time I saw her. We had other patients that needed to be seen. I wasn't aware R133 didn't have any measurements since I last saw her. I'm not sure how her wounds looked in a while. Usually, it's up to the nurse they give me a list of patients to be seen. There's a reason I give orders for the staff to follow these orders, so yes, it's important that the treatment orders are followed in order for the wounds to improve. I recall some of her wound's healing, so yes she is capable of avoiding further wounds or developing them, but I'm not that familiar with everything going on with her. R133's TAR Treatment Administration Record indicates: February and March 2022 have dates of treatment that were not completed per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R55 is a [AGE] year old female admitted to the facility 06/12/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R55 has a BIMS of 13 and was alert and oriented at the time of this investigation. R55 acquired a pressure ulcer to the left abdomen on 11/24/21 while residing in the facility. On 03/08/22 at 10:51AM, R55 said, I got a sore on my abdomen because they don't change my [CONDITION(S)] bag regularly. I get treatments every three days now and that's when they are supposed to change the bag and the dressing. R55's wound care notes reviewed and it was noted that R55 had not been evaluated by the V9 Wound MD since 2/08/22. On 03/09/22 at 03:23 PM V9 said, the last visit with R55 was on 2/08/22. I'm not sure why it has been over a month that I've seen this R55. When I come into the facility the treatment nurse gives me a list of residents that need to be seen. So at this time I don't know if the wound is getting better or worse. The pressure sore could have developed either from moisture or something pressing against the skin. I believe this sore was from the [CONDITION(S)] bag. From the [CONDITION(S)], it may have been leaking, which can cause an irritation from the skin. It could have been prevented by using a skin barrier that is often used with the appliance. Wound Progress note written 11/24/21 assessed a Stage III pressure ulcer to the left abdomen. The wound demonstrated to be stable and healing from 11/24/21 to 1/20/22. Wound Management Detail Report dated 1/20/22 measures wound length 1.5cm, and width 1.5cm. The following visit was 02/08/22 with measurements: width 3.5cm, and length 3.5cm with a depth of 0.1cm. On 03/09/22, V3 treatment nurse said, the measurements mean the wound has gotten worse. I continue to provide the dressing but I have not documented on the measurements or how the wound looks. I just chart on the Treatment Administration Record.

Based on observation, interviews and record reviews, the facility failed to ensure that supervision and limited assistance during dressing and personal hygiene were implemented in preventing fall for one resident (R2) of three residents reviewed for accidents and supervision. This deficiency resulted in R2 complaining of left leg pain requiring subsequent emergent transfer to the emergency room ; sustained a left intertrochanteric [CONDITION(S)] and underwent a closed reduction with nailing of left femur. Findings include: R2 is a [AGE] year old, female admitted in the facility on 11/01/17 with diagnoses of Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Unsteadiness on Feet and Other abnormalities of Gait and Mobility. According to progress notes dated 01/01/22, V19 (Registered Nurse, RN) documented that R2 was observed up in wheelchair getting ready for the day applying makeup and rollers. Approximately 10 minutes later, R2 was heard calling for assistance and observed sitting on the floor directly in front of her wheelchair with her pants around her ankles. Noted cup of water knocked on the floor. Assessment immediately initiated with no complaints of pain, redness, swelling or bruising visibly noted. No leg shortening observed or leg deformity noted. R2 verbalized that she was putting on her pants when she slid out of her chair and unto the floor landing on her bottom. Approximately at around 5:00 PM, R2 complained of pain to buttock area, PRN (when necessary) pain medication administered with effectiveness. On 01/11/22 at 1:00 PM, V19 was asked regarding R2's fall incident on 01/01/22. V19 said, She was in the room, in her chair doing her hair and does not need any assistance. Then, all of a sudden she called out for help. I went into the room, she was sitting on the floor in front of the chair with her pants above to her knees. She was trying to pull up her pants. When she was on the floor, the pants were on her knees. It happened in the [MEDICATION(S)] morning medication pass. She was trying to dress up, put on pants and that's what she verbalized when she had the fall. She was pretty independent on dressing as far as I saw her that morning. I was there five minutes before, her call light was within reach. She was trying to dress herself up when it happened. At that time, she was doing her hair and applying makeup and I asked if she needs anything and said she was okay. Head to toe assessment was done. Range of motion are within normal limits, no complaints of pain. She was transferred back to her wheelchair. At the time, I was busy. I did not notify V24 (Physician) and V17 (Family Member) regarding incident. I did write it on the paper but I did not endorse the incident to the next shift. R2's MDS (Minimum Data Set) dated 11/10/21 documented: Section G - G. Dressing which includes putting on and changing pajamas and housedresses: needs supervision from one person physical assist Section G - J. Personal Hygiene which includes combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers): needs limited assistance from one person physical assist. During interview with V25 (Occupational Therapist) on 01/11/22 at 9:40 AM, she stated R2 needs supervision from one staff during dressing. V25 continued, Before the fall, she needs supervision from one person assist. She does not need any help performing upper body dressing but needs supervision from one person for lower body dressing. Progress notes dated 01/02/22 time stamped 12:40 PM recorded: V23 (Licensed Practical Nurse, LPN) was informed that R2 was going to be transferred to hospital emergency room for further evaluation of left leg pain. V23 (Licensed Practical Nurse, LPN) was interviewed on 01/11/22 at 1:14 PM regarding R2 complaining of left leg pain on 01/02/22. V23 said, She was fine in the morning, no complaints of pain. Around 11 AM to 12 PM, one of the nurses (V7, Licensed Practical Nurse, LPN) came to me, called me that she (R2) complained of pain and needs to be transferred to the hospital. They were saying she had a fall the previous day. There was no endorsement from the previous nurse that she had a fall. I learned it from V17 (Family Member). On 01/11/2022 at 1:48 PM, V7 was asked regarding R2's fall incident. V7 mentioned: That Sunday (01/02/22) when I worked, V18 (Certified Nurse Assistant, CNA) told me that she (R2) said her (R2) side was hurting. She (V18) just happened to be walking past when she (R2) called her and