Every finding on record at Bria of Geneva

Based on interview and record review, the facility failed to develop and implement interventions to prevent the development of pressure ulcers for one resident. This failure resulted in R38 developing a facility-acquired deep tissue injury (DTI) to the right heel.This applies to 1 of 4 residents (R38) reviewed for pressure ulcers in the sample of 20.Findings include: Review of R38's electronic medical record reads is [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including, but not limited to, spinal stenosis, fibromyalgia, and diabetes mellitus. The Minimum Data Set (MDS), dated June12, 2026, documented a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating a mild cognitive impairment, section M indicates R38 skin documents no skin impairment. On July 22, 2026, at 9:35 AM, R38 was observed resting in bed. R38 said, I came here sometime in the past, my skin was okay. I have a bed sore to my right heel. It is painful. I do not want to be touched or moved. I want to get up in the chair and go to therapy.On July 22, 2026, at 11:15 AM, V11 (Licensed Practical Nurse/Wound Care Coordinator) said, R38 was admitted on [DATE], with intact skin but was unable to reposition independently due to discomfort and personal preference. I do not have any documentation to prove that R38 was turned and reposition before July 17, 2026. The care plan interventions need to address the resident's risk for skin breakdown; the care plan was not initiated until June17, 2026. The care plan was not developed or implemented between June 5 and June17, 2026. I know I missed this one, I am sorry. On June,19, 2026, V33 (Certified Occupational Therapy Assistant) informed me: R38 complained of right heel pain. Upon assessment, I observed non-blanchable redness to the right heel, identified a deep tissue injury (DTI). I notified the provider, obtained treatment orders, and arranged for evaluation by the wound nurse practitioner. The care plan was revised as well, after the resident developed the DTI. The interventions included were using a low-air-loss mattress, resident education regarding skin management, keeping the skin clean and dry, repositioning, pain management, and monitoring the skin for redness and blanching.Skin assessment (Braden Scale) was completed on June 5, 2026, with score of 16 indicating R38 is at risk for skin breakdown. The lower the score the higher the risk for the resident to develop any skin impairments. June,19, 2026: New right heel unstageable pressure injury presenting as a deep tissue injury (DTI), measuring 3 cm x 2 cm x 0 cm.June 24, 2026: Wound assessed as stable. Measurements remained 3 cm x 2 cm x 0 cm. Documentation identified the wound as facility acquired.July 1, 2026: Wound, measuring 3 cm x 2.4 cm x 0 cm.July 8, 2026: Wound, measuring 3 cm x 3 cm x 0 cm.July15, 2026: Wound measuring 2.5 cm x 2 cm x 0.2 cm. On July 22, 2026, at 1:55 PM, V2 (Director of Nursing) said, R38 had a facility-acquired right heel wound, when a wound is identified, the facility investigates contributing factors. My expectation is for the care plans to be developed and updated based on admission assessments and hospital information, with preventative interventions implemented upon admission to maintain skin integrity and prevent skin issues. The baseline care plan needs to be developed, that is the responsibility of the wound care nurse. On July 22, 2026 at 2:20PM V5 (MDS Coordinator/ LPN) said, I do the patients care plan. I developed the baseline care plan; I do not do the skin/ wound care plans. The wound care nurse does the skin care plans. My job is to check the care plan for completion not for accuracy. R38 has developed a wound in the facility, it is acquired. On July 23, 2026 at 9:10 AM R38 observed to be in bed, eating breakfast, appeared to be clean and well groomed. R38 said, I am clean, I do not need to have my undergarment change, I am ok. V11 uncovered the right lower extremity, intact dressing noted in the right heel. R38 said, I do not want you to remove my dressing. I am ok. On July23, 2026 at 9:40 AM V33 (Certified Occupational Therapist Aide) said on June19, 2026 I was working on transfers with R38 when she complained of pain to the right heel, I checked the area, it was red, but the skin was intact. I notified V11 immediately, and she came and assessed R38. Facility presented policy titled: Comprehensive Care Plan dated: March 2026, reads: The facility must develop a comprehensive center care plan for each resident. The care plan will include a focus on measurable goal and interventions specific to the resident's medical, nursing, mental and psychosocial needs.

Based on record review and interview, the facility failed to monitor a resident who was identified at a high risk for falls and failed to develop and implement interventions for fall prevention, based on the residents needs related to toileting, leg weakness and lack of safety awareness. This failure resulted in a resident with multiple falls, who also sustained injuries to include a frontal sinus (nasal bone) fracture, related to fall incidents on March 27, June 5, July 3, and July 15, 2026.This applies to 1 of 3 residents (R54) reviewed for fall incidents in the sample of 30. The findings include: R54's admission record showed R54 was admitted on [DATE], with multiple medical diagnoses including epilepsy with status epilepticus, difficulty in walking, history of falling, and muscle weakness. R54's MDS (Minimum Data Set) dated May 1, 2026, showed R54 that has severe cognitive impairment and requires partial/moderate assistance with toileting, personal hygiene, and transfer. R54's nurses' notes with fall incidents from January to July 2026 showed: 1. On January 24, 2026, at 6:15 AM, R54 had an unwitnessed fall. R54 was observed sitting on the floor in his bathroom. R54 was noted with swelling on his forehead. R54 was sent to the hospital for evaluation. Fall care plan was created on January 28, 2026. However, there was one intervention which was initiated on January 24, 2026, which showed Provide proper, well-maintained footwear. 2. On February 27, 2026, at 5:00 AM, R54 had an unwitnessed fall. R54 was observed in his room lying face down on the floor. Hematoma was noted at the back of his head. The EMS (911 Emergency Medical Services) was called and R54 was transferred to the hospital for evaluation. Fall assessment dated [DATE], showed R54 scored 19 which means he was at high risk for fall. Root cause analysis dated February 27, 2026, showed R54 attempted to ambulate, and his knees gave out. Care plan intervention dated February 27, 2026, showed 3 days orthostatic hypotension, floor mat. 3. On March 27, 2026, at 4:50 AM, R54 had an unwitnessed fall. R54 was found on the bathroom floor in supine position, with laceration to left forehead. R54 stated I bump my head in the bathroom. R54 complaint of pain in left forehead and left knee. 911 EMS was called and R54 was sent to the hospital for evaluation. Fall assessment dated [DATE], showed R54 scored 17 which means he was at high risk for fall. Root cause analysis dated March 27, 2026, showed R54's knees gave out while ambulating to the bathroom. Care plan intervention dated March 27, 2026, showed Place resident on get-up list to assist with ADLs (activities of daily living care) and toileting. 4. On June 5, 2026, at 1:20 AM, R54 had an unwitnessed fall. R54 was observed on the floor in supine position beside his roommate's bed. Blood was noted to his right head and nose. 911 EMS was called and R54 was transferred to the hospital for evaluation. Fall assessment dated [DATE], showed R54 scored 22 which means he was at a high risk for fall. Root cause analysis dated June 5, 2026, showed R54's knees gave out and fell while ambulating without shoes. Care plan intervention dated June 6, 2026, showed Provide proper well-maintained footwear non-skid socks at nighttime. 5. On July 3, 2026, at 3:10 AM, R54 had an unwitnessed fall. R54 was observed standing in the bathroom washing his face with a laceration noted to the left eyebrow. R54 was unable to verbalize what happened. 911 EMS was called and R54 was transferred to the hospital for evaluation. Fall assessment dated [DATE], showed R54 scored 22 which means he was at high risk for fall. Root cause analysis dated July 3, 2026, showed R54 attempted to go the bathroom by himself, and his legs gave out. Care plan intervention with initiated date of July 3, 2026, and a revision date of July 23, 2026, showed Rounding frequently at nighttime and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. 6. On July 15, 2026, at approximately 6:15 AM, V36 (Nurse) heard R54's groaning from his bedroom. R54 was last seen at around 5:30 AM during rounds when CNA staff changed his disposable brief. V36 immediately responded and observed R54 lying on the floor mat next to his bed. R54 was conscious, alert, but not in distress. V36 immediately assessed R54, there was no bruising, no cuts or bleeding or other visible injuries were noted. R54 was safely returned to bed via mechanical lift with assistance from CNA staff. Neuro checks initiated. Fall assessment dated [DATE], showed R54 scored 24 which means he was at a high risk for fall. Root cause analysis dated July 15, 2026, showed R54 rolled out of bed. Care plan intervention dated July 15, 2026, showed Provide resident bed with bolster bilateral to define bed bounders. On July 22, 2026, at 3:04 PM, V34 (Certified Nursing assistant/CNA) stated that R54 was confused and mumbles a lot. On July 3, 2026, around 3 AM, V34 found R54 standing in the bathroom with a laceration in one of his eyebrows (V34 was unable to recall which eyebrow) and R54's brow was bleeding. V34 said she did rounds and checked about 10 minutes prior to the fall incident. R54's bed was at lowest position with thick floor mat at bedside. R54's call light within reached. V34 said they do frequent rounding depending on who was assigned to R54, there was specific frequency, but she was not sure how often. They check everyone (all residents) every 2 hours. However, they checked R54 more frequently because he was at high risk for fall. R54 was a wanderer, he does not sleep a lot at night, and he was weaker at night. On July 22, 2026, at 3:46 PM, V35 (Nurse) stated R54 was a high risk for fall, and he has a bedside floor mat, he was ambulatory, they monitored him most of the time about every 30 minutes. That day of the incident (July 3), they checked him 30 minutes before the incident happened, he was in bed sleeping. On July 22, 2026, at 4:26 PM, V36 (Nurse) stated R54 was known as a high risk for fall. Around 6:15 AM on July 15, 2026, V36 heard a groaning sound from his bedroom, his door was wide open. V36 saw R54 lying face down on the floor mat and was groaning. There was no bleeding, no bruising, or laceration. R54 was able to move all his extremities. They assisted R54 back to bed with a mechanical lift machine. V36 called and notified the physician and family. Physician ordered staff to monitor and report if there's any changes. V36 endorsed it to the morning nurse. R36 did not send R54 to the hospital because there was no visible injury. V36 was later informed by the morning shift nurse that R54 developed bruise in the facial area, and he was sent to the hospital. R54 was admitted to the hospital. V36 added, they made sure that R54's bed was at the lowest position, and staff was always rounding. The staff usually do round every 2 hours for all residents including R54. The last time he was seen prior to the fall was around 5:30 AM when they changed his incontinence brief. On July 23, 2026, at 9:40 AM, V37 (CNA) stated she and V36 heard a groaning sound from R54's bedroom on July 15,2026. They saw R54 lying on the floor face down (not on the floor mat). V38 (CNA) came in to help pick R54 from the floor. They assisted R54 to stand up. R54 had a gown on but he was not wearing a brief. R54 had a bowel movement, he had fecal matter on his buttocks and on the bedroom floor. V38 cleaned R54's fecal matter off him. They assisted R54 to walk back to bed once he was cleaned and had an incontinence brief. R54 was groaning in pain. There was no bleeding. On July 23, 2026, at 9:54 AM, V16 (Nurse) said on July 15 (V16 was unable to recall exact time), R54 was noted with swelling on his left cheekbone, she called the physician, and he ordered to send R54 to the hospital. V16 later followed up with the hospital and was informed that R54 was admitted for altered mental status and frontal sinus (nasal bone) fracture. On July 23, 2026, at 10:14 AM, V38 (CNA) said on July 15, when V38 went to the bedroom R54 was lying face down on the floor, there was a floor mattress beside the bed, but R54 was away from the bed. R54 kept groaning in pain. R54 did not verbalize anything. R54 was totally naked on the floor. R54 had fecal matter on his buttocks and fecal matter on the floor. V38 provided incontinence care prior to assisting R54 to walk back to bed. On July 23, 2026, at 2:37 PM, V40 (Physician) stated he was aware that R54 was at high risk for fall. V40 had seen R54, 5-6 times since he started seeing him. V40 stated the facility should update R54's fall interventions for every fall. R54 had end stage dementia. V40 suggested hospice care to family, however, family was resistant to this suggestion. R54 was being treated with Olanzapine and Ativan. R54 was assessed as having a high risk for fall incidents. R54 was admitted to the facility on [DATE], however, he did not have an interim fall care plan. After he had fallen on January 24, a fall care plan was created on January 28, 2026. R54 had multiple fall incidents from January to July 2026, with fall assessment score increased from 19 to 22. Staff who were interviewed were aware that R54 was a high risk for fall. Staff interviewed were saying they were monitoring R54 closely. V34 said they monitor R54 frequently, V35 said they monitor R54 every 30 minutes, while V36 said they monitor R54 every 2 hours, they have no consistent response of how often they were supposed to monitor R54, when all of R54's fall incidents were unwitnessed. R54 sustained injuries with his fall incidents on March 27, June 5, July 3, and July 15, 2026.The July 3 care plan showed Rounding frequently at nighttime and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. R54's electronic medical records did not have evidence of documentation of how frequently they monitor R54. R54's fall incident on January 24, March 27, and July 3 all happened in the bathroom, while the July 15th, though R54 was found face down on the bedroom floor, R54 was soiled with fecal matter. The root cause analysis did not identify why R54 was frequently found in the bathroom. The fall care plan did not have any specific or detailed intervention addressing how often they would check R54 for bladder and bowel assistance to establish bathroom routines /management. Facility's Fall Prevention and Management Policy and Procedure, dated January 2026 with review date of January 2026 showed: General: The facility is committed to maximizing 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 preventive strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.Guidelines: Upon admission: - Resident at risk for falls will have fall risk identified on the interim plan of care and ISP with interventions implemented to minimize fall risk.Facility guidelines following a fall incident: - A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls.- Care plan to be updated with a new intervention based on root cause analysis after each fall assessment.

