Every finding on record at Carlton at the Lake, The

Based on interview and record review, the facility failed to follow their policy and procedure to ensure a resident who was admitted with multiple wounds were obtained initial wound treatment orders for one (R3) out of three residents reviewed for wound care.Findings Include:R3's clinical record shows an initial admission on [DATE], with discharge to the hospital on 5/27/26. R3 was readmitted on [DATE] and again discharged to the hospital on 6/6/26. A review of R3's physician order sheets, Treatment Administration Records (TARs), and Medication Administration Records (MARs) from May through June 2026 revealed no wound treatment orders during either admission period.Review of R3's admission and readmission progress notes dated 5/26/26 and 6/2/26, documented by V11 (Registered Nurse/RN), reads in part: Full body assessment performed. Resident noted with multiple pressure wounds observed at lower back, sacrum, coccyx, split penis, and right hip.R3's clinical progress notes from May through June 2026 document repeated instances of R3 refusing wound care assessments or wound evaluation from the wound care team.On 7/7/26 at 10:49 AM, V6 (Wound Care Director/RN) stated that upon admission, the floor nurse performs an initial skin check and obtains interim treatment orders from the admitting physician as needed. The wound care team conducts a full assessment the following day, documents findings and obtain treatment orders. V6 confirmed that R3 consistently refused wound care every day, refused to be touched, and simultaneously refused to be seen by the wound care NP (Nurse Practitioner). V6 added that nurses assigned to R3 could have attempted wound visualization during hygiene care performed by CNAs (Certified Nursing Assistant/CNA), noting that CNAs were sometimes able to complete ADL (Activities of Daily Living) care despite R3's care refusals. V6 stated that any nurse could have looked at R3's wounds and obtained treatment orders.On 7/7/26 at 12:33 PM, a phone interview was conducted with V11 (Registered Nurse). V11 stated that he completed R3's admission assessments in both May and June and was able to perform full body assessments. V11 stated R3 was assessed with multiple wounds. V11 stated that he reviewed admission orders with V29 (R3's Physician) but did not recall whether the physician ordered any wound treatments. V11 was unsure whether R3 had existing hospital wound orders. V11 stated that he notified the wound care team about R3's wounds.On 7/7/26 at 12:12 PM, a phone interview was conducted with V13 (Registered Nurse). V13 reported caring for R3 twice in June. He stated that R3 did not refuse care during those encounters and took medications without difficulty. V13 said he did not assess R3's wounds because night shift nurses typically do not examine wounds, as wound care is handled by the wound care team. V13 stated night shift nurses only address wound dressings when CNAs report a soiled dressing. V13 did not know whether R3 had any active treatment orders.On 7/7/26 at 12:23 PM, a phone interview V10 (Wound Nurse Practitioner). V10 stated that R3 refused to be seen, and when a resident refuses, she is unable to assess the wounds. As a result, V10 was not able to complete a wound assessment on R3. V10 stated that in such situations, the expectation is for the primary nurse caring for the resident to continue any existing wound care orders or to contact the provider. V10 added that residents typically arrive from the hospital with treatment orders already in place if they were hospitalized for wounds.On 7/8/26 at 12:08 PM, V2 (Director of Nursing) stated that upon a resident's admission, the nursing staff conducts a full assessment. If any skin alterations are identified, the admitting physician is notified, and treatment orders are obtained. The wound care team is also notified. V2 stated the wound care team will follow through and perform their own reassessment and updates or modifies the treatment plan as needed. V2 stated that all wound or skin treatments will be entered into the physician order sheet and will generate in the Treatment Administration Record (TAR) for the nurses to document when treatment is provided. V2 emphasized that it is important to get wound treatment orders upon admission or re-admission. V2 stated that, from what he was told, R3 would not allow nursing staff to provide care. V2 described that R3 was able to form words with his lips and could communicate to staff in that manner. In general, when a resident repeatedly refuses care, the provider is notified. V2 stated that at times R3 would allow some CNAs to clean him, but R3 consistently refused wound care at all times.The facility's Skin Care Regimen and Treatment Formulary dated 7/8/26 reads in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician.