told her that her side hurts. I told V23 that she (R2) had pain on her side. An attempt was made to contact V18 for questions and clarifications but she was not available. V9 (Assistant Director of Nursing, ADON) stated in an interview on 01/12/22 at 12:36 PM, One of the nurses (V23) notified me on a Sunday (01/02/22) when she (R2) was already in pain. I didn't know about the actual fall incident. I was the one who called V14 (Nurse Practitioner, NP) that time. Usually, she (R2) does not need someone to supervise or provide assistance when she dress up her upper and lower body. She puts her own makeup, does her hair, put on earrings, all by herself without staff present. She is alert, oriented to time, place and person. That time when she had the fall, she said she stood up from the wheelchair and was pulling her pants up and accidentally trip over her pants. Progress notes dated 01/02/22 time stamped 10:40 PM documented: R2 was admitted in the hospital for left broken hip. Progress notes dated 01/05/22 time stamped 8:31 PM documented: R2 returned from hospital post procedure closed reduction and nailing of the left femur. On 01/10/22 at 11:35 AM, R2 was observed in her room, sitting in her wheelchair with V17 (Family Member). R2 is alert but forgetful. She is verbal but hard of hearing. She appeared fully made up and hair was curled and combed. R2 was asked regarding her fall incident last 01/01/22, said, I fell backwards. I was sitting in wheelchair. I don't even know how I fell . I called out for help, they picked me up and put me back to bed. R2 was asked if there was a staff present each time she dresses up herself, stated, I dressed up myself with no staff around me. V17 was also asked regarding her (R2) fall incident. V17 said, They didn't inform me that day when she fell . V18 called me that Sunday and told me to come here that she (R2) had fallen. She (V18) went to see her (R2) to wish her happy new year and she (R2) told her (V18) that she fell . V2 was asked on 01/12/22 at 12:16 PM regarding R2 and recent fall incident. V2 replied, I was the one who did the investigation. She has a tendency to get up at times, to get up without assistance, we educate and remind her. We've always make sure that she calls for assistance and good shoes to fit on. She had a fall last 01/01/22, she was trying to do her morning routine - dressing herself up, putting on her make up and do her hair. She does it by herself, likes to do that by herself. Probably someone, a staff needs to provide very limited assistance. She does not need any staff supervising her when she does her morning routine, not at all times. At times, she does need supervision and very limited assistance during dressing and performing her morning routine. She fell because she did not call for assistance. And she is able to. V2 was also asked regarding her expectations on staff in preventing falls. She (V2) said, staff has to follow the fall protocol. V9 was also asked regarding her expectations on staff in preventing falls. V9 verbalized, We have a system here that we follow for one or two person transfers. We make sure that bed is locked, wheelchair is locked. Staff are trained how to use the mechanical lift transfer. For agency staff nurses and CNAs who are new to the facility, we have to inservice them to the floor and know the residents. The first 30 minutes prior to their work schedules are intended for orientation. As far as CNA doing patient care, we encourage the nurses to walk with the CNAs and let them see the resident. We have a 24 hour report which tells the nurses the care to be rendered to a specific resident. MDS documentation are the basis of care plans for each residents. Whatever documentation in the MDS, it should be reflected in the care plan. R2 is independent, able to do everything for herself. She will ask for assistance if she needs it, she goes to the BR by herself, dresses herself up, applies make up on. Staff has to follow fall protocol and part of it is to notify the doctor, family and Supervisors regarding fall incidents. On 01/12/22 at 2:30 PM, V14 (Nurse Practitioner) was interviewed regarding R2. V14 said, She is alert, oriented to person and place. She does a lot of her tasks by herself but she needs limited assistance from staff during dressing. She does her own hair and makeup. But when she dress up her upper body and lower body, she needs limited assistance from staff. Staff needs to be with her for safety measures. I was notified, she was sent out. I received the phone call from V9 that she (R2) was having some pain from her leg and difficult to move so she was sent out. I was notified only that time that she had a fall and was having pain. She lost her balance that is why she had the fall. Staff should be there to provide supervision and assistance during dressing. There was some weakness for sure, when she (R2) bended that low and pressure shifts happened which led to lose her balance. Staff needs to be present with her during bathroom use/shower and dressing so staff could step in if she struggles. If she was struggling on putting her pants on, staff can assist and intervene. She should be rounded on every two hours even during the course of the night to ensure safety. I need to be notified when incident occurred right away so X-rays can be ordered. This fall could have been prevented to happen. R2's Care plan regarding Falls start date 11/02/17 documented: Approach start date 12/11/17 - increased staff supervision with intensity based on resident need. There were no documentation in R2's progress notes dated 01/01/22 indicating that V14, V17 and V24 were notified at the time fall occurred. There were no documentation that endorsements were communicated to V23 and or to supervisors regarding fall incident and for post fall monitoring. Facility's policy titled Fall Reduction Program revised date 04/19 stated in part but not limited to the following: Objective: 1. It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The program intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of approach interventions, supervision, and/or assistive devices deemed appropriate. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Program Contents: The Fall Reduction Program includes the following components: 3. Use and implementation of profession standards of practice. 5. Notification of physician, family, or legal representative 6. Communication with direct care staff members Standards: 3. Safety interventions will be determined and implemented based on the assessed, individualized risks and in accordance with standards of care, interventions to be documented within the resident's care plan. 6. In the event fall incident occurs, nursing staff will complete an assessment of resident and obtain the facts surrounding the fall, and report findings to the resident's physician and responsible party (if applicable) and document findings and notification within the resident's clinical record. 7. Post fall monitoring shall be completed by the nursing staff every shift for 72 hours and findings documented within the clinical record.