Based on observation, interview, and record review, the facility failed to ensure staff personal food items were not stored at resident's kitchen refrigerator, failed to ensure beverages were labeled with the date these were made, and failed to ensure male staff wear appropriate hair restraints in an effort to prevent foodborne illnesses. The (07/20/2026) facility census documented there were 93 residents at the facility.The (undated) list of residents on NPO (nothing per orem/mouth) documented 2 residents on the list.This failure has the potential to affect all 91 residents at the facility. Findings include: On 7/20/2026 at 9:35am with V6 (Dietary Manager) during the initial tour of the facility kitchen, there were two plastic bags in refrigerator #1. One plastic bag contained rice and avocado and the other plastic bag contained salsa and 9 raw eggs. V6 stated the two plastic bags belonged to (V8-Dietary Aide). V6 stated he did not know the source of the employee food items, and these should not be stored in the kitchen refrigerator to prevent cross contamination.On 7/20/2026 at 9:38am, there were pitchers of lemonade, orange punch, and iced tea in refrigerator #2 which were not dated or labeled. V6 stated the staff are expected to label the pitchers with the date the beverages were made to know when the beverages were prepped. V6 stated the importance of dating and labeling is to prevent drinks from losing flavor and to know until when they can serve the beverages so the residents will not get sick.On 07/21/2026 at 10:02am, V26 (Dietary Aide) was inside the kitchen area. V26 has a beard and was not wearing beard guard. V26 stated he had just came back from his break and he used the other door to come into the kitchen. On 07/21/2026 at 10:05am, V9 (Regional Director of Operations - Archway) stated he (V26) is expected to wear beard guard to prevent hair from getting into the residents' food item; to prevent physical contamination of food items.On 07/21/2026 at 11:48am, V24 (Activity Aide) came into kitchen without washing his hands. V24 has a beard, and he was not wearing a beard guard. V24 touched the ice scoop and filled 2 water bottles with ice without performing hand hygiene. V6 (Dietary Manager) stated he should wear a beard guard and wash his hands prior to entering the kitchen area to prevent cross contamination. The (06/2/2025) Proper use of Hairnets and [NAME] Guards for Food Safety Compliance documented, in part Proper use of hairnets and [NAME] Guards for food Safety Compliance. Purpose: To ensure all personnel maintain proper hygiene and prevent contamination of food products by correctly wearing hairnets and beard guards in accordance with healthcare standards and the U.S Food Code. General Requirements: All personnel must wear approved hairnets or beard guards when in food preparation, processing, or storage areas. Hairnets and beard guards must be worn completely covering all hair and facial hair. Hair must be secured under the hairnet; beards and facial hair must be fully covered by the beard guard. Personal hygiene policies must be followed, including handwashing before donning hairnets or beard guards. The (07/30/2023) Labeling and Dating documented, in part Policy: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. The (12/17/2025) Food Safety documented, in part Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Procedure 11. Associate food will not be stored with resident food.

Based on observation, interview and record review, the facility failed to have an adequate water management program for the prevention of bacterial pathogens, failed to follow hand hygiene policy during the provision of medication administration, wound care treatment, while distributing meals, and during incontinence care, and failed to utilize PPE (Personal Protective Equipment) while providing direct care to a resident as required. The failure has the potential to affect all 93 residents who reside in the facility, and R2, R3, R5, R13, R43, R64, R70, R78, R96, R111 reviewed for infection control. Form 671 dated July 22,2026, by V1 (Administrator) showed 93 residents reside in the facility. The findings include:1.On July 22, 2026, 10:32 AM, V25 (Maintenance Director) and V31 (Regional Maintenance Director) stated they do not have a Legionella risk assessment specific to the facility that shows areas where legionella can grow and spread. V25 and V31 stated they only have the Legionella Environmental Assessment Form. V25 stated the only area in the facility that is at risk for growing and spreading Legionella in the facility are the three resident rooms that have bathtubs that are not being used. V25 and V31 stated they do not have any other areas of risk for legionella other than the unused bathtubs. V31 then stated the water heater is another area where they are at risk for legionella. V25 stated he does not have any documentation of the flushing of the bathtubs. On July 22, 2026, at 1:00 PM, V25 and V31 present. V25 stated he looked and did not have any documentation in the facility's electronic system for the flushing of the tubs bi-weekly nor did they have any other documentation for that. Now the facility submitted a list of areas of possible legionella with no control measures. Another form named quarterly water flushing form that showed the following: WH (Water heater) 1-3, and BR (Bedroom) 110, 204, and 504, with each having a time and initial. There was no date on the form. V25 stated this was documentation he just made up and filled out today. The facility's Water Management Program for Control of Legionella dated August 2019 showed the following: Maintenance supervisor will identify water outlets (shower/tubs/faucets) that are underutilized and flush those outlets as required by running the hot water and the cold water, separately, through those outlets for 5 minutes each to remove any stagnation. Program monitoring and documentation: The maintenance supervisor will fill out the water management log sheets and fax to the licensed contractor and place a copy in the water management binder. 2. On July 20, 2026, at 1:16 PM, V21 (Certified Nursing Assistant/CNA) rendered incontinence care to R96 who was wet with urine and had a bowel movement. V21 cleaned R96 from front to back of the perineum. V21 changed her gloves and without hand hygiene applied ointment to R96's buttocks, applied a new incontinence brief, and pulled R96's pants back in place. V21 completed the incontinence care and left the room while propelling the mechanical lift machine without hand hygiene. 3. On July 21, 2026, at 11:56 AM, V20 (CNA) rendered incontinence care to R111 who was wet with urine. V20 cleaned R111's back perineum and placed a new incontinence brief underneath R111 while wearing same soiled gloves. Then V20 removed his gloves, sanitized his hands, and left the room. V20 came back with a washcloth, he donned a new set of gloves, continued to clean R111's frontal perineum, then he closed the incontinence brief, repositioned R111, straightened R111's beddings while wearing same soiled gloves. After completing the care, V20 left the room carrying soiled linens and items without hand hygiene. 4. On July 21, 2026, at 1:48 PM, V18 (CNA) rendered incontinence care to R64 who was heavily saturated with urine. V18, undressed R64, cleaned R64 from front to back of the perineum, helped reposition R64, assisted to dress R64 with clean clothes, straightened the bedding, and adjusted the height of the bed by using the remote control of the bed. V18 wore the same soiled gloves and did not perform hand hygiene all throughout the provisions of care and while conducting different tasks. 5. On July 21, 2026, at 9:35 AM, V16 administered multiple medications to R70 including oral medications and an artificial tears eye drop. V16 did not perform hand hygiene before and after medication administration to R70. On July 22, 2026, at 12:07 PM, V2 (Director of Nursing/DON) stated the staff must perform hand hygiene before starting care and after completion of care. In addition, the staff should change gloves and perform hand hygiene when moving from dirty to clean tasks. The staff nurse should also perform hand hygiene before and after medication administration. When providing direct care for a resident who is under EBP and isolation precaution the staff is expected to wear full PPE (personal protective equipment) such as gloves, gowns, depending upon the isolation. If resident is on droplet precaution, a face shield or goggles and mask should be included in the PPE. This is to be done to prevent spread of infection to residents and staff. 6. On July 21, 2026, at 11:24 AM R2 was resting in bed. There was an EBP (Enhanced Barrier Precaution) sign on his door and PPE (Personal Protective Equipment) set up located outside his bedroom. According to V17 (Nurse) stated that R2 has gastrostomy tube. On July 21, 2026, at 11:32 AM V17 prepared medication to administer to R2. V17 only wore a pair of gloves as he administered the medication via g-tube to R2. V17 did not wear a gown as required for EBP. 7. On July 20, 2026, at 10:30 AM, R5 was resting in bed. There was an EBP (Enhanced Barrier Precaution) sign on her door and PPE (Personal Protective Equipment) located outside of her room. According to V30 (Nurse), R5 is on EBP due to pressure ulcer on her left heel. On July 20, 2026, at 1:33 PM, V18 (CNA) went into the bedroom to dress and help transfer R5. V18 did not wear a gown as required for EBP. V18 only wore gloves while he assisted to dress R5. V19 (CNA) entered R5's room to assist with the transfer. V19 only wore gloves she did not wear a gown as required. The facility's policy titled, Medication Administration last reviewed October 2025, states that, Guideline: . 3. Hand Hygiene must be preformed before and after the: The administration of all topical, ophthalmic, otic, parental, enteral, rectal, and vaginal medication. Any invasive procedure (i.e. blood glucose monitoring, injections, etc.). Administering medication to a resident on isolation or other precautions. The Enhanced Barrier Precaution signage showed, providers and staff must also: wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Transferring, Device care or use: feeding tube. The facility's policy titled, Hand Hygiene last revied April 2026, states that, General: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. Guideline: 1. Hand hygiene is done before and after resident contact, before and after any procedure . when hands are obviously soiled and regardless of glove use. 8. R3's admission record showed he had diagnoses that included chronic kidney disease, stage 2 unspecified dementia, and peripheral vascular disease. R3's wound care note dated July 15, 2026, showed he had a pressure ulcer to the left lateral foot and an arterial ulcer in his left third toe. R3 has the following physician's orders a) Apply wound cleaning solution to left lateral foot, dated July 9, 2026, b) Apply debridement agent to left lateral foot and c) Apply iodine ointment to left third toe dated June 18, 2026, On July 22, 2026, at 9:18 AM, V32 (Wound Care Nurse Practitioner) donned gloves, measured and cleaned R3's left lateral foot pressure ulcer. V32 proceeded to apply debridement agent and calcium alginate pad to R3's left lateral pressure ulcer without removing gloves and performing hand hygiene. V32 removed gloves from previous task, did not perform hand hygiene, donned new gloves, and applied iodine ointment to left third toe arterial ulcer. 9. and 10. On 07/21/2026 at 12:26pm, V23 (Certified Nursing Assistant) touched a chair, sat down next to R13 and R78. V23 touched R13's utensils and fed R13 then touched R78's utensil and fed R78 without performing hand hygiene. These observations were pointed out to V23. V23 stated that he failed to sanitize his hands prior to touching (R13) and (R78) utensils. V23 stated he was expected to sanitize his hands between residents to reduce the spread of bacteria. 11.On 07/21/2026 at 12:21pm on the second floor's main dining room, V22 (Speech Therapist) touched a chair, talked to R43, touched R43 utensils and began feeding R43 without performing hand hygiene. This observation was pointed out to V22. V22 stated she was supposed to sanitize her hands prior to touching (R43)'s utensils to prevent the spread of germs. On 07/22/2026 at 11:55am, V4 (Admissions Nurse/Assistant Director of Nursing) stated that staff are expected to perform hand hygiene before feeding the residents. If their hands are visibly soiled, staff are expected to do handwashing and if not visibly soiled, staff should use hand sanitizer or alcohol-based hand rub. On 07/22/2026 at 11:56am, V2 (Director of Nursing/Former Admissions Nurse) stated the staff is expected to focus on one resident. If staff is assisting 2 residents with feeding, the staff is expected to perform hand hygiene between residents for infection control; for residents' safety. R13's admission record documented that R13's diagnoses (include but are not limited to): hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, dementia, aphasia. R13's (5/28/2026) Minimum Data Set (MDS) documented, in part Section C – Cognitive Patterns. C0700. Short term memory OK: 1. Memory problem. C0800. Long Term Memory OK 1. Memory problem. R43's admission record documented that R43's Diagnoses (include but are not limited to): gastro-esophageal reflux disease, protein-calorie malnutrition, dementia. R43's (06/05/2026) Minimum Data Set (MDS) documented, in part Section C – Cognitive Patterns. C0500. BIMS (Brief interview for mental status) Summary Score 99. C0700. Short term memory OK: 1. Memory problem. C0800. Long Term Memory OK 1. Memory problem. R78's admission record documented that R78's Diagnoses (include but are not limited to): trigeminal neuralgia, severe protein-calorie malnutrition, and multiple sclerosis. R78's (06/15/2026) R13's (5/28/2026) Minimum Data Set (MDS) documented, in part Section C – Cognitive Patterns. C0500. BIMS (Brief interview for mental status) Summary Score: 11. Indicating the resident's mental status as moderately impaired. The (4/2026) Hand Hygiene documented, in part GENERAL: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. RESPONSIBLE PARTY: All facility staff. GUIDELINE: 1. Hand hygiene is done before and after resident contact, before and after any procedure, after using a Kleenex or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use.

Based on observation and interviews, the facility failed to provide a homelike environment that was free of pervasive offensive odors throughout the lower-level dementia care unit.This failure applies to R79, R96, and R100 who verbalized objections to the odors and affected all 42 residents who reside in the dementia care lower-level unit. The Findings include:The facility's detailed census report, dated July 20, 2026, showed 42 residents resided in the lower floor dementia unit.From July 20 to July 22, 2026, during observations at different times in the lower-level dementia unit of the facility, there were strong foul odors in all areas of the unit. The lower-level dementia unit smelled musty, mixed with body odor, urine, and fecal odor. The odors were stronger during incontinence care, and before and after mealtime. However, there were lingering musty, body odor, and urine odor, noted throughout the lower-level floor.On July 22, 2026, at 11:54 AM, R79, R96, and R100 all stated that the unit smells with foul odors and it bothers them.R79's EMR (Electronic Medical Record) showed R79 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, anxiety disorder, and encephalopathy. R79's MDS (Minimum Data Set) dated June 10, 2026, showed R79 was cognitively intact. R96's EMR showed R96 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, moderate protein-calorie malnutrition, and unspecified osteoarthritis. R96's MDS dated [DATE], showed R96 was cognitively intact.R100's EMR showed R100 was admitted to the facility on [DATE], with chronic obstructive pulmonary disease, type 2 diabetes, and unspecified dementia.R100's MDS dated [DATE], showed R100 was moderately cognitively impaired.On July 22, 2026, at 1:21 PM, V30 (LPN), V31 (LPN), and V21 (CNA), who work regularly on the unit, each confirmed that the lower-level dementia unit had unpleasant odors that remain throughout the whole unit and created an unpleasant environment for both residents and staff.On July 23, 2026, at 8:55 AM, toured the lower-level dementia unit with V1 (Administrator). V1 stated he was aware of the unpleasant odors throughout the unit.V1 validated there remains a musty lingering odor at this time, especially noticeable in the dining room. V1 explained a month ago, V1 replaced the housekeeping supervisor as an intervention to correct the housekeeping problems throughout the facility. V1 explained the bins used in the lower-level unit were replaced and clearly labeled for soiled linen and garbage to reduce incidences of staff throwing soiled linen and garbage in the same bin. V1 also explained that 2 weeks ago the lower-level unit flooded after a rain downpour with water from the patio entering the facility under the dining room patio door that resulted in an inch of water throughout the dining room and into the hallway on the unit. V1 acknowledged the floors in the dining room were sticky when walked on and stated the flooring in the dining room now needs to be replaced. V1 stated at the time of the water flooding they instructed the residents to just stay in their rooms during the clean up of the standing water. Facility's Resident Rights Policy and Procedure with revision date of September 2025 showed: Policy: The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Procedure: The residents' environment will be maintained in a homelike manner.

Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 5 residents (R31, R64, R96, R111) reviewed for incontinence care in the sample of 20. The findings include: 1. On July 20, 2026, at 1:16 PM, V21 (Certified Nursing assistant/CNA) rendered incontinence care to R96 who was wet with urine and had a bowel movement. V21 cleaned R96's front and back perineum. However, she did not clean the labial folds and inner part or folds of the left and right groins. R96's face sheet showed multiple diagnoses including history of urinary tract infection (UTI). 2. On July 21, 2026, at 11:56 AM, V20 (CNA) rendered incontinence care to R111 who was wet with urine. And had a bowel movement. V20 cleaned the back and the frontal perineum. However, when V20 cleaned the frontal perineum, he sprayed R111's frontal perineum (Outer labia only) with cleanser and wiped it once with a washcloth in a downward stroke, then he closed the clean incontinence brief without cleaning the inner folds of the labia, the urethra, vaginal vestibule, and the groins. 3. On July 21, 2026, at 1:48 PM, V18 (CNA) rendered incontinence care to R64 who was heavily saturated with urine. The urine overflowed to her pants. V18 cleaned R64's frontal perineum with a washcloth by rubbing the washcloth up and down, left to right, or back and forth, with the same washcloth and the same side of it. When V18 cleaned R64's back perineum, he cleaned only the outer buttocks, but he did not clean the inner buttocks and the rectum. R64's face sheet showed multiple diagnoses including history of urinary tract infection (UTI). On July 22, 2026, at 12:19 PM, V2 (Director of Nursing/DON) stated the staff must clean the resident from front to back of the perineum. They should use different side of washcloth or different wet wipes with each stroke. The staff must wipe the perineum with a downward stroke and not up and down, or back and forth. Every part of the perineum should be cleaned. This must be done to prevent cross contamination and UTI. 4. R31's admission record showed she had diagnoses that included parkinsonism, epilepsy, dysphagia, weakness, muscle weakness, difficulty in walking and cerebral infarction. R31's Minimum Data Set, dated [DATE] showed R31 was severely cognitively impaired and dependent on staff for toileting hygiene. On July 21, 2026 at 1:23 PM, V18 (CNA) and V20 (CNA) donned gloves and used a whole-body mechanical lift appropriately to transfer R31 to her bed. V18 then turned R31 to her right side and folded R31's urine soiled incontinence pad underneath her halfway. Then V18 put the clean incontinence pad under the wet one. V18 then took a single wet wipe and wiped down R31's labia in one downward stroke, proceeded to clean the pubic area, and wiped her left inner thigh while using the same soiled wet wipe. V20 then took the wipe from V18 and threw it away. V18 then took another wipe and cleaned the R31's left buttock but did not wipe R31's rectal area. V18 then turned R31 over to her left side, pulled the incontinence pads from under R31, and did not clean R31's right buttock. R31 proceeded to place the incontinence brief on R31, put her pants on, grabbed R31's remote control and adjusted R31 in bed all while wearing the same gloves used to clean R31. Up to this point, V18 had not removed his gloves nor did he perform hand hygiene when moving from dirty to clean tasks during incontinence care.

Based on observation, interview, and record review, the facility failed to document narcotics as soon as they removed it from the container to ensure accurate count and documentation. This applies to 5 of 8 residents (R38, R51, R52, R56, and R102) reviewed for medication storage in a sample of 20.The findings include:On July 22, 2026, from 10:48 AM to 11:29 AM, medication cart inspections were conducted with V16, V30, V39 (all nurses) and the following were noted:1. R52's Lorazepam tablet 1 milligram (mg) actual count was 11. Individual controlled substance record documented 12 remaining lorazepam.2. R38's Methadone tablet 10 mg actual count was 15. Individual controlled substance record documented 16 remaining methadone.3. R38's Methadone tablet 5 mg actual count was 19. Individual controlled substance record documented 20 remaining methadone.4. R51's Lorazepam tablet 0.5 mg actual count was 13. Individual controlled substance record documented 14 remaining lorazepam.5. R56's Lorazepam tablet 0.5 mg 25 actual count was 25. Individual controlled substance record documented 26 remaining lorazepam.6. R102's Lorazepam tablet 0.5 mg seal broken on medication and resealed with tape. On July 22, 2026, at 12:45 PM, V2 (Director of Nursing) stated that the narcotic medication should be signed out as from the narcotic book as soon as they remove it from the bingo card container to ensure accurate count of the medication. V2 also said that the narcotic medication should be discarded if the seal is broken to prevent diversion.

Based on observation, interviews, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to the initiation of self-administration of medication. This failure affects 1 (R89) resident reviewed for self-administration of medication in the total sample of 20 residents.On July 20, 2026, at 11:33 AM inside R89's room, there was a Symbicort inhaler on top of R89's bedside table. R89 stated one of the staff handed him the inhaler 2 weeks ago. On July 20, 2026, at 11:35 AM, V12 (Medical Records) was requested to check the Symbicort on top of his bedside table and stated the inhaler is labeled with R89's first name initial and full last name, R89's room number and date July 8, 2026. R89 stated he uses the inhaler twice a day and it has been on his table for a while. On July 22, 2026, at 11:44 AM, V4 (Admissions Nurse/Assistant Director of Nursing) stated the resident should be assessed first if able to self-administer the medication; get a physician's order to may self-administer the medication and to may keep medication at bedside, and to care plan the self-administration of medication so everyone on the IDT (interdisciplinary team) is aware that the resident may self-administer the medication. V4 stated these three things should happen first before resident self-administer medication.R89's admission Record documented that R89's diagnoses include but are not limited to add diagnoses that relate to medication Symbicort, which is an inhaled corticosteroid that reduces airway inflammation, and formoterol, a long-acting bronchodilator that relaxes airway muscles to improve breathing. R89's Minimum Data Set, dated [DATE], documented, in part Section C. - Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Moderately impaired. R89's care plan initiated on July 20, 2026, documented, in part (R89) is self-administering medication inhaler/ Medication is at bedside. Education provided. Of note, care plan was created after the medication was observed at R89's bedside. The facility's policy titled Self-Administration of Medications and Treatments dated July 2026. documented, in part GENERAL: Self administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. GUIDELINE: 1. Self-administration of medications and treatments is determined by an order after determining that the resident is able to self-administer. 2. Medications and treatments for self-administration are kept in the resident room. Procedure 2. Determination of the ability to self-administer medications will be done by nursing using the form in PCC titled Medication Self-Evaluation Administration. 6.A care plan is for resident who self-administer, and documentation should be present in the nursing notes of teaching related to self-administration of the medications or treatments.

Based on interview and record review, the facility failed to submit a new PASRR (Preadmission Screening and Resident Review) to appropriate State Agency for a resident with new mental health diagnoses in an effort to provide or meet appropriate services to the resident. This failure affected 1 (R2) resident reviewed for pre admission screening in the total sample of 20 residents. Findings include:R2's (01/30/2026) Notice of PASRR level I screen outcome documented, in part PASRR Level I Determination: No Level II Required - No SMI/ID/RC (Serious Mental illness/Intellectual Disability/Related Conditions). Diagnoses: Mental Health Diagnoses: No mental health diagnosis is known or suspected. Outcome: No Level II Required - No SMI/ID/RC (Serious Mental illness/Intellectual Disability/Related Conditions). Rationale: The level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. R2's admission Record documented that this resident's diagnoses include but are not limited to anxiety disorder with onset date of 04/29/2026, depression with onset date of 04/10/2026, and hemiplegia (paralysis) and hemiparesis (muscle weakness). The facility was unable to provide documentation that a new PASRR Level I screening was submitted to appropriate State Agency after 04/10/2026 and after 04/29/2026. On 07/22/2026 at 11:14am, V10 (Social Services Director) stated PASRR (Preadmission Screening and Resident Review) Level I is typically handled by (V2 - Director of Nursing/Former Admissions Nurse) and if there are new mental health diagnoses, it is her (V10) responsibility to submit a new PASRR to Assessment Pro. V10 was requested to review R2's electronic health record and stated R2 has diagnoses of anxiety with onset date of 4/29/2026 and depression with onset date of 4/10/2026. V10 stated the expectation is to resubmit a new PAS Level I to Assessment Pro and if the onset dates were in April 2026, it should be submitted shortly after the new diagnoses were added in April. V10 stated the importance of submitting a new PAS Level I is to determine the need of the resident and if the facility is able to meet the need and to ensure proper placement of the resident. V10 stated anxiety and depression are two diagnoses that require resubmission of PASRR level I. The (undated) PASRR (Preadmission Screening and Resident Review) Procedures and Policy documented, in part Policy. It is the policy of this facility to f. The facility will consider submitting a new PASRR L1 screen if there is a suspected psychiatric condition and/or a new psychiatric diagnosis is added by a physician. 8) Level II Screen: This is triggered automatically only if the Level I screen flags a potential issue. A Maximus clinician conducts a comprehensive evaluation, reviewing medical records and interviewing the resident. The goal is to confirm the diagnosis and verify if the nursing facility is appropriate. The outcome is a detailed report outlining required psychiatric and behavioral supports. Recompleting Screens. 2) Significant Change in Status (Resident Review): A screening must be completely redone if a resident experiences a major clinical or behavioral shift. This includes a new mental health diagnosis, a drastic increase in behavioral symptoms, or if current interventions are failing and require a total re-evaluation.

Based on observation, interview and record review, the facility failed to initiate new order, follow prescriber orders and administer topical treatments for known skin conditions.This applies to 3 of 4 residents (R10, R64, R96) reviewed for skin conditions in the sample of 20.The findings include: 1.R10's EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including idiopathic epilepsy, chronic obstructive pulmonary disease, basal cell carcinoma of the skin and psoriasis. On July 21, 2026, at 1:00 PM, R10 was sitting in his room in his wheelchair wearing a short-sleeved shirt and long pants. Both of R10's elbows appeared reddened with white, dry patches of skin. R10 stated he had psoriasis on both of his elbows and stated he had psoriasis patches on his legs also. R10 stated he does go to a dermatologist outside of the facility. R10's after visit summary for the dermatologist appointment, dated May 28, 2026, showed the dermatologist prescribed R10 to start clobetasol 0.05% cream to affected areas of psoriasis on the body twice a day to active lesions for two weeks and then reduce treatment to Monday, Wednesday and Friday for two weeks and repeat the 4-week cycle as needed. R10's physician orders from May 28, 2026, through July 21, 2026, and R10's June and July 2026 Treatment Administration records were reviewed and there was no clobetasol 0.05% topical cream prescribed or administered to R10 during that time. On July 22, 2026, at 4:25 PM, V2 (Director of Nursing) stated when a resident comes back from an appointment the nurse should initiate the orders from the after-care summary as ordered by the health care provider. The facility's policy titled Physician Orders dated September 2024, showed physician's orders are to be followed as written and the physician is to be contacted as needed for clarification. 2. On July 20, 2026, at 1:16 PM, V21 (Certified Nursing assistant/CNA) rendered incontinence care to R96 who was wet with urine and had a bowel movement. R96's buttocks had redness and appeared irritated. R96 verbalized that her skin was itchy. V21 applied Zinc Oxide cream to R96's buttocks and stated that it's their standard treatment for skin redness and irritation. On July 22, 2026, at around 2:40 PM, R96 stated that her buttocks are frequently itchy and uncomfortable. Minimum Data Sheet (MDS) dated [DATE], showed R96 was alert and oriented. This same MDS showed R96 was totally dependent on staff for personal hygiene and grooming. R96's Treatment Administration Record (TAR) dated July 2026, showed Clobetasol Propionate E External Cream 0.05%, to apply to buttocks topically as needed for skin flair up. There was no evidence in this TAR that the Clobetasol cream has been given to R96 from July 1, 2026, to present. This Clobetasol cream has been ordered to R96 on June 23, 2026. There was no evidence in the TAR that Zinc Oxide was ordered for R96. R96's active care plan showed, R96 was at risk for skin complications related to decreased mobility, utilizing wheelchair for mobility, requiring assistance with transfers and incontinence. R96 has chronic dermatitis. On July 22, 2026, at 2:45 PM, V30 (Nurse) showed R96's Clobetasol Propionate Cream and it was still sealed or unopened. 3. On July 21, 2026, at 1:48 PM, V18 (CNA) rendered incontinence care to R64 who was heavily saturated with urine. The urine overflowed to her pants. Upon removal of R64's disposable brief and shirt, it was noted that her left and right groins/inguinal areas and underneath the left and right breasts had redness and irritation. There was no sign of any cream on R64's breast and groins/inguinal areas. V18 did not apply any cream or ointment after provision of incontinence care and after changing R64's clothes. R64's MDS dated [DATE], showed R64 was cognitively impaired and requires substantial/maximal assistance for grooming and hygiene. R64's Treatment Administration Record (TAR) dated July 2026 showed: Antifungal External Cream 2% (Topical Miconazole Nitrate), apply to areas of redness topically as needed. This medication was ordered on March 9, 2026. This same TAR does not show any evidence that the facility had applied this medication to R64 from July 1, 2026, to the present. On July 22, 2026, at 3:00 PM, V29 (Nurse) searched in the treatment cart for R64's Miconazole cream but could not find it. V29 stated that nobody told her that R64 needed cream to be applied for her redness/irritation in the skin. On July 22, 2026, at 12:34 PM, V2 (Director of Nursing/DON) stated the staff are supposed to follow orders for skin treatment, to prevent worsening skin issues and prevent development of new skin problems.