Based on observations, interviews and record reviews, the facility failed to provide effective and consistent mice control for residents in the facility. This applies to 5 residents (R14, R15, R16, R17 and R18) in the sample of 9 receiving pest control treatment. Findings include:On 5/27/2026 at 9:31 AM, V23 (Housekeeper) stated that a resident (R15) reported a mouse sighting to V23 and V23 reported it to V23's supervisor. The sighting was listed in the facility's Pest Control Sighting Log. On 5/27/2026 at 9:45 AM, R15 stated R15 saw mice everyday of all colors in R15's room: white, brown, and gray. R15 said they come out and play in the daytime, and the mice run from R16's trash can near the window to R14's laundry bin and nightstand area by the door. R15 stated that the mice were under their beds at night. R14, R15 and R16 were roommates. On 5/27/2026 at 11:25 AM, V22 (Maintenance Director) stated that they place flat glue board under the vents and behind the doors in rooms where residents or staff reported mice. And when a mouse is caught, they throw the trap away and replace it with a new one. V22 said they may sometimes put RDUs (diamond shaped black box to trap mice) in residents' rooms. After the interview with V22 on 5/27/2026, V22 accompanied the surveyors to a sample of rooms listed on the facility's Pest Control Sighting Log including R15's room. In R15's room, there were no RDUs, flat glue boards or any other pest control treatment done to R14, R15 and R16's room. V22 looked throughout every corner, under the vents and did not have an explanation. Although their room was reported on the log on 4/25/2026 and listed in the facility's Pest Control Sighting Log as treated for mice on 4/30/2026. According to their pest control Service Inspection Report, they visited on 4/30/2026 but did not service R15's room. Other rooms and locations were noted as visited in the inspection report. On different floors, R17 said they have mice in their room and R17 reported it. R17 and R18's room had just one RDU and no glue traps. And their room was reported in the log on 4/14/2026 and listed the on facility's Pest Control Sighting Log as treated for mice on 4/15/2026. According to their pest control Service Inspection Report, they visited on 4/15/2026 but they did not do what they indicated Today I set up 3 glue boards under radiator. V22 did not know why there were no glue boards in R17's room.(Face Sheets and MDS-Section C were received and reviewed for R14, R15, R16, R17 and R18.)The facility failed to follow their Pest Control policy dated 7/3/2025 which documents It is the facility's policy to ensure that there is an effective pest control process in the building.

Based on observation, interview and record review the facility failed to ensure the Daily Nurse Staffing was visible to the public and updated daily. This failure has the potential to affect all 169 residents residing in the facility. Findings include:On 3/23/2026 at 8:55am surveyor did not observe Daily Nurse Staffing posted at the front desk.On 3/23/2026 at 9:15am surveyor did not observe the Daily Nurse Staffing posted at the front desk.On 3/23/2026 at 9:16am V3 (Receptionist) stated I don't know where that (Daily Nurse Staffing) is posted.On 3/23/2026 at 9:16am V4(HR) stated it's posted on the bulletin board in the hallway.On 3/23/2026 at 9:17am surveyor observed the daily nursing staffing dated 3/19/2026 posted on a bulletin board. V4 stated she is having them (Scheduler) update it now. On 3/24/2026 at 8:36am surveyor observed the daily nursing staffing dated 3/23/2026 on the bulletin board in the hallway.On 3/25/2026 at 9:58am V36 (Scheduler) said, Yes, I am responsible for posting the daily nursing post every day on Monday through Friday and in my absence the nursing supervisor posts the nurse daily staffing on the weekends.On 3/25/2026 at 2:38pm V1 (Administrator) stated the Posted Nurse Staffing information is not visible to all persons entering the building where its currently posted now. V1 stated she will put the posting form in a stand-up holder at the reception desk.Policy titled Staffing with a revised date of 7/03/2025 documents, in part, it is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirement under the federal regulations.

Based on observations, interviews and record review the facility failed to monitor the temperature in the walk-in refrigerator, failed to ensure male staff were covering facial hair, failed to discard expired food, failed to ensure the dish washer machine sanitized the dishes at the proper temperature. These failures have the potential to cause foodborne illnesses to all 172 residents receiving oral nourishment in the facility. Findings include: On 3/23/26 V27 (Food Service Director) presented a list of 154 residents who were receiving an oral diet in the facility. On 3/23/26 at 9:16 am, a tour was conducted with V27 and observed the following findings:At 9:18 am, two male dietary employees (V29 Cook/Aide and V32 Cook) in the kitchen with facial hair not covered. Both had a covering for the hair on their chin, but their mustaches were not covered. At 9:20 am, walk in refrigerator had no inside thermometer in the refrigerator. V27 stated that a thermometer should be in the refrigerator to make sure the food is at a safe temperature. Thawed chicken was noted on the bottom shelf. At 9:25 am, Tour of the dry storage room with V27, chocolate cake mix with a use by date of 11/30/25 was observed. V27 stated, This should have been tossed out. If there is a question about expiration than I would rather throw it out.At 9:30 am, requested V27 to test the dish machine sanitation level, A wash cycle (wash, rinse, and final rinse) was observed and the three gauges during each cycle did not move. Surveyor asked V27 if the gauges should change during each cycle. V27 stated that she would call Maintenance to look at the machine. At 9:45 am, V27 and V28 (Cook) went to the refrigerator to check the temperature of the thawed chicken. V28 stuck a thermometer into the chicken, and the thermometer read 42.9 degrees. V28 stated that the chicken temperature should be 41 degrees or below to prevent bacteria and residents getting sick.On 3/24/26 at 9:40 am, V29 (Cook) in kitchen with facial hair not covered. On 3/24/26 at 10:37 am, V27 food Service Director stated, The company came out to fix the dishwasher yesterday. There was something wrong with the machine. The dishwasher temp is not normal if the test strip doesn't turn orange which means the dishwasher temperature is not right for