Based on interview and record review, the facility failed to ensure that staff performed an assessment when resident complained of foot pain; failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure applied to one (R2) of three residents reviewed for nursing care and resulted in R2's emergent transfer to a local hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2 is a [AGE] year old male with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress notes dated 8/6/21 document that R2 was at [CONDITION(S)] when R2 complained of bilateral foot pain. The [CONDITION(S)] center called the facility and reported to the nurse. These progress notes also document that on 8/11/21, R2 refused to go to [CONDITION(S)] because of the foot pain. On 9/9/21 at 11:43am, V3 (Wound Care Nurse) indicated that 8/19/21 was the first time that the wound care team assessed R2. V3 stated, I was doing rounds with (V15-Wound Care Doctor) when nurse on staff came to us and said to look at (R2's) left foot and that something was going on. (V15) did assessment and ordered venous and arterial dopplers of both legs. He then ordered [MEDICATION(S)] treatments to be done daily between 2nd and 3rd toes and medial left foot by the great toe. There was eschar (blackened areas) on toes between 2nd and 3rd digits. V3 indicated that the bilateral lower extremity venous and arterial dopplers were ordered emergently by V15 on 8/19/21. V3 stated, Bilateral dopplers were ordered due to the necrosis and to make sure there was no blockage going on. The venous and arterial dopplers were ordered to be done STAT (right away). R2's medical record indicates that the arterial dopplers were not performed until 8/20/21 and the venous dopplers were not performed until 8/24/21. R2's progress notes and diagnostic result document that on 8/25/21, R2 was diagnosed with a DVT ([CONDITION(S)]) in both the right and left femoral veins. R2 was immediately sent out to a local emergency room for treatment. R2's emergency room records document that an ultrasound was done and the results show bilateral lower extremities [CONDITION(S)], gangrene and a foul odor to the second and third toes on the left foot. On 9/8/21 at 12:17pm, V3 (Wound Care Nurse) stated, No one ever reported to me about (R2) having any foot pain. On 9/9/21 at 10:16am, V16 (Diagnostic Representative) stated, We have the order for the arterial doppler and the venous doppler but because Medicare won't approve them to be done on the same day, we had to move one to the next day. We did the arterial doppler on the (August) 20th and were supposed to do the venous doppler on (August) 21st but it wasn't done. It wasn't done on the (August) 22nd or on the 23rd. (R2) was in [CONDITION(S)] so we did (venous dopplers) on 8/24/21. I'm not sure why it wasn't done on the 21st. On 9/9/21 at 12:13pm, V17 (License Practical Nurse - LPN) stated Yes, I was (R2's) primary nurse. When we do assessments of residents, we document on skin assessment sheet/shower sheets. We're supposed to do skin assessments on shower days and as needed. I can't recall if I did a skin assessment on (R2's) foot. V17 continued to state, No certified nurse assistant (CNA) reported to me (R2) had issues with his feet. He had his shoes off when I saw them. This surveyor asked V17 why there were no skin assessments done on R2's feet from the time he first complained of pain on 8/06/21 to 8/19/21, when the wound care team saw him. V17 stated, I don't know. There were no skin assessments of R2's foot in the medical record. On 9/9/21 at 1:50pm, V15 (Wound Care Doctor) stated, I was unaware that the diagnostic test was not done on the day that it was ordered. I ordered them stat and I expected them to call me and let me know it wasn't done. I ordered the test because (R2's) toes had necrotic tissue. It was eschar necrotic tissue. I felt it was an arterial vascular issue, that's why I ordered the arterial doppler. I ordered the venous doppler to rule out any blood clots. We use the arterial doppler to see if the extremities are getting enough blood and oxygen flow to and the venous doppler tells us if the blood is moving away from the extremities back to the heart. On (August) 19th is the first time I was made aware of (R2's) foot. The results I got back from the arterial doppler showed mild to moderate blockage. So that means that (R2's) foot was getting some type of circulation but not enough. For the toes to become gangrene, something must have happened from the time I saw him and he was sent to the hospital. Yes, the facility should have noticed any changes before they sent him out to the hospital. Yes, with mild to moderate arterial blockage they had time to notice. It will start as a small little discoloration on the skin then it progresses into eschar. With venous, they have swelling and complaints of pain. They should have seen it before the 19th. It would have been noticeable. If he was having pain, they should have did a full assessment of his feet to make sure there was no swelling or wounds. It would have to be severe blockage for it to become necrotic overnight. It starts with the