Based on observation, interview, and record review, the facility failed to follow physician orders during medication administration. There were 30 medication opportunities with 7 errors resulting in 23% medication error rate. This applies to 2 of 5 residents (R70, R79) reviewed for medication administration in the sample of 20.The findings include.1. On July 21, 2026, at 9:35 AM, V16 (Nurse) administered multiple medications to R70 including aspirin, clopidogrel, cranberry tablet, furosemide, metoprolol succinate, baclofen, Methenamine Hippurate, potassium chloride, fluticasone propionate nasal spray, artificial tears, and Vitamin D3 tablet 25 micrograms (1000 units). R70's Medication Administration Record (MAR) dated July 2026, showed that R70 was prescribed Vitamin D3 125 mcg (5000 units) and not 25 mcg (1000 units). The artificial tears ophthalmic solution was supposed to be administered at 5 AM, 2 PM, and 9 PM, the MAR showed that the artificial tears was already administered at 5 AM. In addition, R70 was also prescribed memantine hydrochloride 5 mg, Pataday ophthalmic solution, Biotene dry mouth liquid (Mouth wash), isosorbide mononitrate. These medications were supposed to be given at 9 AM, however, V16 did not administer these medications. On July 21, 2026, at around 4:15 PM, V16 (Nurse) stated that when state representative left after R70's medication administration, V16 realized that R70 had a scheduled Cyanocobalamin (B12) injection solution. V16 administered this medication to R70 via IM (Intramuscular) injection. That was the only added medication she had given. V16 also stated, whatever the state representative observed that was administered to R70 were all the medications that R70 was supposed to receive that morning (9 AM scheduled medications). 2. On July 21, 2026, at 9:54 AM V30 (Nurse) prepared and administered several medications for R79 including famotidine 10 mg tablet. R79 medication administration record dated July 2026 showed that the physician ordered famotidine 20 mg. V30 administered famotidine 10 mg tablet to R79 instead of famotidine 20 mg tablet as ordered by physician. On July 22, 2026, at 12:25 PM, V2 (Director of Nursing) stated when administering medication, the staff must follow the physician order and follow the principles of medication administration such as the right dose, patient, medication, route, and time. The facility's policy titled, Medication Administration last reviewed October 2025, states that, General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: . 13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.22. If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with oral hygiene, dressing and personal hygiene. This applies to 4 of 4 residents (R12, R47, R50 and R51) reviewed for ADL (activities of daily living) in the sample of 20. The findings include: 1. R12 had multiple diagnoses including moderate protein-calorie malnutrition, cerebral palsy and right hand contracture, based on the face sheet. R12's quarterly MDS (Minimum Data Set) dated April 4, 2025 showed that the resident was cognitively intact. The same MDS showed that R12 had functional limitation in range of motion on one side of her upper extremity and required maximum assistance from the staff with oral hygiene. On June 15, 2025 at 10:30 AM, R12 was sitting in her wheelchair by the unit television lounge. R12 was alert and oriented. R12's teeth were observed with food debris in between her teeth and with strong mouth odor. R12 stated that she had not brushed her teeth after eating breakfast. According to R12 she needs the assistance of the staff with brushing her teeth. During the same observation, R12 was noted with limited range in motion on her right hand and fingers. V10 (CNA/Certified Nursing Assistant) was informed of R12's oral hygiene concerns. On June 16, 2025 at 9:57 AM, R12 was sitting in her wheelchair by the television area. R12 was wheeled to her room by V7 (ADON/Assistant Director of Nursing). R12 was alert and oriented. R12's teeth were observed with food debris in between her teeth and with mouth odor. V7 acknowledged that there were food debris in between R12's teeth. At 10:00 AM, V14 (CNA) stated that she has not provided oral care to the resident since she started her shift at 6:00 AM that morning, because the resident was already sitting in her wheelchair and was gotten up by the previous shift. R12's active care plan initiated on November 23, 2018 showed that the resident requires assistance from the staff with ADLs. R12's active care plan initiated on March 13, 2015 showed that the resident is at risk for oral complications. The same care plan showed multiple interventions including, Assist as needed with oral care. 2. R47 had multiple diagnoses including, including neurocognitive disorder with Lewy bodies, dementia with other behavioral disturbance and weakness, based on the face sheet. R47's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition and required assistance with personal hygiene and upper body dressing. On June 15, 2025 at 11:19 AM, R47 was sitting in his wheelchair inside the unit dining/activity room with other residents. R47 had accumulation of long facial hairs. R47 stated that he wanted the staff to help him shave because he cannot do it on his own. V15 (CNA) was present during the observation and confirmed that R47's facial hairs were long and needs shaving. According to V15, R47 requires the assistance of the staff with shaving. On June 16, 2025 at 10:28 AM, R47 was sitting in his wheelchair inside the unit dining/activity room with other residents. R47's black shirt had multiple white debris on the shoulder and chest area and a white liquid stain on the abdominal area. V7 (ADON) was present during the observation and stated that R47's shirt needed to be changed because it had food debris. R47's active care plan initiated on December 13, 2022 showed that the resident requires assistance with daily care needs related to dementia. The same care plan showed multiple interventions including, hygiene and dressing extensive assist of one for upper body. 3. R50 had multiple diagnoses including, senile degeneration of the brain, dementia with other behavioral disturbance, type 2 diabetes mellitus and weakness, based on the face sheet. R50's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required assistance with personal hygiene. On June 15, 2025 at 11:03 AM, R50 was in bed, alert and verbally responsive. R50's fingernails were long, jagged with black substances under the nails. R50 stated that she wanted her fingernails trimmed and cleaned. V4 (LPN/Licensed Practical Nurse) and V14 (CNA) were present during the observation. V4 stated that R50 is on hospice care. R50's active care plan initiated on November 15,2023 showed that the resident requires assistance with daily care needs. On June 17, 2025 at 11:26 AM, V2 (DON/Director of Nursing) stated that it is part of the nursing ADL care and service of all residents at the facility to be assisted with their ADL care, including oral care, nail care, removal of unwanted/unkempt facial hair and dressing. According to V2, staff are expected to provide ADL assistance to all residents to ensure and maintain the resident's hygiene and grooming. 4. R51 was admitted to the facility on [DATE], with multiple diagnoses, including other frontotemporal neurocognitive disorder, unspecified dementia, major depressive disorder and pressure ulcer of the sacral region. R51's MDS (Minimum Data Set) dated May 29, 2025, showed R51 was severely cognitively impaired and required substantial assistance with upper body dressing and bed mobility and was dependent on staff for eating, lower body dressing, personal hygiene, oral care, bathing, toileting and transfer. R51's ADL Care Plan for ADLs (Activities of Daily Living) dated December 2, 2022, showed R51 needed extensive/dependent assist of one/two for grooming. On June 16, 2025, at 10:00 AM, R51 had long facial hair on his neck and chin and a beige substance on the left side of his mouth dripped to his chin. V6 (CNA) was present and was assisting R51 with repositioning during wound treatment. R51 was not alert and did not respond when spoken to. On June 17, 2025, at 9:19 AM, R51 was lying in his bed, did not respond when spoken to, still had facial hair on his cheeks, upper lips and neck in need of shaving. The facility's policy titled Activities of Daily Living dated September 2024, showed A program of activities of daily living is provided .A. Hygiene a. Resident self-image will be maintained .B. Dressing .d. Residents are given instructions and assistance as required. The facility's policy titled Oral Hygiene dated September 2023, showed Provisions will be made to maintain oral hygiene based on individual patient/resident needs. The facility's policy titled ADL Nail Care, dated September 2024, showed General: To provide care and maintain hygiene of the resident's nails. The facility's policy titled Shaving, dated September 2017, General: to provide direction for the staff on how to shave a resident .4. Shave resident's face to avoid mustache or beard .6. If resident refuses to be shaved, inform the nurse so it can be documented.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe, secure, and sanitary manner. This deficient practice affected 9 of 10 residents (R21, R26, R31, R44, R52, R70, R73, R78, R146) reviewed for medication storage from a sample of 20 residents. The Findings include: 1. On [DATE], at 10:30 A.M., during observation of V5 (Registered Nurse), the following concerns were noted: -R31: Hydromorphone 30 cc bottle (a Schedule II narcotic) was not secured in a double-locked narcotic box and was stored next to other medications. -R146: Fluticasone nasal spray and Albuterol inhaler had no date when it was opened. Both medications were multidose administration in a single container. -R26: Fluticasone nasal spray had no date of when it was opened. -R44: Ipratropium Bromide nasal spray lacked a date label of when it was opened and remained in circulation for administration, despite being discontinued on [DATE], per the Physician Order Sheet (POS). During this observation, V5 stated that facility policy requires multidose medications to be labeled with the date of opening to ensure disposal within 28-30 days. V5 added that narcotics like Hydromorphone must be secured in a double-locked container. 2. On [DATE], at 10:43 A.M., observation of V3's (Registered Nurse) medication cart revealed: -Two sets of unlabeled dentures, eyeglasses, two hearing aids, hearing aid batteries, two nail clippers, oxygen tank opener, electric shaver charger, and a rusted wristwatch were stored next to medications intended for administration. V3 stated This watch is rusty, and these belongings were not supposed to be stored in the medication cart. -R21: Insulin Lispro vial had a date label of [DATE], and expired on [DATE]. V3 acknowledged the insulin was expired but still stored in the cart. -R52: Humalog insulin multidose vial was unopened and labeled to be refrigerated; however, it was stored in the cart at room temperature. -Aplisol Tuberculin Test multidose vial (house stock) was labeled as opened in [DATE] and not refrigerated. V3 confirmed it was expired. -R73: Latanoprost 0.0005% eye drops had no label indicating when it was opened. 3. On [DATE], at 10:59 A.M., review of V4's (Licensed Practical Nurse) medication cart revealed: -R70: Fluticasone multidose nasal spray with no date when it was opened. -R78: Tobramycin 0.3% eye ointment had no date label when it was opened and remained in circulation, despite a stop order dated [DATE], per the POS. On [DATE], at 2:00 P.M., V2 (Director of Nursing) stated that staff are expected to follow facility policy for safe medication storage. V2 stated that personal belongings should not be stored alongside medications; narcotic medications must be double-locked or discarded if not in use; multidose vials must be labeled with the date of opening and disposed of after 28-30 days, per manufacturer guidelines. Review of the facility's medication storage policy dated [DATE]) states: Medications are stored safely, securely, and properly following the manufacturer or supplier recommendations .9. All drugs classified as Schedule II . will be stored under double lock .11. Medications requiring refrigeration . are kept in the refrigerator .14. Outdated drugs will be immediately withdrawn from stock and disposed .15. Medication storage areas are kept clean and free of clutter .18. Staff will ensure that multidose vials are stored per manufacturer's suggested conditions . Review of the facility's policy on multidose medications dated [DATE]) states: Opening a vial triggers a shortened expiration date unique to the product. The date opened and the corresponding expiration date must both be recorded on the vial .

Based on observation, interview, and record review the facility failed to properly disinfect a glucometer and perform hand hygiene during the provision of resident care. This applies to 5 of 5 residents (R4, R18, R26, R65 and R69) reviewed for infection control in the sample of 20. The findings include: 1. On June 15, 2025, at 11:25 AM, R69 was in bed. V5 (Registered Nurse/RN) and V13 (Certified Nurse Assistant/CNA) said they were going to transfer R69 to his recliner chair. They said R69 required EBP (Enhance Barrier Precautions) because he was at risk for infections and donned a gown and gloves. They said R69 was soiled and incontinent of bowel. They proceeded to render incontinence care to R69. After completing R69's incontinence care they failed to remove their soiled gloves and perform hand hygiene. They then placed a mechanical lift sling underneath him and transferred him with a mechanical lift to his recliner. They continued to place pillows around R69 and change his footwear with the same gloves. R69's care plan reviewed on June 17, 2025, said R69 was at risk for infections related to his gastrostomy and indwelling catheter tubes. The care plan showed multiple interventions including for staff to implement infection prevention precautions as per facility protocol. 2. On June 16, 2025, at 9:40 AM, R26 was in bed. V12 (CNA) said he was going to provide R26 with his morning care and transfer him to his wheelchair. V12 said R26 required EBP and donned a gown and gloves. V12 proceeded to clean R26's catheter tube and then his perineal area. After completing R26's catheter and perineal care V12 failed to remove his gloves and perform hand hygiene. V12 proceeded to dress, placed a mechanical lift sling underneath R26, and then opened the room's door to call for staff assistance with R26's transfer. V17 (CNA) then assisted V12 with R26's mechanical lift transfer. V12 continued to wear the same gloves. R26's care plan reviewed on June 17, 2025, said R26 was at risk for infections related to his indwelling catheter tube. On June 17, 2025, at 1:45 PM, V2 (Director of Nursing/DON) said the nursing staff was expected to doff gloves and perform hand hygiene after rendering incontinence and catheter care to prevent the transmission of potential infections. The facility's policy titled Hand Hygiene dated April 2024 said Proper hand hygiene is necessary for the prevention and the transmission of infectious disease .1. Hand hygiene is done before and after resident contact, before and after any procedure . 3. On June 15, 2025, at 11:15 A.M., V5 (Registered Nurse) retrieved a blood glucose monitoring device from the medication cart and donned a pair of gloves. V5 proceeded to check R18's blood sugar using the machine. Upon completion of the procedure, V5 used a disinfectant wipe to clean the glucose meter, wiping the device for six (6) seconds. The device was not visibly wet after wiping. Subsequently, V5 removed her gloves but failed to perform hand hygiene. V5 then proceeded to check the blood sugar level of R65, repeating the same process without properly disinfecting the glucose meter and again not performing hand hygiene following glove removal. Following these observations, V5, still without washing her hands, prepared and administered Gabapentin oral tablet medication to R4. The facility's hand hygiene policy dated June 15, 2025, showed: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease .2. Hand hygiene is to be done before putting on gloves and after removing gloves. The manufacturer's disinfectant wipe instructions showed: Use one or more wipes, as necessary, to wet surface sufficiently and to thoroughly clean the surface. To disinfect, use one or more wipes, thoroughly wet the surface to be treated, and ensure the surface remains visibly wet for one (1) minute to achieve complete disinfection of all pathogens .

Based on observation, interview, and record review, the facility failed to identify, assess and provide treatment to new skin alterations. This applies to 2 of 3 residents (R49, R80) reviewed for skin alterations in the sample of 20. The findings include: 1. R49's admission record showed R49 was admitted to the facility on [DATE], with multiple diagnoses including spastic hemiplegia affecting right dominant side following cerebral vascular disease, chronic obstructive pulmonary disease and psoriasis unspecified. R49's MDS (Minimum Data Set), dated May 12, 2025, showed R49 was moderately cognitively intact and required assistance with ADLs (Activities of Daily Living) including supervision with upper body dressing, partial assistance with bathing, toileting, personal hygiene, bed mobility and transfer and substantial assistance with lower body dressing/footwear. R49's care plan for at risk for skin complications dated February 14, 2023, showed R49 had psoriasis and the interventions included to notify MD of abnormal findings, and notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises or discoloration noted during bath or daily care. On June 15, 2025, at 10:46 AM, R49 was alert sitting up in his wheelchair dressed in a short sleeved shirt. R49's right elbow had reddened skin with white plaque skin lesion. R49 stated he was sure his psoriasis was back, and his concern was it needed treatment. R49 stated the skin lesions had been present for a couple weeks and were getting worse. A review of R49's physician order summary on June 16, 2025, and June TAR (Treatment Administration Record) showed no orders for treatment of the right elbow psoriasis. On June 17, 2025, at 9:12 AM, V2 (DON) was shown the reddened area on R49's right elbow. R49 stated the area was itchy. R49 showed V2 his left elbow which was also reddened and an area on his right lower leg that had a plaque of redness and skin lesion. R49 told V2 he thought the areas were caused by a psoriasis flare. V2 stated the areas of reddened patches of skin on the right and left elbow and right leg on R49, looked uncomfortable and needed to be reported to R49's Health Care Provider. V2 stated she was unaware of R49's skin lesions prior to today. 2. On June 15, 2025, at 10:20 AM, R80 was in bed and not interviewable. R80 had undated white bordered dressings to his right posterior hand and left forearm. On June 16, 2025, at 9:05 AM, V12 (Certified Nurse Assistant/CNA) was dressing R80. R80 had the same undated bordered dressings to his right posterior hand and left forearm. V12 did not know why R80 had dressings to his upper extremities. On June 17, 2025, at 9:20 AM, R80 still had the same undated bordered dressings to his right posterior hand and left forearm. V3 (Registered Nurse/RN) did not know why R80 had dressings to his upper extremities. V3 reviewed R80's EMR (Electronic Medical Record) and said there was no skin alteration documentation or treatment orders for R80's right hand and left arm. V3 removed the dressings and R80 had a dry scab on his right hand and three open areas with serosanguineous drainage on his left forearm. V3 said she was going to assess the wounds and notify the physician to obtain proper treatment orders. On June 17, 2025, at 1:50 PM, V2 (Director of Nursing/DON) said nurses were expected to assess, document, and notify the physician to obtain treatment orders when residents were noted with new skin alterations to ensure proper wound care was provided and promote healing. R80's care plan reviewed on June 17, 2025, said R80 was at risk for skin complications related to frequent skin tears and fragile skin. The care plan showed multiple skin interventions including Observe and assess regularly. R80's Order Summary Report reviewed on June 17, 2025, did not show treatment orders for R80's right posterior hand and left forearm prior to June 17, 2025. R80's EMR did not show documentation for his right hand and left forearm skin alterations for when they were initially identified and assessed prior to June 17, 2025. R80's Change in Condition Evaluation form dated 6/17/2025 (completed during the survey) said R80 had new skin wounds. The form said R80 had three abrasions on his left forearm and a scab on his right posterior hand. The facility's wound report dated June 11, 2025, did not have either R49 or R80 listed on the report with identified skin alterations. The facility's Skin and Wound Management Guidelines undated showed New Facility Acquired Wounds Staff Nurse 1. Notify wound care nurse of new alteration in skin integrity. If wound care nurse is not in the facility, then you must notify the physician and obtain treatment order. Either the staff nurse or the wound care nurse must also notify family. 2. Complete an occurrence report in the Risk Management Portal of PCC or complete an Incident Report if not using PCC .Wound Care Nurse 1. Assess, measure, photograph, and document in Wound Rounds .3. Obtain or ensure appropriate treatment order is in place .5. Update plan of care with identified site and new interventions.