sanitizing the dishes. A normal sanitation strip is orange. Surveyor and V27 looked at the dishwasher temperature log and V27 stated, I was not aware of the dishwasher strip being black yesterday. We should have used paper products yesterday because dishes that are not sanitized could cause bacteria, and the residents can get sick. The staff should have notified me of this.On 3/24/26 at 11:30 am, V34 (Dietary Aide) observed in kitchen with mustache not covered. On 3/25/26 at 2:10 pm, V40 Maintenance Director stated, During the wash cycle the gauge should change during the final rinse. The dishwasher company came out and changed the final rinse jet and adjusted the temperatures. If you (surveyor) hadn't said anything we would not have known. The staff should have said something. The test strip should be completely orange for sanitizing and if it did not turn orange we should have been notified. Facility policy titled Staff Attire and dated 10/2019, documents, in part, Action steps: 1. The dining services director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Facility policy titled Food Storage: Cold and dated 10/2019, documents, in part, Policy Statement: It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Action Steps: 2. The Dining Service Director/ [NAME] (s) ensures that all perishable foods will be maintained at temperature of 41degrees Fahrenheit o below except during necessary periods of preparation and service. 4. The Dining Services Director/ [NAME] (s) ensures that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures is recorded. Facility policy titled Kitchen and dated 6/30/25, documents, in part, Dishwasher: a. Hot temperature dishwasher should turn the strip black or orange depending on the type of strips when the hot water temperature sanitizes the dishes, utensil, and blenders. 7. Staff: a. Hair restraint is required except for those who are bald. [NAME] restraint for those whose facial hair might fall on food during food preparation. Facility job description, titled Dietary Aide and dated 12/1/2019, documents, in part, Essential Functions: 8. Assist in the operation of the dishwashing machine. 15. Report all equipment malfunctions and breakdowns to the supervisor and keep the supervisor informed of supply needs. 16. Report on all hazardous conditions and equipment alone with any accidents/ incidents to the dietary supervisor. Facility job description, titled Cook and dated 12/1/2019, documents, in part, Essential Functions: 4. Make changes to meal plan, when necessary, with approval from the Director of Dietary Services. 8. Assure that established sanitation policies and procedures are followed at all times in accordance with federal, state, and local regulations.Facility job description, titled Director of Dietary Services and dated 12/1/2019, documents, in part, Essential Functions: 1. Plans, directs, and supervises the activities of the dietary staff. 2. Operates the dietary department in a safe and sanitary manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures.

Based on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs; and failed to ensure that a resident's personal refrigerator had a thermometer. These failures affected four residents (R22, R110, R135, and R146), out of 67 residents in the total sample. Findings include: R22's diagnoses include but are not limited to unspecified multiple sclerosis, vitamin D deficiency, chronic respiratory failure, cerebral infarction, hypertension, chronic embolism, and hemiplegia affecting left nondominant side. On 3/23/26 at 12:10 pm, R22's refrigerator log was noted hanging on the wall near R22's personal refrigerator. R22's refrigerator temperature log was last checked on 3/12/26. R146's diagnoses include but are not limited to seizures, hypokalemia, diabetes, myocardial infarction, heart failure, hypertension, and acute kidney failure. On 3/23/26 at 12:15 pm, R146's personal refrigerator thermometer reads 50 degrees. There was no refrigerator temperature log for R146's refrigerator. On 3/25/26 at 10:24 am, V41 housekeeper stated that the resident's personal refrigerators are checked by the housekeeping supervisor. On 3/25/26 at 11:00 am, V43 Housekeeping Supervisor stated, The housekeeping department is responsible for checking the resident's personal refrigerator. Once they are completed for the month, I go around and collect them. The housekeepers know they are supposed to check the resident's personal refrigerators. Every refrigerator should have a temperature gauge in them. Temperatures are checked every day and should be documented on the log. If not checked it could cause spoiled food, bacteria, mold and the residents can get sick. The refrigerator temperature should be 40 degrees. Staff should let me know if the temperature is not at the right temperature, so we can notify maintenance. On 3/25/26 at 11:20 am V43 and surveyor checked R146's refrigerator. R164's refrigerator thermometer read 50 degrees. V43 stated that the staff should have reported the thermometer is reading 50 degrees. It is not at a safe temperature. Facility job description, titled Housekeeper and dated 12/1/2019, documents, in part, Essential Functions: 6. Follow established safety precautions when performing tasks and using equipment and supplies. 7. Report all hazardous conditions, damaged equipment.to the supervisor. Facility job description, titled Director of Housekeeping and dated 12/1/2019, documents, in part, Essential Functions:6. Provides guidance and education to staff regarding their performance. 8. Responsible for training and educating staff members. 10. Follow established safety precautions when performing tasks and using equipment and supplies. On 3/23/2026 at 10:52am surveyor observed R110's personal refrigerator with no temperature log. On 3/23/2026 at 10:52am R110 stated no one comes to check the temperature of the refrigerator. On 3/23/2026 at 11:24am surveyor observed R135's personal refrigerator with no temperature log. On 3/23/2026 at 11:24am R135 stated no one comes to check the temperature or defrost her personal refrigerator. Policy titled Refrigerator and Resident Appliance Maintenance Service with a revised date of 7/03/2025 documents, in part, it is the policy of this facility to provide maintenance services for refrigerator units in residents room, the maintenance department or facility designee is responsible for maintaining that resident appliance e.g. refrigerators are safe, clean, and operable at all times and temperature is maintained below 41 degrees and above 32 degrees.