CNA's. If they are cleaning and looking at the patient they would see something new like discoloration or wounds. They can report it to the nurse and then she would do the full assessment of the patient. They should let me know what they found so I can see the resident and start treatment. On 9/9/21 at 2:27pm, V2 (Interim Director of Nursing) stated, Nurses should assess whatever the patient presents with then they should check the patients diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 indicated that they call the doctor, then the doctor will make the decision if it can be treated in house or if they should be sent out to the hospital. V2 stated that the diagnostic company does not do stat procedures. V2 stated, We would have to send them to the emergency room . V2 continued to state, If the nurses don't get results, I expect for them to call and do a follow up to why the results were not sent. If it wasn't done they should follow up and find out when they are coming to do it. I expect them to call the doctor and let them know the test was not done and get a new order or get the okay to use the old order. (Staff should) call the diagnostic center to find out when and what time they will come out to complete the diagnostic test because it was not done on the date it was ordered. They should then document stating why the test was delayed. Skin assessments are usually done on shower days after the CNA has done the shower or bath. The nurse is supposed to come in and do a head to toe assessment. If the CNA is repositioning a resident and find something they should report it right away to the nurse and then the nurse should complete the assessment. The facility submitted their policy and procedure titled, Change in resident's condition or status revised on 05/17 that states: Objectives - our facility shall promptly notify the resident, his or her attending physician and representative of any changes in the resident condition and or status. Procedures: 1) the nurse will notify the attending physician when: B) there is a significant change in the resident's physical, mental or psychosocial status. C) there is a need to alter the resident's treatment significantly. F) deems necessary or appropriate in the best interest of the resident. 3) except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's condition or status. 5) the nurse will record in the residents medical record any changes in the resident's medical condition or status.

Based on interview and record review, the facility failed to follow the Restorative Assessment and the Minimum Data Set (MDS) by not providing an extensive, two person assist during bed mobility for one resident (R1) out of three residents reviewed for improper nursing care in a total sample of five residents. This failure resulted in R1 sustaining an impacted fracture to the left distal femur. Findings include: R1 is an [AGE] year old with the following diagnoses: [CONDITION(S)], fracture of the lower end of the femur, other specified disorders of bone density and structure, left sided [CONDITION(S)], vitamin D deficiency, and [CONDITION(S)]. R1 admitted to the facility on [DATE]. A Restorative Nursing note dated 3/23/21 documents both of R1's legs are in an extended position and range of motion is severely limited. R1 receives physical assist with bed mobility and is able to use side rails for support. R1 is to continue receiving extensive to total assist with bed mobility. A Nurse Practitioner note dated 5/12/21 documents new recent pain with palpation to bilateral lower extremities. Venous Doppler scans were ordered as well as x-rays. A Nursing note dated 5/13/21 documents R1 complained of pain in the lower extremities and was rated 6 out of 10. Tylenol was given and reassessment the pain was 2 out of 10. The X-ray of the left leg dated 5/13/21 documents mild arthritic changes to the knee with possible distal femur fracture. A Nursing note dated 5/14/21 at 1:30AM documents the x-ray results came back around midnight and showed a possible distal femur fracture. The doctor was paged and the nurse is awaiting a call back. A Nursing note dated 5/14/21 at 6:45AM documents the doctor was paged again at 4:00AM after missing a return call around 3:30AM. A Nursing note dated 5/14/21 at 8:17AM documents the doctor ordered R1 be sent out to the hospital to rule out possible fracture. An ambulance company was called and the estimated time of arrival is 30 to 45 minutes. A Nursing note dated 5/14/21 at 3:04PM documents R1 was admitted to the hospital with a distal, impacted femur fracture. The Hospital Records dated 5/14/21 document R1 presented from the nursing home with a possible left distal femur fracture. Repeat x-rays of the left knee confirmed a nondisplaced, impacted fracture of the distal femur. Osteopenia (low bone mass - a person's bones are not as strong as they should be) and severe [CONDITION(S)] are also noted in the x-ray. A knee immobilizer was placed and R1 is to stay non-weight bearing until further instruction. No surgery is recommended as R1 is non-ambulatory. On 5/18/21 at 12:30PM, V3 (Certified Nursing