Based on observation, interview, and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain their vision and hearing abilities. This applies to 1 of 2 residents (R62) who were reviewed for vision and hearing abilities in a sample of 20. Findings include: On June 15, 2025, at 10:18 AM, R62's room television was at its highest volume. R62 said he can't hear and keeps his television loud so that he can hear, and he also needs eyeglasses. R62 said he has been waiting for his hearing aid and eyeglasses for few months. The review of R62's EMR (Electronic Medical Records) showed R2 was admitted to the facility on [DATE], and R62's diagnoses included type 2 diabetes mellitus, hemiplegia and hemiparesis, seizures, restlessness and agitation, and psychosis. The Minimum Data Set (MDS) dated [DATE] (Admission) and June 9, 2005, showed R62's cognition was moderately intact, his hearing abilities were severely impaired, and he required maximum one-to-one assistance for most activities of daily living. R62's June 17, 2025, physician admission order showed the audiologist and optometrist might see R62. On June 15, 2025, at 10:22 AM, V10 (Certified Nursing Assistant) attended when R62 screamed out loud for help and stated that R62 screamed for even simple help because he thinks other people cannot hear him, as he is hard of hearing. V10 said he has been waiting for his hearing aid and eyeglasses for a while. On June 16, 2025, at 09:54 AM, V8 (Licensed Practical Nurse) said R62 did not get his hearing aid, and she was not sure about his eyeglasses. V8 said because he can't hear, he puts on his television and calls for help very loudly. V8 stated that she did not know the reason why R62 did not receive his hearing aid and believed that the staff provided the receptionist with a list of residents who needed to be evaluated and thought V11(Social Worker) followed up. On June 16, 2025, at 1:12 PM, V11 (Social Worker) stated that she was not involved in the process. The receptionist has the list, and the provider obtains the information from the receptionist when they visit the facility. V11 stated that he might have had the hearing evaluation but was unable to provide documentation. On June 16, 2025, at 1:22 PM, V18 (Certified Nursing Assistant/Receptionist) stated that she does not function as a receptionist all the time and checked the binder for the list of residents that had a hearing evaluation but was unable to find R62 on the list. On June 17, 2025, at 10:47 AM, V2 (Director of Nursing) stated that it's the facility's responsibility to facilitate and assist residents in obtaining hearing and vision aids. V2 stated that when residents require ear and eye evaluations, the facility is supposed to notify the facility physician and get an order for an audiologist and ophthalmologist consultation. V2 said that upon receiving the order, the staff listed them for the receptionist to call the provider to schedule. V2 said that after receiving the schedule, it is provided to the unit to coordinate the visits. V2 said after the visit, the provider will deliver the notes and orders to the facility, and the facility will review and follow through on the orders.

Based on observation, interview, and record review the facility failed to provide residents with proper urinary catheter care. This applies to 3 of 3 residents (R26, R40, and R69) reviewed for catheters in the sample of 20. The findings include: 1. On June 15, 2025, at 11:25 AM, V5 (Registered Nurse/RN) and V13 (Certified Nurse Assistant/CNA) said R69 had a urinary catheter and was at risk for infections. They said R69 was soiled and incontinent of bowel. They rendered incontinence care and then transferred R69 to his recliner chair. They said they had completed rendering R69's care. They failed to provide R69 with urinary catheter care. R69's care plan reviewed on June 17, 2025, said R69 required an indwelling catheter. The care plan showed R69's goal was to remain free of complications and infections related to his catheter. 2. On June 16, 2025, at 9:40 AM, V12 (CNA) rendered R26 with urinary catheter care. V12 cleaned R26's catheter tube by wiping repeatedly in upward (towards his urethra) and downward strokes with a washcloth. R26's care plan reviewed on June 17, 2025, said R26 required the use of an indwelling catheter. The care plan showed R26's goal was to remain free of complications and infections related to his catheter. 3. On June 17, 2025, at 1:35 PM, V16 (CNA) and V17 (CNA) rendered R40 with urinary catheter care. V17 proceeded to clean R40's catheter tube by wiping repeatedly in upward (towards her urethra) strokes with a washcloth. R40's care plan reviewed on June 17, 2025, said R40 required the use of an indwelling catheter. The care plan showed R40's goal was to remain free of complications and infections related to her catheter. On June 17, 2025, at 1:45 PM, V2 (Director of Nursing/DON) said the nursing staff was expected to provide catheter care to residents when providing incontinence care and as needed. V2 continued to say the staff was also expected to clean catheter tubes by wiping in a downstroke direction away from the urethra to prevent urinary catheter infections. The facility's policy titled Indwelling Catheter Care dated September 2022 said Catheter care will done to promote comfort and cleanliness .12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, using same procedure for rinsing .

Based on the interview and record review, the facility failed to ensure a resident was not served a food item to which the resident had an allergy. This applies to 1 of 3 residents (R1) reviewed for food concerns in a sample of 9. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including allergy status to unspecified drugs, medications, and biological drugs, irritant contact dermatitis, and disorder of skin subcutaneous tissues, asthma, heart failure, chronic obstructive pulmonary disease, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated [DATE] showed R1's cognition was severely impaired and required one to two maximum assistance for activities of daily living. R1's allergy status upon admitted d [DATE] showed R1 was allergic to peach and lactose, and R1's face sheet also listed R1's allergy under other information. On [DATE] at 9:00 AM and on [DATE] at 8:20 AM, V10 (R1's family) said the facility served peach on her lunch tray, and she caught it and reported it to the staff. V10 said R1 gets severe skin irritation and her throat closes, and she would have died . The resident/family concerns report dated [DATE] showed that peaches were on R1's meal tray, and R1 is highly allergic to peaches. On [DATE] at 2:39 PM, V11 (Dietary Manager) said the kitchen staff should set up the meal tray by referring to the meal card where food allergies are documented, and the staff who is delivering the tray also should verify that residents are not receiving any food they are allergic to, so that potentially serious consequences could be avoided. V11 said the staff missed it on [DATE] for R1. On [DATE], at 1:00 PM, V8 and V9 (Dietary Aides) said they set R1's lunch tray on [DATE], and it was a very busy day, and they missed it. On [DATE] at 2:00 PM, V2 DON (Director of Nursing) stated there are clear instructions on the meal card and staff should followed the meal card and verify before setting up and delivering the meal tray to residents to avoid any serious consequences. The facility's policy and procedure titled Dining and Food Preference and dated ,d+[DATE] showed that the diet requisition form will notify the dining services department of food allergies upon admission and before any meals served. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerance, and preferences.

Based on observation, interview, and record review, the facility failed to provide a portable oxygen tank that was full for a resident. This applies to 1 of 3 residents (R1) reviewed for oxygen in a sample of 3. The findings include: On 9/27/24 at 10:15 AM, surveyor and V2 (DON-Director of Nursing) went to R1's room. R1 was sitting in her wheelchair. At the back of her wheelchair, R1 had a portable oxygen tank that was connected to her nasal cannula. The dial was turned to 3 liters but it read empty. V2 removed the nasal cannula as instructed by the surveyor and put the nasal prongs near her wrist. Then, she passed it to surveyor who did the same thing. Both V2 and surveyor confirmed no air was able to be felt. R1 was asked if she felt any air and she said No! Surveyor asked R1 if she had any problems breathing or if she was in any type of distress. She stated no she was not. R1's oxygen saturation rate was 91%. On 9/27/24 at 10:18 AM, V2 stated that the tank should have been full or changed out. V2 also confirmed that when R1 was brought back to her room from the dining room, she should have been connected to her concentrator. On 9/27/24 at 10:21 AM, V4 (CNA-Certified Nursing Assistant) stated, I'm (R1)'s CNA today. She was on her concentrator last night. Then, I switched her to the portable oxygen tank and took her to the dining room so she can eat her breakfast. It was not empty then. Then I brought her back to her room. The oxygen tank was on yellow. I'm sorry. I should have changed it out. Did they bring a new oxygen tank for her? On 9/27/24 at 10:29 AM, V2 stated, (V3-Hospice Nurse) brought it to my attention that my staff wasn't using the portable oxygen concentrator that was provided by hospice for (R1) when she is in the dining room. Instead, they were using the portable oxygen tank. I inserviced my staff and made sure this was communicated to all the staff. I talked to V5 (LPN/Licensed Practical Nurse) and she told me the portable oxygen concentrator is charging, but it's not turning on. I told (V3) this but she said our staff is not charging it at night. We checked it today and it's not turning on. So, I have to tell hospice again to send a new one. On 9/24/24 at 1:48 PM, telephone interview was done with V3 (Hospice Nurse). V3 stated, The staff there are not using the portable oxygen concentrator when they are taking (R1) to the dining room. Instead, they are using the portable oxygen tank. Today and a couple of days ago, I saw the tank was turned off. I told them they have to get a new tank or (R1) is going to die. She is on hospice and has COPD. They are having problems keeping the tank full. R1's face sheet shows diagnoses of COPD (Chronic Obstructive Pulmonary Disease), Unspecified, cognitive communication deficit, unspecified atrial fibrillation, heart failure, schizophrenia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Parkinson's disease without dyskinesia, without mention of fluctuations. R1's MDS (Minimum Data Set) dated 9/23/24 shows a BIMS (Brief Interview for Mental Status) score of 8, which means she is moderately impaired in cognition. R1's POS (Physician Order Sheet) for September 2024 shows the following orders: Admit to hospice with diagnosis of COPD (3/20/24), DNR (Do Not Resuscitate), Plug in portable oxygen at bedtime and apply during the day. Every day and night shift related to COPD. Plug in portable oxygen at bedtime and apply during the day. Progress notes show the following: On 8/20/24 at 6:10 AM (Medical Doctor's Note): [AGE] year old female admitted to facility on 2/24/23. Patient came in to ER (emergency room ) due to acute hypercapnic and hypoxic respiratory failure. Felt to be due to COPD exacerbation. CT Chest shows extensive COPD with emphysema. 1. Severe COPD, oxygen deprivation. Appears compensated. Patient requires close monitoring, high risk for decompensating. On hospice care. On 9/17/24 at 8:38 AM (Nurse Practitioner Note): Oxygen down to 93% on 9/12, otherwise stable, occasionally forgets to apply oxygen cannula. Watch for respiratory status changes, any new symptoms. V3's (Hospice Nurse) Hospice Communication Log Note dated 9/26/24 shows: Routine visit. Patient SOB (Shortness of Breath) Oxygen tank turned off. This writer turned on and ensured patient comfortable breathing prior to leaving. R1's care plan (Undated) shows: (R1) has potential for difficulty in breathing related to COPD, Chronic Respiratory Failure, CHF (Congestive Heart Failure). Goal: (R1)'s respiratory symptoms will be managed through next review. Interventions: Administer oxygen as ordered. Hospice: (R1) is under the hospice care with terminal diagnosis of COPD. (R1) has oxygen therapy related to congestive heart failure, ineffective gas exchange, respiratory illness to COPD. Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Intervention: Give medication as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be give to the resident but in different manner (changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Oxygen inhalation at 2-5 LPM (Liters Per Minute) PRN (As Needed) related to SOB (Shortness of Breath) and/or respiratory distress. Facility's policy titled oxygen therapy (9/2022) shows the following: Oxygen therapy may be provided through various type of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders or concentrators. Guideline: 1. Residents who require oxygen therapy will have a physician order in their medical record which includes amount of oxygen to be administered, route of administration and indication of use.

Based on interview and record review, the facility failed to report an allegation of abuse to the abuse coordinator and Illinois Department of Public Health per facility policy. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in a sample of 3. The findings include: Face sheet, printed 8/22/24, shows R1 was admitted to the facility on [DATE] and his diagnoses included acute kidney failure, adjustment disorder, vascular dementia, congestive heart failure, history of falls, depression, transient ischemic attack, and weakness. MDS (Minimum Data Set), dated 7/25/24, shows R1's cognition was moderately compromised. Face sheet, printed 8/22/24, shows R2 was admitted to the facility on [DATE] and his diagnoses included dementia, unspecified psychosis, depression, anxiety, psychoactie substance abuse, and insomnia. MDS, dated [DATE], shows R2's cognition was severely impaired. On 8/21/24 at 11:40 PM, R1 stated R2 was very confused and continuously wandered. R1 stated R2 continuously entered R1's room because the room used to be R2's room prior to R2 moving to another room. R1 stated on 8/18/24, R2 came into his room and tried to move his roommate while in bed. R1 stated he yelled at R2 to stop coming into R1's room and R2 placed his hands on R1's right and left side of R1's upper torso and shoved R1 backward while he was sitting in his wheelchair. R1 stated his wheelchair rolled back, hit his dresser in the back of the room, and R1 fell out of his wheelchair on to the floor. R1 stated staff came to assist him back into the wheelchair. R1 stated he experienced pain in his knee, hip and upper torso and R1 received an X-ray the evening of 8/18/24 to examine his knee. On 8/21/24 at 3:00 PM, V1 (Administrator) stated he was informed by the police that R1 called the police and reported that R2 hit/shoved R1 during their altercation earlier in the day. V1 stated he did not report the allegation to IDPH because he did not think the allegation was credible since the allegation did not surface from R1's nurse at the time of the incident. On 8/21/24 at 10:30 AM, V1 stated on 8/18/24 R1 alleged R2 wandered into R1's room and R2 shoved R1 causing R1 to go backward in his wheelchair. V1 stated there were no witnesses and no injuries and V1 did not believe the incident happened so V1 did not report/investigate the allegation. V1 stated R1 was alert and oriented and desired to go home, so R1 made up the story to convince R1's family to take him out of an unsafe facility. V1 stated he could not be sure the incident actually occurred. Facility document provided by V1, signed 8/21/24, shows, Initially [R1] told the nurse that he was trying to sit in his chair and slid out, but later, when I spoke to [R1] about 8:00 PM [R1] said he was pushed. That [R2] was in the room and had pushed him into his chair as he was trying to stand. I asked why he hadn't said that initially to the nurse and he stated that he just remembered it. There were no injuries and ]R2] left the room immediately. On 8/21/24 at 3:00 PM, V1 stated he had not yet reported R1's allegation of abuse to IDPH. On 8/21/24, V7 (Agency LPN - Licensed Practical Nurse) stated she was first to respond to R1 on the floor on 8/18/24. V7 stated she asked R1 what happened and R1 reported that R2 shoved him while sitting in his wheelchair in his room and R1 fell out of his wheelchair as a result of the push. V7 stated when V5 came into the room to assess R1, V7 told V5 that R1 reported R2 shoved R1 and then left the room because R1 was not assigned to her that day. Progress note, written by V7 on 8/18/24, shows R1 was observed in a sitting position in front of his wheelchair as R2 was walking out of R1's room. The progress note fails to show R1 reported R2 physically touched R1. On 8/21/24 at 1:45 PM, V5 (LPN - Licensed Practical Nurse) stated at the time of the 8/18/24 incident, he located R1 on the floor in his room and stated R1 did not report that he was shoved or touched by R2 during the incident. V5 stated a nurse coworker responded to R1 first at the time of the incident. Progress note written by V5 (LPN - Licensed Practical Nurse), shows no report that R1 was physically touched by R2. The note shows R2 stated R1's chair rolled back and he slid off the chair while yelling at R2. Physician note, dated 8/19/24, shows, R1 received an X-ray of his left knee due to a fall the day prior. The note shows no acute findings were shown. Progress notes, dated 8/18/24, show the facility performed a fall risk evaluation, skin condition form related to R1's fall, and a pain evaluation assessment related to R1's reports of pain in his left front knee. Facility Abuse Policy and Prevention Program 2022 document, dated 10/2022, shows, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or the compliance officer. In the absence of the administrator, reporting can be made to and individual who has been designated to act in the administrator's absence Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an incident investigation Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately but not more than two hours after the allegation of abuse.