Based on observation, interview and record review the facility failed to ensure that consent was provided for psychotropic medications prior to administration. This failure affected one resident R42 in a sample size of 67 reviewed for psychotropic medications.On 03/23/2026 at 10:40 AM, R42 was observed sitting on bed in his room, he is alert and responsive and has capped trach, states that he is not aware of the reason why when he readmitted to facility after a hospital stay, he was placed on Quetiapine, and he never consented to these medications. R42 stated he never consented for any psychotropic medication, R42 stated he is his own responsible party and that his father is only listed in case of an emergency. R42's face sheet dated March 25, 2026, documents in part that R42 was admitted to the facility on [DATE], with diagnosis of Malignant neoplasm of glottis, tracheostomy, adrenal gland, protein calorie malnutrition, psychoactive substance abuse, dysphagia, squamous cell carcinoma of skin. No supporting diagnosis for use of Quetiapine list on diagnosis sheet. R42 is listed as his own responsible party on his face sheet. R42's minimum data sheet for cognitive patterns dated February 9, 2026, documents in part that R42 has a score of 9 which means that R42 has moderate cognitive impairment. R42's care plan with no date documents in part that R42 uses anti psychotropic medications Quetiapine related to Psychosis, [Interventions: staff to educate resident about risk and benefits and the side effects and or toxic symptoms of Quetiapine. R42's medication administration record dated February 2026 documents in part that R42 received Quetiapine Fumarate 150mg oral tablet from February 16, 2026, to February 28, 2026. R42's medication administration record dated March 2026 documents in part that R42 received Quetiapine Fumarate 150mg oral tablet from March 1, 2026, to March 10, 2026. R42's consent for psychotropic medication uses dated February 16, 2026, documents in part that Quetiapine Fumarate 100mg oral tablet at bedtime listed on the form, form has a signature of R42's fathers name and R42's name. On 03/25/2026 at 10:25 AM, V37 (Registered nurse/Psychotropic nurse) stated that she normally calls the power of attorney (POA) on file for psychotropic consents even though the resident may be alert and responsive. V37 stated when patient is displaying behaviors she doesn't like to come near the resident. V37 stated she could not remember if R42 was displaying any behavior on the date that she called the POA and or R42's sister because she failed to document anything in the medical record of R42.V37 stated moving forward she will begin to document. V37 stated that psychotropic medications are not supposed to be administered to residents without a consent. V37 stated that R42 was administered psychotropic medications in the month of February and March 2026.V37 presented a psychotropic consent form that was signed with the POA's name on the form, and also has R42's name on the form which stated that R42 did not consent for the medication.V37 stated that R42 is alert and able to sign for himself and does not remember why she called the POA to sign.V37 stated when she makes telephone calls for consent she normally has a nurse present with her to sign, there is no name on consent form that displays a nurse signed and witnessed this conversation and form displays that consent was not given. On 02/25/2026 at 1:15 PM V37 returned for further interview and stated she was unable to clarify why she phoned the POA of R42 but stated R42 can sign his own consent forms and then V37 stated yikes I made a mistake. On 03/25/2026 at 1:31 PM, V2 ( Director of Nursing) stated no resident should be given any psychotropic medications without a consent and that the responsible party can sign for the psychotropic medication if the resident is unable to sign.V2 stated it is his expectation that V37 obtains consent for psychotropic medication from resident's and or family if it applies prior to administration of medication. Facility policy titled Psychotropic medications with a revised date of July 3,2025 documents in part; procedure: 2). obtain consent for each psychotropic medication from the resident or person responsible for resident, additionally there should be documentation that the resident or representative was informed of the benefits and risk.Facility job description dated January 20,2023 titled Psychotropic medication and fall prevention and management nurse(RN) documents in part that: essential functions: 5).ensure that informed consents both telephone and written are obtained for all residents,24) provide quality nursing care to residents in an environment that promotes their rights, dignity and freedom of choice.