Assistant/CNA) stated, The first night I went in with another CNA to change R1 and R1 was grunting and pointing at R1's leg. The other CNA (V4) and I go into everyone's room and change them together because it's easier and more comfortable for the resident. R1 can't really help you do anything. R1 can't move R1's legs and R1 only moves R1's arms a little bit so that's why it's safer to always use two people when caring for R1. On 5/18/21 at 12:47PM, V4 (CNA) stated, R1 needs a two person assist to change. R1 can't help you do anything. You use two people for safety and it is what I was taught in school. I usually go in with the other CNA working on that unit and we go in together and change everyone. I never try and do it alone. On 5/18/21 at 2:22PM, V2 (Director of Nursing/DON) stated, We just had R1's sister here to help kind of translate for R1 and get an idea of what happened. R1 kept motioning like over, over as if it happened when R1 was being turned. So it's likely R1 got this fracture while being turned in bed and R1 having osteopenia causes everything to be weaker. On 5/19/21 at 10:47AM, V8 (Nurse) stated, R1 is a two person assist due to being heavier and stiffer. R1 can't move R1's legs at all. On 5/19/21 at 11:00AM, V9 (Restorative Nurse/Fall Coordinator) stated, R1 is bedbound. R1 is also dependent on all ADL (Activities of Daily Living) care except eating. R1 can't move R1's legs. R1 does have some limitations on R1's upper extremities as well. R1 can't sit up by herself. One to two people can change her. R1 can hold the side rail. Staff does the weight bearing work. Two people help out just to lighten the load. I know staff sometimes do a buddy system where they go in together but not all staff do it. R1 does have some bone disorders but I'm not sure what they are. I know it says that in the MDS and in the restorative assessment but if R1's able to help out two staff aren't needed. On 5/19/21 at 11:47AM, V10 (Nurse) stated, I don't really change R1 but I believe R1 is changed with two people because R1 can't really help out and R1 isn't very strong. On 5/19/21 at 12:02PM, V11 (CNA) stated, R1 is a complete total assist with changing; R1 can hold the rail but that's about it. When I saw R1 in the morning R1 was fine. I went to change R1 right after lunchtime and after I changed R1, R1 seemed uncomfortable and kept pointing to the lower half of R1's body. I did change R1 by myself because R1 is able to help hold the rail so I can hold her bottom with one hand while I do the rest of the work. If I can find someone to help I will call them to help me change her but I usually do it alone. On 5/19/21 at 1:13PM, V13 (Orthopedic Surgeon) stated, It can happen for a lot of different reasons. Based on the x-ray, R1's bones have severe osteopenia if not [CONDITION(S)] which make fractures a lot more likely as well. If R1 wasn't being turned properly in bed this could have happened. If R1's body was going one way and R1's leg was going a different way this is what could've caused this. With someone with R1's age and condition of R1's bones, they would definitely need to always follow their protocols on properly turning residents and taking extra care and precaution with them because they can fracture so easily. R1's bones were extremely fragile and taking extra precautions while turning or providing care could have prevented this from happening. She would have been in pain immediately after this occurred and then probably anytime she moved R1's leg after that. On 5/19/21 at 2:39PM, R1 was observed lying in bed. There was a black brace on R1's left leg starting at the mid-thigh and extending down to the ankle. R1 was unable to speak but kept pointing to leg and shaking head no to signal R1 did not want R1's leg touched at this time. R1 was unable to answer any further questions from the surveyor about what happened to R1's left leg. On 5/19/21 at 2:41PM, V15 (Rehab Aide) stated, R1 needs 2 people always when you are moving or turning R1 in bed. R1 is pretty weak and can't really help with moving at all. I mean R1 can grab the rail but R1 can't really hold R1's weight up. R1 is a bigger lady to be having one person try to do everything too. She can't really move her legs at all and her left side is her bad side. You always want 2 people moving her to make sure nothing happens to her when R1 is being repositioned. You just want to make sure R1 is staying safe. The Care Plan dated 12/29/20 documents R1 requires supervision and set up for ADLs related to left sided [CONDITION(S)] with an intervention of providing maximum assistance during (eg. range of motion, bed mobility, transfers, wheelchair, mobility). The Minimum Data Set (MDS) dated [DATE] documents R1 requires an extensive, 2 person physical assist with bed mobility. R1 is totally dependent on staff for transfers and requires a two person physical assist. The Restorative assessment dated [DATE] documents R1 is an extensive assist when rolling from the left and right side and back to supine. R1 is a total assist for supine to sit position, sitting position to supine, moving up in bed, and moving down in bed.