Based on observation, interview and record review, the facility failed to implement specific interventions to prevent pressure ulcers from developing to a resident assessed as high risk. This applies to one of three residents (R1) reviewed for pressure ulcers. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old with diagnoses that include but not limited to diabetes mellitus type 2, dementia, hypertension, Alzheimer's disease, cerebral infarction, hyperlipidemia, hyperkalemia, lack of coordination, weakness, kidney failure, metabolic encephalopathy, obesity, psychotic, mood and anxiety disturbance, and cognitive communication deficit. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 7/25/2023 showed that R1 was severely impaired, required extensive to total assistance with ADLs (Activities of Daily Living) such as transfer, bed mobility, hygiene and eating. The MDS also showed that R1 had functional impairment of range of motion on one side of the body of the upper extremity and both sides of the lower extremities. The assessment showed that R1 had no pressure ulcers, no DTI (deep tissue injuries) that were pressure related, no open lesions, diabetic ulcers or any kind of ulcers or tissue injuries of the feet. The initial nursing assessment dated [DATE] showed that R1 was free of skin alteration and had no pressure ulcers. On 9/11/2023 at 2:00 P.M. the Braden Scale skin assessments and current care plan was reviewed with V3 (Director of Nursing) and V4 (Licensed Practical Nurse/Wound Care Nurse). V3 and V4 stated that the Braden Assessment of 7/18/2023 with a score of 17 (at risk for pressure ulcer development) was not accurate. V3 and V4, said that if the Braden Assessment was done correctly, the score should be 11 and that would place R1 as high risk of developing pressure ulcer. The Braden Scale dated 7/26/2023 showed that R1 had a score of 11. The current care plan initiated on 7/19/2023 showed that there were no specific interventions to prevent R1 from development of pressure ulcer. The care plan was discussed with V3 and V4. Both have confirmed that there were no specific interventions to prevent R1 from development of pressure ulcer. In fact, they both said that heel protectors were only applied on 9/5/2023 when R1's daughter had discovered the unstageable pressure ulcer to R1's both heels on 9/5/2023. The care plan was updated on 9/7/2023 for R1 to always have the heel protectors after the discovery of the unstageable pressure ulcer of both heels. V4 said that on 9/5/2023, R1's daughter had complained regarding a skin tear to R1's right lower leg. V4 added that due R1's daughter complaint, V4 did skin assessment on same day with R1's daughter at bedside and V3. Both V3 and V4 said that they assessed R1's heels as black discoloration to both heels which were unstageable pressure ulcer. (V7/Nurse Practitioner) came to see the wounds and categorized it as DTI (deep tissue injury). Both heels were covered with black discolored skin and was unknown what was building inside the wound. The skin /wound assessment shows the wound measurement as follows: The 9/5/2023 wound measurement of the left heel was 6.76 cm. on the affected surface area; length was 3.78 cm x 2.72 cm. in width. The right heel measurement was 2.69 cm on affected surface area; length was 2.54 cm. x 1.4 cm. in width. The 9/8/2023 wound measurement basement of the left heel was 7.2 cm, on the affected surface area; length was 3.64 cm. x 2.71 cm in width. The right heel measurement was 12.06 cm on the affected surface area; length was 5.45 cm x 2.98 cm. in width. The 9/12/2023, the left heel measurement was 22.5 cm in affected surface area, length was 6.7 cm.: x 4.7 in width. The right heel measurement was 19.4 cm in affected surface area, length was 6.0 cm. x 5.5 cm. The measurements from 9/5/223 through 9/12/2023 showed an increased in size for the unstageable pressure ulcers. The progress notes dated 9/7/2023 showed that R1 was sent to the hospital at 1:30 P.M. for evaluation of stroke. R1 returned to the facility on same day at 10:48 P.M. The hospital ER (emergency room ) record showed that R1's daughter had expressed concern regarding R1's lesions on feet. Does have what appears to be an eschar (dead tissue) are thick callus over the lateral aspect of the right heel and less so to the plantar aspect of the left heel. These do appear to be pressure related. The ER record documents that the clinical impression of the heels was pressure injury of the skin feet, with unspecified stage of injury stage. On 9/11/2023 at 11:45 A.M., R1 was observed sitting in her reclining wheelchair. R1 was in the dining room. R1 was confused and was not conversant. R1's skin was checked with the assistance from V4, V5 (LPN/License Practical Nurse) and V6 (CNA/Certified Nurse Assistant). R1 was transferred via the mechanical transfer lift device. It was noted healed scars noted on the sacrum, right below knee and perineal area was clean and no altered skin. The right mid leg was with an open wound. V4 said it was a skin tear that R1 had acquired when R1 was out from the facility to the hospital on 9/7/2023. There was a gauze dressing to the right mid leg. The dressing was intact, and a date labeled 9/11/2023. The skin tear measured 2.7 in length x 0.9 cm in width and 0.1 cm in depth. R1 was also noted with black discoloration that covered entire areas of both heels. The blackened area looked rubbery and shiny looking. V4 said that these blackened discolorations were DTI due to pressure related injuries. The Nurse Practitioner progress notes dated 9/5/2023 documented by V7(Nurse Practitioner) showed that she examined R1 and called the wound on the heels as unstageable DTI. The notes also showed for a wound physician specialist to check R1 ASAP (as soon as possible) whether in -house or outside the facility. On 9/11/2023 at 3:15 P.M., V7 stated that on 9/5/2023, V7 was called to check R1's blackened/discolored skin of both heels. V7 said she documented the discolored heels as deep tissue injury because of injuries of the tissues. I don't know about wounds, not my specialty, so I refer (R1) to wound physician specialist ASAP to determine what was building inside the unstageable tissue injuries on both heels. Since there was no certainty on what was going on inside the tissue injury that was covered with blackened discoloration. V7 stated I want the wound clinic /wound doctor to see (R1) ASAP whether outside wound clinic or in house wound doctor specialist. Obviously if the wound clinic cannot see (R1) till 9/22/2023, this is far way out of range for R1 to be seen, the tissue injuries must be evaluated and treated ASAP. On 9/12/2023 at 10:00 A.M., V3 said that the in-house wound physician specialist (V9) was not available on 9/5/2023 and therefore R1 was not seen. However, V3 said V9 will evaluate R1 today (9/12/2023.). On 9/12/2023 at 9:30 A.M., V8 (R1's Attending Physician) said that he is not involved with R1's wound management and care since it was not his specialty, and it was up for the wound care team to take of R1's wounds. On 9/12/2023 at 2:46 P.M., V10 (CNA/Certified Nurse Assistant) said that she took care of R1 several times since R1 was admitted to the facility. V10 said that it was only a week ago sometimes around 9/5-7/2023 when staff had been applying the heel protectors to R1's heels. On 9/12/2023 at 2:47 P.M., V11 said that she had helped during R1's transfers using the mechanical transfer lift device. V11 said that she did not know or had seen R1 with heel protectors on. The wound physician specialist (V9) had documentation dated 9/12/2023 that showed the wound assessment were as follows: -right heel categorized as DTI and etiology was pressure injury; measurement of affected area was area of 55.16 cm; length was 5.8 cm x 5.7 cm in width and an unstageable deepness. -left heel measure categorized as DTI and etiology was pressure injury; measurement of affected area was area of 19.95 cm; length was 3.5 cm. x 5.7 cm. in width and an unstageable deepness. On 9/12/2023 at 2:15 P.M., V9 stated that R1 was a high risk for development of pressure ulcer and preventative measures and interventions were a must to be implemented to prevent pressure ulcers from developing. V9 added that he examined R1 on 9/12/2023 and that R1 had an unstageable pressure ulcer to both heels. V9 added that the reason of the DTI was related to pressure related injuries. V9 added that since R1 was highly dependent from staff's assistance for offloading from pressure that would cause pressure ulcers. V9 added that prevention for heel pressure ulcer would include using foam boot protector to offload pressure from the heels. The facility's policy for Skin Care Prevention dated 1/2023 showed that all residents will receive appropriate care to decrease the risk of skin breakdown. The policy also showed that 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment .2. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider .6. Unless contraindicated, elevate heels off bed surface and avoid skin-to-skin contact. The facility's policy for Skin Management; Pressure Injury Treatment /General Wound Treatment dated 1/2023 1. Implement prevention protocol according to resident needs.