Based on observation, interview and record review the facility failed to ensure ADL's (Activities of Daily Living) was completed for 4 dependent residents (R8, R51, R95, R110) to maintain dignity and good oral and personal hygiene. This failure affected 4 residents out of a sample size of 67.Findings include: R51 has a diagnosis of but not limited to Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Left Foot, Bilateral Primary Osteoarthritis of Knee, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene and Chronic Kidney Disease, Stage 3a. R51 has a Brief Interview of Mental Status score of 15 that indicates cognition intact. R51's Minimum Data Set section GG (Self Care) dated 2/02/2026 documents, in part, for Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment and 02.: Substantial/maximal assistance-Helper does less than half the effort. R51's Care plan focus requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) dated 1/17/2026 documents, in part, R51 will be assisted with ADLs as needed. On 3/23/2026 at 12:13pm R51 stated she (R51) has not been changed all day (incontinence care), and it is 12:13pm. R51 stated no one has come in to bring her a basin of water and a face towel so that she can wash up. On 3/23/2026 at 12:19pm surveyor observed the inside of R51's incontinence brief and it was full of a yellow liquid substance. On 3/23/2026 at 12:20pm V6 (Restorative Aide) stated R51's incontinence brief is filled with urine, and it does not look like she has been changed at all this shift and that R51's incontinence brief should not look like that. V6 stated rounds are supposed to be done every 2 hours and as needed. On 3/25/2026 at 8:46am V2 (Director of Nursing) stated rounds are done every 2 hours and as needed and Incontinence care should be offered and provided at least once by 11:00am. R110 has a diagnosis of but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Encephalopathy, Acute Embolism and Thrombosis of Left Popliteal Vein, Gastrointestinal Hemorrhage, Mild Cognitive Impairment of Uncertain or Unknown Etiology, and Altered Mental Status. R110 has a Brief Interview of Mental Status score of 15 that indicates cognition intact. R110's section GG (Functional Limitation of Range of Motion) dated 1/09/2026 documents, in part, Upper extremity: Impairment on one side, Personal Hygiene (The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands): 03.: Partial/ Moderate Assistance-Helper does less than [NAME] the effort. R110 care plan focus for ADL Self Care Performance Deficit and Impaired Mobility r/t dated 3/27/2019 documents, in part, BATHING: I would like staff to check nail length and trim and clean on bath day and as necessary. On 3/23/2026 at 11:02am surveyor observed R110's fingernails to be long with a grayish black substance underneath the nail. On 3/23/2026 at 11:54am V6 (Restorative Certified Nursing Assistant) stated nail care is provided as needed and on bath days. On 3/23/2026 at 11:58am V5 (Licensed Practical Nurse-LPN) stated nail care is provided when ADLs are done and as needed. On 3/25/2026 at 8:46am V2 (Director of Nursing) stated nail care is done as needed and on shower days or when a bed bath is given. Policy titled Incontinence and Perineal with a revised date of 6/30/2025 documents, in part, it is the policy of the facility to prevent infection and skin irritation and to observe the resident's skin condition and do rounds every two hours to check for incontinence during shift. Undated Job Description titled Certified Nursing Assistant documents, in part, J. wash, clean and dry all incontinent residents. Nail Care policy the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections, nursing staff shall check the residents for nail care which includes cleaning and regular trimming and trimmed, and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. On 03/23/2026 at 11:01 AM, R8 was observed in bed awake with the television on, R8 did not respond to any questions on interview. R8 is observed with facial hair that is full under beard and face, and fingernails long and curved over towards his skin. R8 is observed with right hand mitten in place and left-hand assistive hand device in palm, R8's mouth displayed old food particles on teeth and lips presented dry. R8 presents clean without odors or debris in room walkway. On 03/23/2026 at 11:03 AM, V30 (Restorative aide) and V22 (Certified nursing assistant, CNA) came into the room of R8 to reposition him and provide range of motion exercises to extremities. On 03/23/2026 at 11:06 AM, V22 stated he performed Activity of daily living ( ADL) care to R8 at around 09:00AM and normally does rounds every two hours to check on R8 and reposition him, bed change and incontinence care, check R8's motor skills, and skin alteration checks and to also make sure side cushions are in place.V22 stated he did not have time to provide any grooming to R8's facial hairs or nail care because he did not have time this morning. V22 stated that nail care should be done when assessed to be long to decrease the risk of skin tears occurring, teeth should be brushed or wiped off, to decrease plaque buildup and tartar on teeth and possible tooth lost, V22 stated he did not have time to perform oral care this morning. V22 stated the nurses normally check nails themselves so that is why he did not inform the nurse that R8's nails were long. On 03/23/2026 at 11:23 AM, V20 (Registered nurse) stated R8 requires total care assistance for ADL care, brief changes, medication administration and grooming. V20 stated he did administer medication and feeding to R8 on this morning but did not pay attention to his facial hairs or fingernails. V20 stated it is the responsibility of the aides to clip the fingernails unless the resident is a diabetic then the physician is called. V20 stated the length of R8's nails are long and could place him at risk for injuring himself or staff by scratching staff during care or the nails in growing into the skin of R8. V20 stated that V22 never informed him of any concerns with R8's grooming and that he will have R8 shaved, and fingernails cut today. R8's face sheet dated March 25,2026 documents in part that R8 was admitted to the facility on [DATE] with diagnosis of Atherosclerosis of native arteries of left leg, non-pressure chronic ulcer of left heel, contractures, seizures, dysphagia, schizophrenia, anxiety, essential hypertension, pulmonary embolism, aphasia, tracheostomy, gastrostomy. R8's Minimum data sheet for cognitive patterns dated January 23,2026 documents in part; that R8 has a score of 3 which means R8 is severely cognitively impaired. R8's Minimum data sheet for functional abilities dated January 23,2026 documents in part; that R8 has a score of 1 for personal hygiene which indicates that R8 is dependent on staff to provide all effort for hygiene and grooming and R8 does none of the effort to complete the