Based on interview and record review the facility failed to provide the necessary care and services by not assessing a resident on admission to the facility, assessing a resident with a change in condition, and obtaining vital signs as ordered for a resident returning from an eight day hospitalization for [MEDICAL CONDITION] for one of three residents (R7) reviewed for change in condition in the sample of 12. Findings include: R7's face sheet showed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's history and physical (late entry dated [DATE]) showed R7 was scheduled for a right lower extremity angiogram where he developed [MEDICAL CONDITION] and required intubation. On [DATE], a [MEDICAL CONDITION] was placed. On [DATE], R7 developed [MEDICAL CONDITION] with RVR (Rapid Ventricular Rate) and a [MEDICAL CONDITION] embolism (blood clot in the lung). R7 was stabilized and sent to an acute rehab facility and then to the current facility for continuity of care. R7's face sheet showed R7's Respiratory Admission assessment dated [DATE] at 3:50 PM showed R7 was on a ventilator. R7's Physician order [REDACTED]. The POS showed R7 was a full code status. R7's progress note dated [DATE] at 1:13 PM showed R7 was found unresponsive and without a pulse during [MEDICAL TREATMENT] at the facility. R7's progress note dated [DATE] at 9:24 PM showed admission to a local hospital for [MEDICAL CONDITION]. R7's progress note dated [DATE] at 11:08 PM showed R7 returned to the facility at 3:00 PM. There is no nursing assessment documented for this admission back to the facility. R7's progress note dated [DATE] at 2:48 AM showed the resident was still the same. R7's vital signs were documented in the nursing record on [DATE] at 9:18 PM. No other vital signs were documented in R7's record by nursing until [DATE] at 12:34 AM in a progress note. This progress note showed a temperature of 99.9 and the nurse was unable to obtain other vital signs (heart rate, respiratory rate, blood pressure). R7's [DATE] at 7:15 AM progress note showed the resident was unresponsive, a code blue was initiated, CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called. R7's 7:49 AM progress note showed R7 was pronounced dead. On [DATE] at 2:15 PM, V2 (Director of Nursing) stated, If a nurse is unable to obtain vitals (temperature, pulse, respirations, blood pressure) on a resident they should try doing it manually. The blood pressure machine doesn't always work. I would expect the nurse to do a head to toe assessment and listen to an apical pulse. That is not a good note. Sometimes the staff write vital signs on the 24 hour sheet. The 24 hour sheet is not part of the resident's record. If you can't get vital signs, you should start CPR. On [DATE] at 12:39 PM, V17 (Registered Nurse/RN) stated, If a resident is readmitted from a hospital stay, we do a head to toe assessment and do a narrative in the progress notes. There are packets in our electronic charting system for admission, readmission, and observation. This is where we document our assessment. If I was unable to obtain a resident's vital signs, I would never, never stop trying. I would call the supervisor, the doctor, or send them back to the hospital. It's our protocol to do a head to toe assessment. It helps us understand their care needs. If there is no pulse on a resident, I would start CPR if they were a full code. If a resident returned to the facility after being hospitalized for [REDACTED]. At 1:23 PM, V18 (Licensed Practical Nurse/LPN) said if she receives a resident back from a hospitalization , she fills out the admission packet in the electronic record. V18 stated, This packet includes head to toe assessment data including skin integrity, vital signs, mental status, ventilators, etcetera. I would also document in the progress notes. If I couldn't obtain a resident's vital signs, I would call the supervisor, doctor, or ask another staff person to try. You don't just do nothing. A head to toe assessment determines and documents how the patient was received and what they require. It's the protocol to do an assessment. In general, it could be detrimental to a resident if an assessment is not done or if vital signs are not monitored. At 1:57 PM, V20 (R7's Physician) stated, The facility is responsible to the resident, to provide the care and services ordered by the physician. You absolutely have to do an assessment on admission. It's nursing home protocol. It's the standard of care. There is no excuse for not taking and/or recording vital signs. If you can't get someone's vital signs, you should contact someone to recheck the resident or call 911. V20 said he was not notified staff were unable to obtain R7's vital signs. The facility's [DATE] Admission of a Resident Policy documented to complete the Nursing Body Assessment in its entirety in the admission Nursing Assessment in the electronic health record. Take TPR (temperature, pulse, respirations) and BP (blood pressure). Assess heart sounds, lung sounds, and bowel sounds. Assess resident's condition specific to the admitting [DIAGNOSES REDACTED]. Obtain and process physician's orders [REDACTED]. Complete Admission/Readmission Assessment Observation in the electronic health record. The facility's [DATE] Change in a Resident's Condition or Status Policy documented the nurse will notify the resident's attending physician or physician extender when there is a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review, the facility failed to provide two-person assist to a resident resulting in a right ankle fracture and hospitalization . This affected 1 resident, Resident # 160, of 2 residents (R 160 and R 123) reviewed for accidents in a total sample of 35. Findings include: On 12/5/17 at 11:20 am during an initial tour, this writer noted R160 sitting in a reclining high back chair in the dining room with a Velcro splint on her right ankle. R160 stated I was taken to the hospital after a fall about two months ago. I was being transferred by a CNA (Certified Nursing Aide) from my bed to my wheelchair, I should be a two person assist. R160's progress note dated 10/11/17 at 2:30pm signed by V11 (RN-Registered Nurse) reads, writer was called to check the resident on the floor, writer immediately went to resident's room, resident was asked what happened, resident verbalized, resident was trying to transfer to wheelchair from bed with CNA assistance however her knees and body gave in 2:40pm 911 called and came to the facility, took over, transport to hospital for evaluation R160's progress noted dated 10/11/17 at 2:34pm, signed by V4 (ADON- Assistant Director of Nursing) reads, writer was notified by resident floor nurse and CNA that resident has fallen in room transferring with CNA to wheelchair. Resident noted lying on the floor with head resting against seat of wheelchair, gait belt noted secured around residents waist. Resident reports that she was trying to get into the wheelchair with her legs and body just gave away, she slumped down with her CNA behind her .awaiting 911 for transfer to hospital as NP (Nurse Practitioner) R160's NP progress note dated 10/11/17 at 3:12pm signed by V12 (NP) reads, 1. S/P (status [REDACTED]. R160's hospital records read, dates of hospital stay: admitted on [DATE], discharged on [DATE]. Extremities: Right lower leg is in cast Active Problems: Closed bimalleolar fracture of right ankle . . R160's fall risk assessment dated [DATE] documents risk scores: 17.0 Level: High Risk. R160's Restorative progress note dated 9/18/17 at 2:26pm signed by V8 (Restorative Nurse) documents with restorative staff able to let resident sit at the side of the bed with two person assist, attempt to stand with extensive two person assist R160's MDS (Minimum Data Set) dated 9/18/17 documents under Section G- Functional Status, G0110, Activities of Daily Living (ADL) Assistance: B. Transfer- 3 (Extensive Assistance), 3 (Two+ persons physical assist). On 12/7/17 at 11am, V6 (CNA) stated Around 10:30am on the day R160 fell , I was in R160's room helping her to get to her wheelchair from her bed. I put a gait belt around her waist to transfer her. She started going down and fell to the floor, I reported to the nurse right away. R160 is a one-person assist and I have been transferring her by myself all the time. On 12/7/17 at 12:10pm, V7 (Director of Restorative Services) stated, R160's MDS was revised on 9/18/17 from a one-person physical assist to a two-person physical assist in transfer because staff reported that an additional person is needed to transfer the resident.