Based on observations, interviews, and record reviews the facility failed to identify a newly admitted resident as an elopement risk and provide supervision and safety for R1. As a result of this failure, R1 was able to elope from the facility after admission from a local hospital for dementia, falls, and memory care. R1 was able to travel to a family member's home from the facility and during this time suffer a fractured clavicle and rib. R1 required emergency room (ER) treatment. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on April 14, 2022, when R1 left the facility after admission to the facility at 7:04 PM and was readmitted to the local ER (emergency room ) at 8:38 PM. This applied to 1 of 4 residents (R1) reviewed for elopement in the sample of 4. V1 (Administrator), V2 (Assistant Administrator) and V3 (DON/Director of Nursing), were notified of the Immediate Jeopardy on June 29, 2022, at 3:30 PM. Although the immediacy was removed on June 30 at 5:00 PM, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new policies and procedures and Quality Assurance monitoring. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included dementia in other diseases with behavioral episodes, unspecified lack of coordination, Wernicke's [CONDITION(S)], and anxiety. R1 was discharged from the facility on June 10, 2022, and was not able to be interviewed at the time of this investigation. R1's Hospital records showed that on April 12, 2022, R1 was admitted to the ER (emergency room ) from another nursing home. The progress notes written from April 12, 2022, until transfer to facility on April 14, 2022, showed various progress notes documenting R1 wandering the hallways, climbing out of bed, removing clothing, and removing the medical equipment needed to monitor his heart. R1 had a 1:1 sitter for safety while in the ER up to his discharge from the ER. R1's progress notes document that R1 was admitted to the facility on [DATE], at 7:04 PM without any family present. V6 (LPN/Licensed Practical Nurse) charted that R1 was alert and oriented times two and admitted to the facility with dementia and risk for falls. V6 went on to document that R1 was orientated to his room. Hospital records document on April 14, 2022, that R1 arrived in ER at 8:38 PM and was discharged at 2:18 AM. ER Social worker documented, Patient to the ED via EMS after daughter called stating {R1} had made it to her house from {facility}. {R1} was there for nursing home placement and memory care. {R1} complained of right shoulder pain and noted a bruise to face. On April 15, 2022, at 3:12 AM, V12 (RN/Registered Nurse) documented that R1 had returned from the local hospital at 2:35 AM with a sling on the right arm due to right clavicle and right second rib fracture. On April 15, 2022, at 10:27 AM, V31 (Physician) documented that R1 was status post fall with fractured right clavicle and right rib. On June 30, 2022, at 10:58 AM, V14 (R1's wife) reported on April 14, 2022, sometime in the late afternoon, the local hospital let her know that R1 was going to be transferred to the nursing home. Later that same evening, V14 reported she received a call from her daughter letting her know that R1 had shown up at her house with a bruise on his face and was complaining of right shoulder pain. V14 stated, I called the facility around 8:20 PM, and asked the nurse (unknown name) if R1 was in the facility. The nurse told me he was there. Not long after I talked to that facility nurse, the hospital called to tell me R1 was back in the ER and had arrived at 8:38 PM. Later that night V3 (DON) called me to let me know they had seen R1 get into a black SUV (Sport Utility Vehicle) on their parking lot camera and wanted to know who I knew that drove a black SUV. I told her no one that I know of. On June 30, 2022, at 11:07 AM, V13 (R1's daughter) reported on April 14, 2022, at approximately 8:00 PM, R1 showed up at my house and started pounding on the front door saying, 'let me in'. I called the local hospital to ask them why R1 was at my house. The hospital told me, he had been transferred to the nursing home earlier that evening and then told me to call 911. I noticed a bruise on R1's face and he was complaining of shoulder pain. The paramedics arrived and took R1 back to the local ER. V13 went on to add that R1 does not have access to any money or credit cards because of his dementia. V13 continued to add that R1 would not know what a (request a ride) driver is and would not know how to call one. V13 added, He can barely answer his cell phone by himself. On June 28, 2022, at 2:32 PM, V1 (Administrator) reported on the night of the incident R1 told V8 (Receptionist) his daughter was picking him up. V8 opened the door and let him out. V8 was new at the time and is no longer working here. According to V1, R1 had only been in the facility about one hour when he left the building. On June 30, 2022, at 1:02 PM, V27 (Previous Administrator) stated I was out to dinner (April 14, 2022) when the hospital called letting me know R1 was in the ER and asked me why he came from his daughter's house and not the facility? I called the facility to see what was going on. V8 (receptionist) told me R1 came to the front desk and told her he was going home. V8 stated she tried to call me, but she had already let R1 out the door. I called V14 (R1's wife) to let her know what was going on and she told me that R1 needs to be in the facility. I called the facility back and asked them to make some room changes so R1 could come back to the facility and be placed on the locked unit. The next day I called V13 (R1's daughter) to ask her exactly what happened. V13 told me that R1 just showed up at her house. V13 went on to add that she called 911 and the paramedics took R1 to the hospital and diagnosed him with a fractured right clavicle and fractured right rib. V27 went on to add that she tried to talk to R1 the next day and that R1 told me he fell when he went home. According to V27, R1 started to get agitated with V27 when I was asking him questions, so I stopped. The receptionist and staff who cover the desk when the receptionist takes her break were all trained that even with an alert and oriented resident, staff at the front desk are to call the nurse to see if it is ok to let the resident go outside the facility. I thought R1 was an AMA (Against Medical Advice) discharge and that is why I called V32 (Human Resources) to start an in-service on AMA policy and procedure. V27 continued and stated, I know it should have been documented and it wasn't. On June 27, 2022, at 1:17 PM, V3 (DON-Director of Nursing) reported on the day R1 left the facility, he waved to the receptionist and said, I'm going to my daughters. I was told that V8 saw R1 get into a car. V3 stated that she was not sure how R1 set up getting a ride, but he made it to V13's house. V3 added that R1 either told V13 he had fallen, or she witnessed his fall. V3 stated that the facility was not sure how R1 fell but that we knew that V13 drove R1 to the hospital. V3 reported that the facility has parking lot cameras, but these cameras only record for two weeks and then tape over what was previously recorded. On June 30, 2022, at 10:02 AM, during a meeting with V1 (Administrator) V1 presented the following information: R1 came in as an Emergency Situation R1 not appropriate for hospital admission and could not go home. V1 stated that the facility was not told that R1 had history of elopement. The hospital records in our system appear to have been printed prior to his discharge from the hospital so they must have arrived when R1 did but within one hour of his admission, R1 went to the front desk, told the receptionist he did not want to be here, called a (ride share driver), and left. V1 then added that the facility has 24 hours to assess a resident. V1 stated that the facility uses a triple check process-three set of eyes review documentation - hospital liaison, admissions, admitting nurse. V1 reported this was an AMA (Against Medical Advice) discharge. V1 stated If hospital had given us accurate information, we would not have taken this resident or we would have placed on locked unit when he was first admitted to us. Facility provided policy titled Elopement, with revision date of January 2021 showed All residents will be assessed for elopement risk upon admission . Facility provided policy titled Admission Approval, with revision date of September 2021 showed: General: The facility accepts the patient or resident for care, treatment, and services based on its ability to meet the patient's or resident's needs. Responsible party: IDT (Intradisciplinary Team), RN, LPN. Protocol: 1.) The patient screened prior to admission by at least one of the following: Marketing Director, Nurse Liaison, Admission Director, and/or Director of Nursing. 2.) The patient or resident is screened for acceptance based on the [NAME] clinical capabilities Policies On June 28, 2022, at 10:57 AM, V5 (Admissions) stated, We have a hospital liaison (V7) who the hospital contacts when a resident needs to be admitted to a facility. Once the hospital contacts her, she will contact me to see if we are able to accept this resident. I have access to the hospital EMR (Electronic Medical Record) should the hospital not provide us with the admission documentation. When we admit a resident for memory care the meaning varies based on the severity of the memory care needs. Sometimes we are told before arrival what their needs are and other times, we find out their needs once they are at the facility. I do not remember much about {R1}, but I know I was not in the building when he was admitted . We do have wander guards if required, but I am not sure how the need is determined. I believe the assessment is with the Administrator. On June 27, 2022, at 3:50 PM, V6 (LPN/Licensed Practical Nurse) stated, I remember this guy being admitted to this facility close to shift change. When I was done with my part of the admission, I placed the hospital records and my nurse- to- nurse report sheet in the medical records box in the nurses' station. V33 (Medical Records) will come around during the day and pick up the records to scan into the computer. I later heard from someone that he had left the facility. Interviews were held with V3 (DON), V10 (LPN), V11 (RN), and V23 (LPN) regarding the admission process. On June 28, 2022, at 10:32 AM, V10 (LPN/Licensed Practical Nurse) stated, with a new admission I have to assess the resident to see if they are alert and oriented and if the resident is confused, I will call the family. I will review transfer packet from hospital or facility resident arrived from, do a head-to-toe assessment, alert staff including the DON (Director of Nursing) and ADON (Assistant Director of Nursing) that we have a new admission and share any concerns, complete resident charting, document progress note, and round on the resident every 1-2 hours. At 10:37 AM, V11 (RN/Registered Nurse) stated when she gets an admission she checks on the patient and orients them to the room and call light, does a skin assessment, get vital signs including the weight, check orders with the physician including labs, enter orders, call pharmacy for STAT delivery of medications, round on resident every 2 hours, but if they have dementia round hourly for the next 72 hours, and write a progress note. At 1:37 PM, V23 (LPN) stated with a new admission I have to review nurse to nurse assessment, do a head-to-toe assessment, vital signs, skin assessment, fall risk assessment, start baseline care plan, hourly rounding for the first 72-hour, progress note (Admission note), medication reconciliation with physician, pain assessment, and dehydration assessment. On June 29 at 12:34 PM V3 (DON) stated when a new admission arrives at the facility the nurses are responsible for assessing the resident including vital signs, room orientation, reviewing the paperwork from the hospital, and if family is there orient them as well as resident to the facility, locations of bathroom, closet, daily schedules. If there is no family present and/or the resident has dementia, the nurse will still go over room orientation with resident, they will explain the call light system and make sure the resident is able to use it or see if they need an adaptive call light. Depending on what time the resident is admitted , if close to change of shift, the nurse on duty starts the admission process when resident arrives, and the oncoming nurse will need to finish the admission. There are seven assessments that need to be completed during the admission process: 1.) Falls 2.) Elopement 3.) Pain 4.) Dehydration 5.) Skin 6.) Call light and 7.) Head to toe assessment. The nurse needs to write an admission progress note that documents specifics about that resident, do a baseline care plan, initial nursing observation, and if resident is being admitted for rehab a skilled nursing note needs to be completed. If a resident is alert and oriented, the nurse can ask the resident questions as part of their assessment, but if not, the nurse needs to review the hospital records, and call the family. When we use agency nurses, the nurse on the unit will orientate them to the facility, the unit, and the residents assigned to. If they are working the day shift, once I get to work, I will check in with them and see if they need anything. Nurses will round on residents every hour or every 2 hours depending on their needs. If they are high risk falls or elopement risk, then we would round every hour (Nurse or CNA). R1 was an emergency admission which means the hospital was unable to find placement and R1 did not require hospitalization . We had basic information on R1, the nurse was responsible for reviewing the hospital paperwork that arrived with the resident. At around 8-9 at night on April 14, V27 (previous Administrator) called, and I was made aware that R1 had left the facility and said he was going to his daughter's house. The facility's initial incident report dated April 15, 2022, showed Description of Occurrence: {R1} sustained a fall with injury while out of facility; went to ER for evaluation and treatment; diagnostic findings include right clavicle fracture and right rib fracture. The facility's final incident report dated April 19, 2022, showed: Occurrence resolution: A thorough investigation was conducted which included interviews with {R1}, {V14 wife}, and {V13 daughter}. Facility medical record and hospital records reviewed. {R1} stated 'I was walking and fell .' {R1} returned to the facility from the ED (Emergency Department) with orders for sling to right arm and follow-up with orthopedic physician. {R1} monitored for pain and comfort, care plan updated. During the investigation there was no evidence of any form of abuse, neglect, or mistreatment. The facility is located on Illinois Route 38 also known as State Street, a four-lane highway. The distance from the front of the facility to the highway was measured as 194 feet by V28 (Maintenance Director). R1's MDS (Minimum Data Set) dated May 5, 2022, showed R1 had moderately impaired cognitive skills for daily decision making. R1 required supervision and one staff physical assistance for walking in corridors and locomotion off the unit. R1's baseline care plan with an effective date of April 14, 2022, could not be provided. Per V1 (Administrator) it does not appear as though (V6/LPN) completed all of the evaluations on the 14th. It appears as though the other nurse completed the assessment (April 28). Through observation, interview, and record review on July 7, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation. Education/training was provided to all staff regarding supervision and staff accountability of residents identified as elopement risk. Education was completed by 5:30 PM on June 30, 2022. New hires on July 6, 2022, were educated during their core orientation process, prior to starting and will continue with all new hires. Staff on vacation will be educated upon return and prior to start of their first shift. Education will be completed weekly for 90 days and longer if deemed necessary by QA (Quality Assurance) committee. The education/training provided included: All staff being educated that no member may open the main entry door and permit residents to exit facility unless they are confident that the resident is not a high-risk elopement. Nurses are to properly complete the initial elopement assessment and care plans. Those assessed to be at High Risk for elopement must have the face sheet printed and the Administrator or nurse manager called and informed. The admission process includes reviewing the referrals and receiving adequate information to meet resident's needs. This information will include obtaining behavior specific and elopement risk information on Admission notices/[NAME]'s hospital nurse to nurse report form. The CNAs are to round on all new admissions a minimum of every 2 hours based on resident specific needs.

Based on observation, interview, and record review the facility failed to ensure safety measures were in place to reduce the risk of resident injury and failed to revise care plan interventions. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's Face Sheet shows resident is a [AGE] year old with the following Diagnoses: [REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 24, (YEAR), shows R1's cognitive status is severely impaired and requires extensive assistance of two staff member for bed mobility, transfers and toileting The MDS also shows R1 has limited range of motion to left upper and lower extremities. The Witnessed Fall Report shows R1 sustained a fall on (MONTH) 6, (YEAR). Resident was found lying on the floor next to her low bed with her bed sheets around her. Was alert but very confused and mumbling unintelligible words. Responsive to sound and tactile stimuli but unable to provide information regarding what happened. Resident with probability of rolling down from bed to the floor as she was lying with her bed sheets around her when she was found. The Witness Fall Report form shows R1 sustained a fall on (MONTH) 13, (YEAR). CNA (Certified Nursing Assistant) called nurse in resident room, noted resident lying on left side bleeding to her left side forehead. R1's Fall Risk assessment dated (MONTH) 24, (YEAR) shows R1 is at a High risk for falling. The facility did not present a fall risk assessment for (MONTH) 13, (YEAR) when R1 sustained a Cervical Fracture of C1 & C2 and a laceration requiring 26 sutures. R1's Care Plan dated through (MONTH) 26, (YEAR) shows R1 is a high risk for falls related to generalized weakness, receipt of medications which could potentiate falls, impaired balance and safety awareness. R1 sustained 2 falls from (MONTH) 6, (YEAR)-September 13, (YEAR). R1's Nurses note dated (MONTH) 14, (YEAR), patient returned from hospital with a [DIAGNOSES REDACTED]. Laceration to top left of her forehead with 26 sutures with some dry blood. Left eye orbital is bruised purple in color. Will have continuous hospice care. R1's Physician documentation dated (MONTH) 14, (YEAR) shows, cervical fracture of C1 and C2 fractures with severe dementia. Patient is going to have a very difficult time with this. She is already losing weight and having a hard time with eating. If cannot find brace, would recommend palliative/hospice at nursing home. R1's Physician note dated (MONTH) 20, (YEAR), shows discussed with family on (MONTH) 18, (YEAR) at family meeting to discuss hospice, patient is status [REDACTED]. Patient is lying in bed, occasionally mumbling and not as interactive. R1's Restorative note dated (MONTH) 20, (YEAR) shows resident is now on continuous hospice for comfort measures, appetite is poor and now dependent on staff to feed her when before she required limited assistance. On (MONTH) 26, (YEAR) at 9:18 AM, V9 POA (Power of Attorney) stated R1 was a high risk when she came to the facility. V9 stated he was called on (MONTH) 13, (YEAR) that his mother had fallen out of bed and 911 was transporting her to the local hospital. V9 stated he was told his mother sustained two cervical fractures and a shear laceration to her forehead that required approximately 26 stitches. V9 stated V3 (R1's Physician) told him his mother is not a surgical candidate and his mother would never go back to her previous status and we would see a decline. V9 stated V3 suggested hospice with comfort care. V9 stated he came the next day and went into R1's room and no fall mats or body pillow was in her room. R1's Care Plan dated (MONTH) 23, 2014 to (MONTH) 26, (YEAR) shows assist with turning and repositioning of 1 to 2 people, call light and demonstrate use, monitor for adverse medication effects and report if noted, observe for decrease of loss of functional status, offer to toilet resident prior to going to bed, offer toileting after dinner, replace dycem to seat, restorative care as appropriate and staff to assist as needed. Change air mattress with bolsters to regular mattress with bolsters to help define the edges of the mattress. On (MONTH) 6, (YEAR) shows body pillow while in bed. On (MONTH) 17, (YEAR) shows bolsters applied to prevent sliding off mattress which is necessary for potential recurrent skin issues, bedside floor mats. On (MONTH) 26, (YEAR) at 10:00 AM, V2 DON (Director of Nursing) stated R1's accident happened in afternoon at around 6:00 PM. V2 stated R1's care plan does not show the interventions that were in place before the fall. V2 stated R1 had fall mats in place but it does not show on her careplan. V2 stated she would work with V5 (MDS Nurse) to revise R1's care plan. V2 stated a nurse called her and stated R1 fell out of bed and it was unwitnessed. V2 stated she asked how R1 fell out of the bed and stated she was told R1's bed would not go up or down so the wound nurse and wound doctor decided to kneel. V2 stated a CNA (Certified Nursing Assistant) was asked by V4 to provide incontinence care to R1. V2 stated V7 (CNA) went into R1's room with an incontinent brief in her hand and saw R1 on the floor and called for help. V2 stated upon her investigation of the accident she was told by the staff working with R1 the bed was working in the afternoon for the 3PM-11PM shift. V2 stated in the re-enactment of the accident by the facility the bed had to be at least 2 feet from the floor and it was not in its lowest position at the time of fall. V2 stated the wound nurse told her there was no fall mat by the side of the door in which R1 fell . V2 stated R1's protocol was to have the bed in the lowest position closest to the floor. V2 stated it depends how the resident falls out of bed to determine if she would have 2 fall mats. V2 stated R1 was extensive assistance and needed two staff members to assist. On (MONTH) 26, (YEAR) at 11:00 AM, V4 (Wound Care Nurse) stated she was with the wound doctor in R1's room and her bed would not raise so we kneeled down to assess the skin injury. V4 stated the wound doctor left the room and she placed R1 on her back in the bed. V4 stated she told V7 CNA (Certified Nursing Assistant) to provide incontinence care to R1. V4 stated she was out in the hallway with the wound doctor when V7 came out of the room and stated R1 was on the floor. V4 stated she went into R1's room and noticed R1 was laying on the floor on her left side and noticed she had a laceration to her left side of her forehead and the bed was in a higher position than what I left R1. V4 stated she put pressure on the wound and told V7 to have someone call 911. V4 stated R1 the air mattress did not have bolsters or a body pillow and the fall mat was on the rights side of her bed no fall matt was placed on the side of the bed she fell , the mat was behind the headboard. V4 stated she placed the call light near R1 but stated R1 never uses her call light because she is severely cognitively impaired. V4 stated R1 was to receive checks every two hours when in bed, fall mats and bed in lowest position. V4 stated the fall mat on the left side should have been placed alongside of her bed before she left the room. V4 stated R1's fall mats should have been placed on each side of her bed before I left the room. V4 stated R1 is a two person staff member assist to roll and we use 2 staff members because R1 gets agitated. On (MONTH) 26, (YEAR) V3 (R1's Physician), stated he and the facility discussed R1's fall and tried to figure out what happened that she fell and sheared her head and there were no actual witnesses. V3 stated he took care of R1 at the hospital and R1 did fracture C1 and C2 as well as sustained a shear laceration requiring 26 sutures. V3 stated if the fall mats were on both sides of her bed and the bed was in its lowest position, maybe she would have had a laceration but not to the extent of requiring 26 sutures but she still could have sustained the fractures. On (MONTH) 26, (YEAR) at 12:00 PM, V8 (Wound Physician) stated on (MONTH) 13, (YEAR) he and the wound nurse went into R1's room to assess her left thigh scratch and the bed was not functioning V4 (Wound Nurse) she could not raise the bed up. V8 stated per protocol he leaves the room and the wound nurse places the dressing on the patient and puts the patient in the middle of the bed. V7 stated he and the wound nurse went into another resident's room and when they both came out the CNA (Certified Nursing Assistant) stated R1 was on the floor. On (MONTH) 27, (YEAR) at 8:40 AM, V4 stated R1's air mattress did not have bolsters and I knew she was a high fall risk. V4 stated they had an inter-disciplinary meeting after R1's fall and the next day we discussed the body pillow and bolsters were not in place at the time of the fall. The only fall interventions that I could remember being used were a low bed and fall mats. On (MONTH) 27, (YEAR) at 9:40 AM, V7 CNA (Certified Nursing Assistant) stated she started her shift at 2:00 PM on (MONTH) 13, (YEAR) and was assigned to R1. V7 stated she laid R1 down to bed around 3:15 PM. V7 stated she came back from break around 5:25 PM and was told by V4 (Wound Nurse) that R1 needed to be changed. V7 stated she walked into R1's room and saw R1 on the floor with quite an amount of blood on the floor. V7 stated she noticed the bed had been raised to around her waist about 2 ½ -3 feet from the floor, fall mat was on the right side of the bed, no mat was at the left side of the bed where she fell , and nobody pillow was ever ordered. We would just use regular pillows to position R1. V7 stated the day of the fall she did not use any pillows to reposition R1 she left R1 on her back and the bed in the lowest position. On (MONTH) 27, (YEAR) at 11:15 AM, V6 (Restorative Nurse) stated the MDS (Minimum Data Set) only needs to be coded once for turning and repositioning for the need for 2 staff members and if R1 is in bed and needs to be toileted (incontinence care) while in bed it is up to the Certified Nursing Assistant to determine if they need another staff member for assistance. The Fall Prevention Policy and Procedure dated (MONTH) (YEAR), shows the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible .during rounds, ensure residents are positioned safely and fall preventative measures are in place .The ISP (Individualized Service Plan) will identify residents specific safety interventions such as reacher, bolsters, fall mats etc .Placement of these interventions will be verified at the beginning of the shift.