activity. R8's Care plan dated February 2, 2026, documents in part; that R8 requires assistance with ADL care for personal hygiene; [Intervention: staff to assist R8 with ADL as needed]. On 03/23/2026 at 12:17 PM, R95 was observed in bed watching television, she stated she would like her nails clipped because they are too long for her and would like her hair combed. R95 was able to answer all interview questions and make needs known to staff, she was able to push call light for staff assistance, and she displayed by pushing call light. R95's nails are long and curving inward towards palm on both hands and her hair appeared tangled up into a rubber band. On 03/23/2026 at 12:28 PM, V26 (CNA) stated that she performed ADL care on R95 this morning around 09:00 AM which consisted of washing face and washing her body. V26 stated that R95 will not allow staff to brush her hair or cut her nails. V26 stated that she normally informs the nurses of refusal for care by R95 but states that the nurses and the agency nurses do not do anything to assist in the care of combing hair or cutting nails. Long nails can lead to scratch and break her skin. R95's face sheet dated March 26,2026 documents in part that R95 was admitted to the facility on [DATE] with diagnosis of Major depression disorder, adult failure to thrive, diabetes mellitus, depression, osteoarthritis of knees, anxiety, essential hypertension. R95's Minimum data sheet for cognitive patterns dated March 20,2026 documents in part; that R95 has a score of 12 which means R95 is cognitively intact. R95's Minimum data sheet for functional abilities dated March 20,2026 documents in part; that R95 has a score of 3 for personal hygiene which indicates that R95 receives partial/moderate assistance from staff and staff provides less than half of the effort for task. R95's Care plan dated January 5,2026 documents in part; that R95 requires assistance with ADL care for personal hygiene; [Intervention: staff to assist R95 with ADL care]. On 03/25/2026 at 1:28 PM V2( Director of Nursing) stated that his expectations of the staff is to ensure that grooming is provided to all residents to ensure that the residents needs are met and that the residents present clean and well groomed.V2 expects that if staff is receiving any resistance from residents that the CNA would communicate with the nurse and the nurse that can inform the nursing managers and the physicians can be informed.V2 stated there is no reason why a reason should not be groomed including nails cut or facial hairs shaved.

Based on observation, interview and record review, the facility failed to label and date oxygen tubing and nebulizer equipment for three residents (R17, R48, and R167) per the facility policy. The facility also failed to ensure the nebulizer mouthpiece was contained for two residents (R167 and R48) when not in use by the residents. These failures affected three residents (R17, R48, and R167) reviewed for respiratory equipment, in a total sample of 67 residents. Findings include: R48's diagnoses include but are not limited to Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypercapnia, plural effusions, and Atherosclerotic heart disease. R48's Brief Interview of Mental Status (BIMS) score is 15. R48 is cognitively intact. On 3/23/26 at 11:48 am, R48 was observed in bed with a nebulizer mouthpiece not dated and not contained, lying on R48's nightstand. R48 stated she gets nebulizer treatments every day. R48's Physician Order Sheet (POS) shows active order dated 3/25/26 documents, in part: Ipratropium-Albuterol inhalation Solution 0.5-2.5 (3) MG (Milligram)/3ML (Milliliter) 3 ml orally every 6 hours as needed for Shortness of Breath/Wheezing via nebulizer. Facility job description titled Respiratory Therapist and dated 12/1/19, documents, in part, Specific Responsibilities: 16. Provides medication nebulizers via inhalation. 25. Follow departmental policy and procedure manual. On 03/23/2026 at 11:30am, observed R17 lying in bed awake and alert. R17 was observed with 3 liters oxygen via nasal cannula with tubing in place not dated. When R17 was asked regarding R17's nasal cannula oxygen tubing, R17 stated, The nurse came in last night to change the tubing. On 03/25/2026 at 3:00pm V2(DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing weekly. V2 stated the nurses should label oxygen tubing with a date indicating when the oxygen tubing was changed. This is done to prevent infections. R17's Physician Order Summary Report dated 03/25/2026, documents that R17 has the following diagnosis that include, but are not limited to, Chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, and chronic respiratory failure with hypoxia. R17's Brief Interview for Mental Status (BIMS) dated 03/03/2026 documents that R17 has a BIMS score of 15, which indicates that R17's cognition is intact. R17's Physician Order Summary Report dated 03/25/2026 documents, in part, 3L(liters) supplementary oxygen via nasal cannula continuously every shift. The facility's policy with a revision date of 07/03/2025 titled Respiratory Therapy Equipment Use documents, in part, underneath Procedure: All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. Once opened, the equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. R167 has a diagnosis of but not limited to Palmar Fascial Fibromatosis, Inflammatory Disorders of Scrotum, Chronic Diastolic (Congestive) Heart Failure, Chronic Pulmonary Edema, Occlusion and Stenosis of Left Carotid Artery, and Solitary Pulmonary Nodule. R167 has a Brief Interview of Mental Status score of 13 that indicates cognition intact. R167's Order Summary with active orders as of 3/25/2026 documents, in part, Change Oxygen Tubing every night shift every Sun and as needed. R167's care plan focus for oxygen therapy dated 12/10/2024 documents, in part, give oxygen as ordered by the physician. On 3/23/2026 at 11:48am surveyor observed R167's oxygen tubing with no date on it and R167's nebulizer mouthpiece was uncovered and not contained and the tubing had a date of 7/28 on it. On 3/23/2026 at 11:50am R167 stated staff are not changing his oxygen tubing on a weekly basis. On 3/23/2026 at 11:58pm V4 (License Practical Nurse) stated oxygen tubing is changed weekly and as need and should include a date of when it was changed. V4 also stated that nebulizer mouthpiece should be contained in a bag to prevent contamination. On 3/25/2026 at 8:54am V2 (Director of Nursing) stated oxygen tubing is changed weekly on Sunday, and it should include date of when it was changed and if equipment is not being used it should be contained in a plastic bag and nebulizer tubing and mouthpiece should be changed weekly on Sunday. Oxygen Therapy and Administration policy with a revised date of 7/02/2025 documents, in part, date your equipment and oxygen setups should be changed every seven days and as needed if heavy soiling is present.