Based upon observation, interview and record review, the facility failed to notify and consult the physician of a persistent complaint of pain and unavailability of pain medication and failed to consistently and completely document [MEDICAL TREATMENT] communication report treatment flow sheets. These failures have the potential to affect all 21 residents who receive [MEDICAL TREATMENT] services within the facility; affected 4 of 4 residents (R12, R17, R18, R25) reviewed for [MEDICAL TREATMENT] services, in the sample of 26 and 17 residents (R29, R53, R64-R78) from the supplemental sample. Because of these deficient practices, R29 was not able to sleep at night due to pain and discomfort and failed to participate in activities due to continuous pain and discomfort. Findings include: Per physician order [REDACTED]. On R29 ' s MDS (Minimum Data Set) dated 11/25/15 indicates BIMs (Brief Interview for Mental Status) as a 12 for moderate impairment. On 1/6/16 at approximately 12:15 pm R29 was noted moaning and groaning in bed. R29 complained of generalized pain all over and inability to sleep all night. When asked if R29 was able to participate in the activities in the facility, R29 stated he was not able to because of pain. R29 further indicated that the nurses were aware of the complaints of pain and motioned to the nursing staff in the room. E10 (Licensed Practical Nurse) was asked about R29 ' s pain, and E10 indicated she would look into it. During the survey, R29 was observed in the room. Review of R29 ' s progress notes from 12/1/15 through 1/12/16, there is no documentation related to identification, assessment or management of R29 ' s pain. Review of R29 ' s MAR (Medication Administration Record) and Medication Review report with order date of 12/23/15 indicated that R29 has an existing order for pain management [MEDICATION NAME] 72 hours for pain management and remove as scheduled and apply new patch; [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg give 1 tablet via [DEVICE] every 6 hours as needed for moderate (4-6) to severe (7-10) pain. Further Review of R29 ' s MAR indicated [REDACTED]. R29 was provided the [MEDICATION NAME] on 1/4/16, eleven days after the physician order. A medication for [MEDICATION NAME]-[MEDICATION NAME] was ordered for R29 on 12/22/15 as an alternative pain medication to be offered but was not given per record review. Review of progress notes for 1/4/16 documented by E46 (licensed practical nurse) states, Called pharmacy for [MEDICATION NAME]. Needs prescription. Prescription form faxed to pharmacy. Interview with E46 on 1/12/16 at 1:10pm indicated that E46 was very familiar with R29. E46 went on to say that R29 had intermittent complaints of pain and that it was the facility ' s practice to access for pain based on a 1-10 pain scale however could not recall if she did any assessment for this resident. E46 confirmed she ordered the [MEDICATION NAME] because R29 was out of the medication but could not recall if she ordered it due to R29 ' s complaints of pain. Interview was conducted with Z6 (Pharmacist consultant) on 1/7/16 at approximately 3:15pm. Z6 indicated she conducted medication regimen reviews for the facility on a monthly basis and would provide the results of the report to the administrator and director of nursing. Asked what the process would be if she saw circled medications on the MAR (medication administration record) indicating not given or unavailable, Z6 indicated that she would report it to the administrator and director of nursing and would show up on her report. Review of consultant pharmacist medication regimen review lists R29 as one of the resident ' s not requiring any recommendations pertaining to her medications and fails to identify the unavailable [MEDICATION NAME] medication. Pain assessments for 12/25/15 indicate R29 was in severe pain during the evening and night shifts with no pain medications provided. Pain assessments for 12/26/15 indicate R29 was in severe pain again during the evening and night shifts. E2 (Director of Nursing) provided the surveyor with copies of MAR (Medication Administration Records) dated 12/2015 and 1/2016, which confirmed that no medication were provided to alleviate R29 ' s pain. Despite surveyor ' s request, E2 was unable to provide evidence of other pain management measures for R29. On 1/11/16 at approximately 2:00 pm Z1 (Physician) was telephoned and interviewed. Z1 indicated that he was not informed by the facility about R29 ' s complaints of pain nor was informed that R29 ' s [MEDICATION NAME] pain medication was not available. Z1 indicated if he was informed he would have taken care of the issue. Z1 further indicated that it was his expectation to be informed when there is any change in condition with any of his patients and the facility would usually do that. On 1/11/16 at 3:10 pm E2 (Director of Nursing) was interviewed. E2 indicated she expected her nurses to assess and document pain