Based on observation, record review and interview the facility failed to ensure the residents (R1, R2, R4 and R5) are free from mistreatment and verbal abuse from E3 (Nurse). As a result of this failure, R1 sustained anxiety and feelings of being upset and afraid of E3. This applies to four of four residents (R1, R2, R4 and R5) evaluated for mistreatment in the sample of 15 residents. Findings include: On 12/3/14 at 11:15 AM E3 (Staff Nurse) was in R1's room to give her medication. E3 began talking loudly to R1 and stated, "I am going to tell you what I do for you in front of these nice people so I have proof, (referring to Surveyors present in the room). E3 stated, "I do everything for you," in a loud angry voice while standing over R1's bed and pointing finger at her. R1 became upset and raised her voice as well. E3 continued to yell at R1 about how R1 does not recognize everything E3 does for her and it is not her problem. Both R1 and E3 continued to escalate. At this time surveyor intervened and asked E3 to speak to surveyor in private. E3 continued to say 'no', she (R1) needs to hear this and I (E3) need to be heard and continued her loud talking. Then E3 walked into the hall with surveyor and was still yelling. "I need to be heard, I want to tell my side." E3 was assured by surveyor they could talk in private so as not to disrupt or frighten other residents. On 12/3/14 at 11:30 AM, R1 stated," E3 is always like that she yells and is so forceful. When I (R1) first came here I was afraid of her, now I am used to her so I just don't call her for help or medication because I don't want to provoke her." R1 stated the whole incident that happened made her upset and anxious. On 12/4/14 at 12:30 PM R1 stated she had talked to E1 (Administrator) about E3 on 12/4/14 AM. R1 stated the "E3 just shouldn't be taking care of people." On 12/3/14 at 11:45 am surveyors notified E1 of the E3's behavior of mistreatment towards R1. E1 stated she removed E3 from all residents' contact and begun an initial investigation and the incident was reported to Illinois Department of Public Health. E1 also stated she received, a written concern about E3 treating the residents, from R2's family (Z1) which she (E1) became aware on 12/2/14. In the written concern Z1 alleged "in my opinion she (E3) is rude and condescending which I did not appreciate ... is it these people are too old to matter? and don't pay enough." E3's personal file had documentation to show E3 was written up for direct patient care and communication with families (7/16/13 and 12/10/13), yelling and needs to present a calm, anti-chaotic environment for patients and staff (5/23/12 and 5/30/12). On 12/4/14 at 9:25 AM, E5 (Social Services) stated there was a family complaint about E3 earlier in the year but unsure of the exact date. E5 stated it was during a care plan meeting the family complained E3 was too loud and talked too fast. E5 stated she has heard other staff talk about how loud she is but that everyone felt, "That's just how she is." On 12/3/14 R5 stated he does not have a problem with any nurse except one. R5 stated he did not want to give the nurses name. R5 stated the nurse works day shift and was here earlier but now is gone for the day. R5 stated "I don't know why but I won't miss her." ( E3 was sent home that day by E1( administrator ) pending an investigation). R5 stated the nurse is "loud and not very nice." On 12/3/14 at 11:00 am E3 administered R4's 9:00 am scheduled medications. At this time R4 declined to take one of her medications (steroid). E3 told R4 loudly and pointing finger at her (R4) "you have a right to refuse, but you are under the care of nursing home doctor and the facility doctor prescribed medication for you." R4 continued to say her lung doctor did not want her to take it. E3 told (R4), "aren't you lucky, you are living for several years after [MEDICAL CONDITION]." This incident occurred in hall way and there were other residents standing next to R4. On 12/3/14 at 11:52 PM, E3 stated, "I was upset today and I should keep my personal stuff to myself. I don't hide my emotions positive or negative, that is how I was raised that is part of my culture. I was told in the past to keep my emotions down but this is not how I am. This happened in the past because I misunderstood someone." E3 then apologized for her behavior that day. On 12/5/14 at 3:00 PM E1 stated she was going to terminate E3, but E3 decided to resign to her job at the facility effective 12/5/14.

Based on observation, interview and record review, the facility failed to use appropriate methods to prepare and serve potentially hazardous food. This deficient practice resulted in an Immediate Jeopardy (IJ) for two residents (R1) and (R2) who were served unpasteurized fried, shell eggs that were not cooked to a safe temperature that would congeal the yolks. R1 and R2, who requested fried eggs, are considered to be in a highly susceptible population; immunine compromises, and at risk for the development of food borne illness (Salmonella). An IJ was identified on 4/8/13 at 8:30am after observing R2 in the first floor dining room with over easy fried eggs on her breakfast plate. The yolks were runny as R2 has requested. E13 Registered Dietitian (RD) consultant verified that the facility did not use pasteurized shell eggs. R1 was also served a fried egg at this breakfast meal. The breakfast plates for R1 and R2 were removed from their breakfast tables and shown to E1 Administer, E5, Dietary Supervisor, and E13, and three members of the survey team. Part of the liquid yolk remained pooled around the bottom of the plate. E1, E5 and E13 were informed of the IJ at 8:50am on 4/8/13. The immediate jeopardy was removed on 4/8/13 at 3:35 pm. The dietary policy was changed to indicate only pasteurized shell eggs will be used for any item that is not thoroughly cooked, the unpasteurized eggs were discarded, dietary staff was trained, pasteurized eggs were purchased for the breakfast meal on 4/9/12.. This applies to two residents R1 and R2 in the sample of 18. Findings include. The breakfast meal was observed in preparation and service on 4/8/13 to include juice, cereal, egg and sausage casserole, toast and milk. R1 and R2 were served fried eggs per their request. The dietary cook E24 said that these are the only two residents who have asked for fried eggs. The facility recipe for Fried eggs indicates that a sheet pan should be place in a 350 F. oven until hot, take eggs from refrigerator and crack on to sheet pan. Bake 15 minutes (eggs should be at internal temperature of 155 for 15 seconds). Unpasteurized eggs when cooked to order in response to resident request and to be eaten promptly after cooking shall be cooked to an internal temperature of 145 for 15 seconds IF UNPASTEURIZED EGGS ARE USED, EGGS MUST BE COOKED UNTIL THE WHITE IS COOMPLETELY SET AND YOLK IS CONGEALED. The interpretative guidelines under F371 in Appendix P the state operations manual state: Some foods are considered more hazardous than others and are called "potentially hazardous foods (PHF) or Time/Temperature Controlled for Safety (TCS)" food. Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese. Unpasteurized eggs when cooked to order in response to resident request and to be eaten promptly after cooking; - 145 degrees F for 15 seconds; until the white is completely set and the yolk is congealed; The Food Service Sanitation Code, 2008 77 Ill. Adm. Code 750 state the following: Section 750.325 Special Requirements for Highly Susceptible Populations In a food establishment that serves a highly susceptible population: a) the following criteria apply: b) Pasteurized eggs or egg products shall be substituted for raw eggs in the preparation of foods using raw or undercooked shell eggs. c) Time only, as the public health control specified under Section 750.153, may not be used for raw eggs. (Source: Added at 32 Ill. Reg. , effective July 10, 2008). This code also includes the definition of: "Highly susceptible population" means persons who are more likely than other people in the general population to experience food-borne disease because they: Are immunocompromised, preschool age children or older adults; and Obtain food at a facility that provides services such as custodial care, health care, or assisted living (such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home), or nutritional or socialization services (such as a senior center). Review of R2 ' s admission record dated 1/24/2013 shows she is a [AGE] year old with [DIAGNOSES REDACTED]. During an interview with R2 her room at 11:30am on 4/8/13 R2 said she only likes her eggs fried, and she eats them most days. She likes the yolks runny so she can dip her toast into it. R2 ' s tray card placed at her table reads at the breakfast meal fried egg only. R1 ' s admission record dated 2/21/13 that she is an [AGE] year old with [DIAGNOSES REDACTED]. R1 ' s care plan (not dated) with a target date of 7/6/13 indicates she receives renal [MEDICAL TREATMENT] three times a week.

Based on observation, record review, and interview the facility failed to assess and analyze 2 residents' falls to prevent the residents from falling and sustaining injuries. This is for 2 residents (R12 and R11) in the sample of 17. As a result of this failure R12 had several falls and sustained skin tears and was hospitalized with a spinal fracture at L4. As a result of this failure R11 had a fall and sustained a laceration to the back of her head which required an ER visit and insertion of 6 staple sutures. The findings include: 1. Review of R12's admission face sheet showed R12 is an [AGE] year old resident with [DIAGNOSES REDACTED]. Review of the facility's incident reports showed R12 had 3 fall incidents from 10/28/12 to 3/22/12. Incident report documentation showed the following: 10/38/12 - 3:45 p.m. - Found on floor in hallway (no specific area documented). Skin tear to right lower forearms. (No size, length, description, or treatment documented). 11/18/12 - 11:40 a.m. - On floor in bathroom. No injury. 3/22/13 - 3:30 p.m. - Found laying on right side next to bathroom door. Skin tear to right arm. Steri strips applied. Incident investigation report also showed R12 is noted to frequently self transfer and toilet self but resident has impaired independent mobility and weakness. Review of nursing documentation dated 3/24/13 at 9:07 p.m. showed R12 refused to get up for supper and complained of back pain. PRN (as needed) medication given. There was no documentation in the nurses notes or the MAR (Medication Administration Record) of what PRN medication was given (pain med, antianxiety med, etc...). Review of nursing documentation dated 3/26/13 at 10:25 p.m. showed, "Upon arriving on shift CNA (Certified Nurses Aide) on duty reported that resident was complaining of lower back pain. When assessed, resident refused to get up for dinner and upon movement resident screamed out and stated he wanted to die. Ok to sent to ER per MD. Resident admitted for back pain." Further review of nurses notes and R12's MAR showed no pain medication was given prior to R12 being sent to ER, even though R12 was screaming out in pain. Review of hospital Physician Discharge Summary dated 3/29/13 showed R12 was admitted to the hospital on [DATE] for pain control and evaluation of pain. Physician Discharge Summary notes R12's MRI showed R12 with a L4 vertebral compression fracture. Further review of the Physician Discharge Summary showed R12 was found to have compression fracture as the cause of his pain which required IV morphine and Norco (narcotic pain medications). R12 was readmitted to the facility on [DATE]. Observation of R12 on 4/10/13 at 2:30 p.m. noted R12 to be resting in bed. Interview with R12 at this time noted R12 to say, "I fell and hurt my back here. I injured it a long time ago but I re-injured it here. I was taking pain meds. I don't have to take too much med now. I tried to go to the bathroom and fell ." Since two of R12's falls occurred while R12 was attempting to go to the bathroom; R12's fall plan of care was reviewed to identify interventions initiated to decrease falls during toileting. The fall plan of care showed on 8/10/12 R12 was placed on a toileting program. The plan of care was not individualized and not specific as to what type of toileting program R12 was on, how often R12 should be toileted, when R12 should be toileted etc... Interview with E4 (RN - Restorative Nurse) on 4/11/13 at 11:50 a.m. noted E4 to say, "R12 is toileted every 2 hours on odd hours." At this time E4 was asked about the assessment procedure for residents in the toileting program. E4 responded, "I don't save the paper work for the assessment of the Bowel and Bladder programs. I contact the staff for 3 consecutive days and ask them about the resident." E4 admitted she does not assess the residents to identify the type of incontinence a resident has (such as mixed, stress, functional, etc...). E4 also admitted she did not assess and or analyze R12's falls identitying that R12 had falls attempting to go to the bathroom. E4 also admitted she did not identify that 2 of R12's falls (10/28/12 and 3/22/13) occurred within 15 minute timeframes (3:30 p.m. and 3:45 p.m.). Further review of R12's fall plan of care included interventions to evaluate cause of falls, and to gather and assess information on past falls. (2) R11 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the facility Incident Log documented that R11 fell in the facility on the following dates: 11/20/2012 and 1/06/2013. Review of the Unusual Occurrence Report Form, dated 11/11/2012 documented the following: "...Observed patient (R11) laying on patient's side. Back of head opened and pressure dressing applied." R11 was sent to the hospital and required approximately 6 staple to close her laceration to the back of her head. The Investigation Report, dated 11/12/2012, documented R11's incident, but it did not analyze the specific factors about her fall that caused her head laceration. The restorative nurse, E4, was interviewed on 4/09/2013 at 1 PM. E4 said she is responsible for completing resident's fall investigations. E4 said that R11 had mats on the floor when she fell on [DATE]. E4 could not explain why R4 sustained a laceration to the back of her head if she landed on the mattress. E4 replied, "That's a good question... Its possible she (R11) could have hit the dresser or side rails." However, a complete analyze of R11's fall was not done.