Based on observation, interview and record review, the facility failed to ensure that the medication carts were kept clean with no loose medication pills, failed to store medication as recommended by dispensing pharmacy and manufacturer's guidelines, failed to discard expired medication. This failure has the potential to affect all 21 residents assigned to the medication carts for 3rd floor and all 60 residents assigned to the medication carts for 5th floor. Findings include: On 03/23/26 at 11:46am V47 (Licensed Practical Nurse/LPN) unlocked the 5th floor medication cart 1 and was present with this surveyor during the inspection of the medication cart. V47 removed loose pills from the medication cart drawers. R146's Lispro Insulin pen with open date of 02/01/26. R157's Novolog insulin with open date of 02/28/26. Observed R122's, R157's and R70's unopened insulin pens in medication top drawer with pharmacy label that documents in part to refrigerate unit opened. On 03/23/26 at 11:46am V47 (LPN) stated that R146's and R157's insulins were expired and that insulin is only good for 30 days after opening and should be discarded by use by date. V47 stated that none of the unopened insulin pens are refrigerated, and she does not know why the insulin should be refrigerated. V47 stated that loose pills should not be in the medication cart. V47 stated that loose pills are dirty and cannot be identified. On 03/24/26 at 1:15pm V49 (LPN) unlocked the 5th floor medication cart 2 and was present with this surveyor during the inspection of the medication cart. V49 removed 10 loose pills from the medication cart drawers. On 03/24/26 at 1:15pm V49 (LPN) stated that he does not know the name or dosage of the loose pills. V49 stated that it is not safe to administer medication that is not located in its original packaging. R70's physician order dated 02/08/26 documents in part, Insulin Glargine Solostar 300 unit/ml (milliliter) solution pen-injector. R122's physician order dated 07/27/25 documents in part, Insulin Glargine Solostar Subcutaneous Solution Pen Injector 300 unit/ml (milliliter). R146's physician order dated 01/25/23 documents in part, Humalog injection solution 100 unit/ml (insulin lispro). R157's physician order dated 02/08/26 documents in part, Novolog solution 100 unit/ml (insulin Aspart). Facility's policy titled Medication Storage, Labeling and Disposal revised 07/02/25 documents in part, Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedures: 1. Medications from pharmacy will be labelled by the pharmacy to include the name of the resident, route of administration, instruction, medication name (generic/brand), strength, and expiration when applicable. 3. Medications will be stored safely under appropriate environmental controls. Facility's policy titled Medication Pass revised 07/02/25 documents in part, Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded 6 weeks after opening. 2. Follow pharmacy recommendation as to when the medication should be discarded after opening. 3. Insulin vials are to be discarded withing 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening. On 03/24/206 at 11:00 AM, V17 (registered nurse) opened the medication room on the 3rd floor for medication storage observation. On 03/24/2026 11:03 AM, Medication room cabinet observed with 1. Prostat grape, 15g of protein expiration date 1/7/2026, 2. Prostate wild cherry punch, 15g of protein expiration date 7/10/2025, 3. Vitamin d 10 mcg dietary supplement expiration date 5/2025,4. One daily multivitamin with minerals- 11/2025. On 03/24/2026 the medication observed expired on medication cart of 3rd floor team two cart were as follows: Vitamin B12 one bottle expired 01/2026, (2) bottles opened of Liquid acetaminophen 500 milligrams , Expiration date: 01/2026, (1) bottle unopened of liquid acetaminophen Expiration date: 01/2026, Prostat liquid: 11/18/2025,Reguloid natural psyllium husk: 02/2026, Bisacodyl 5 mg Expiration date: 02/2026. On 03/24/2026 11:20AM V21 (Assistant nursing director) stated the purpose of labeling medications with open date is to ensure that staff follows pharmacy guidelines, if medication is given after expiration date it can decrease the potency of the medication and the medication would no longer be effective. V21 verified the medications had expired dates that were in medication room.V21 stated that medication supplies are stocked in medication room daily. On 03/24/2026 11:15 AM V18 (Central supply coordinator) stated he supplies the medication rooms by request from the nurses, and that he just brings the medications to the unit because it's hard to keep track of expiration dates. V18 verified the medications had expired dates that were in medication room. V18 stated he does not know what could happen if the nurses administer expired medications. On 03/24/2026 at 11;28 AM, V16 (Assistant administrator) stated all medications placed in the medication room should be accounted for by the nurses for residents. Once V18 