and to provide pain medications as ordered by the doctor. E2 went on to say that she expected to be informed, along with the doctor and pharmacy if there were any issues with medications being unavailable. On 1/12/16 at 3:15 pm, E45 (PM Nursing Supervisor) indicated she was very familiar with R29 and was aware of her complaints of intermittent pain. E45 indicated they would assess pain on a scale of 1 to 10, 10 being the most severe. She added that they would give pain medications per doctor ' s orders and that they ' d assess and document the results in the MAR indicated [REDACTED]. R29 ' s care plan dated 11/20/2015 states in part: Resident will be comfortable and free of pain. Administer pain medications as ordered. Evaluate/record/report effectiveness and any adverse side effects. Administer pain relief measures e.g., distraction, relaxation, music, pillows, repositioning, etc. Monitor and record effectiveness. There is no documentation noted pertaining to pain relief measures being administered to R29. The facility ' s policy dated 2/28/13 titled Pain Management states in part: Objective: It is the policy of this Facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan. Procedure: All residents will be screened for the presence of pain symptoms. The facility nursing staff will complete the Pain Screening Form upon admission, with the Quarterly Assessments, Readmission from Hospital Stay, and if the resident experiences a new onset of recurrent pain. If a resident scores a total of 5 or more on the paper screening form, the Comprehensive Pain Assessment will then be competed. The physician will be informed of resident ' s initial complaint of pain and review the resident ' s pain management plan during routine visits. On 1/6/16 at 9:45 am during an interview with Z3 ([MEDICAL TREATMENT] Nurse), Z3 was asked, how does [MEDICAL TREATMENT] staff communicate with the facility nurses to ensure continuity of care between the nursing unit and the [MEDICAL TREATMENT] unit. Z3 stated, We use a communication log between the [MEDICAL TREATMENT] (nurse) and the unit nurses each time the patient comes to [MEDICAL TREATMENT]. On 1/7/16 at 3:06 pm during an interview with E2 (Director of Nursing), E2 was asked, what is your expectation for communication between the unit nurses and the [MEDICAL TREATMENT] staff. E2 stated, The [MEDICAL TREATMENT] nurses may call the unit nurses and the unit nurses may call the [MEDICAL TREATMENT] nurses. E2 was asked, what is the purpose of the [MEDICAL TREATMENT] communication report. E2 stated, Each time the resident goes to [MEDICAL TREATMENT], the communication report goes with them to [MEDICAL TREATMENT] staff but, the policy is not limited to paper only, nurse may call. The unit nurses do not have to use the [MEDICAL TREATMENT] communication report because they can just call. E2 was asked, does your [MEDICAL TREATMENT] policy or contract with the [MEDICAL TREATMENT] service indicate that the (unit) nurses should use the communication report. E2 stated, No the contract does not say that and we do not have a policy that says that. On 1/7/16 received from the facility [MEDICAL TREATMENT] Communication Report forms for the third floor residents receiving [MEDICAL TREATMENT] from E3 (nursing supervisor). The [MEDICAL TREATMENT] Communication Report forms were incomplete in the section labeled to be completed by long term facility staff prior to sending patients to [MEDICAL TREATMENT]. The incomplete [MEDICAL TREATMENT] communication reports were regarding; R29, R69, R17, R70, R71, R72, R73, R74, R75, R76 and, R77. On 1/7/16 requested from E1 (Facility Administrator) copies of all [MEDICAL TREATMENT] communication reports for all residents receiving [MEDICAL TREATMENT] at the facility. E1 presented all [MEDICAL TREATMENT] communication reports on 1/11/16. [MEDICAL TREATMENT] communication reports for all residents receiving [MEDICAL TREATMENT] in the facility (R12, R17, R18, R25, R29, R53, R64-R78) and presented by E1 were incomplete. Duplicate [MEDICAL TREATMENT] communication reports that were incomplete as presented by E3 (nursing supervisor) on 1/7/16 were partially completed for R77, R17, R74, R29, R70, R73 and, R12 as presented by E1. A review of the undated facility policy initialed, Care of the [MEDICAL TREATMENT] Resident , indicates in part: Pre-[MEDICAL TREATMENT] weights are to be obtained. If resident attends in-house [MEDICAL TREATMENT] the weights are to obtained by nursing staff. Correlation of services will be established between the [MEDICAL TREATMENT] team and the facility staff. A review of the Home [MEDICAL TREATMENT] Coordination and Services Agreement indicates in part: Patient care personnel shall complete a treatment flow sheet, one copy of which shall be maintained on the facility premises. Patient care personnel shall be responsible for recording all weights in the [MEDICAL TREATMENT] treatment record of each Home [MEDICAL TREATMENT] Patient.