receives the medication supply that is when he checks the expiration dates, then V18 gives the nurse the supplies to stock the medication room. V16 stated that the nurse should check the expiration dates. On 03/25/2026 at 1:31 PM,V2 ( Director of Nursing) stated that his expectations for the nurse is to check the medication room and the medication carts for expired medications prior to administration to ensure residents do not receive any expired medication because the expired medication decreases the risk of residents receiving the full benefits of the medication and the therapeutic effects may be low from the expired dosages. On 03/25/2026 at 1:43 PM, V1 (Administrator) stated that her expectation is for V18 to order all house stocks supplies including medications and keep the items in a secured locked area, V18 should check the dates of all supplies before placing on the units. V1 stated V18 should not be placing expired items on the units and if he notices an item is expired the expectation is to remove from the unit and inform V1. V1 stated she was not made aware of any expired medications in medication rooms or on medication carts.

Based on observation, interview and record review the facility failed to ensure that infection control practices were performed for two residents. This failure affected two residents R33 and R147 out of a sample size of 67.R33's face sheet dated March 25, 2026 documents in part that R33 admitted to the facility on [DATE] with diagnosis of: Hemiplegia, essential hypertension, atrial fibrillation, chronic systolic congestive heart failure, dysphagia, gastro esophageal reflux disease, constipation, tracheostomy, gastrostomy, acute respiratory failure. R33's Minimum data sheet dated February 6, 2026 documents in part that; R33 has a score of 2 which means that R33 is severely cognitively impaired; Functional abilities section dated February 6, 2026 documents in part; that R33 has a score of 1 which means that R33 is dependent on staff for all effort to complete task for bath/showers and activities of daily living. R33's care plan dated 02/18/2026 documents in part that R33 is on Enhanced Barrier precautions for: Candida auris, carbapenem-resistant Enterobacterales, klebsiella pneumoniae carbapenemase of the rectum, tracheostomy/ventilator, feeding tube and wound;[Interventions: staff to wear gown and gloves during high contact resident care activities like bathing and showering and providing hygiene, changing linens for R33]. On 03/23/2026 at 11:40 AM, at the outside door of R33's room a sign titled Enhanced barrier precautions (EBP) was taped to the door with personnel protective equipment that is required to be worn prior to performing care to R33. R33 was observed laying in her bed receiving a bath from V22 (certified nursing assistant). R33 was unable to answer any interview questions. Feeding tube in place and running, urine catheter in place draining yellow color urine in drainage bag, wound care dressing observed on R33's feet. V22 was observed providing bath with no gown on at time of observation. V22's uniform was observed touching the bed and linens of R33 during the bath. On 03/23/2026 at 11:42 AM, V22 stated I forgot to put my gown on and I believe R33 is on contact isolation but I'm not sure.V22 stated he understands that he was supposed to put on a gown to decrease risk of infection from R33 but that he was rushing and forgot. On 03/23/2026 at 11:48 AM, V19 (Registered nurse) came to the room of R33, and stated gloves and gown should be worn prior to providing baths/care to R33 because this protects the resident and staff from bodily fluids, R33 has EBP because she has a feeding tube, wounds and a urine catheter. V19 observed V22 providing care to R33 with a gown on and stated V22 should have had on a gown and V19 educated V22 at that time on the importance of wearing a gown prior to any care being provided to R33. On 03/25/2026 at 09:45 AM, V35 (Licensed practical nurse/Infection preventionist) presented the facility's document which is undated and titled Steps to implementation of enhanced barrier precautions; which documents in part;1). contact resident care activities that require use of gowns and gloves,8). provide education to staff. On 03/25/2026 at 09;47 AM, V35 presented EBP resident listed with date of March 24,2026 which displays R33 listed as having: Candida auris, carbapenem-resistant Enterobacterales, klebsiella pneumoniae carbapenemase of the rectum, tracheostomy/ventilator, feeding tube and wound. Facility in-service dated October 17, 2025, with Topic: respiratory virus and appropriate personal protective equipment (PPE) to wear when entering isolation rooms documents in part that: V22 attended the in-serviced and was educated on the appropriate PPE to wear when entering isolation rooms and providing care to residents. Facility policy with revised date of 06/30/2025 titled: Infection Prevention and Control documents in part: Procedures: 5). Enhanced Barrier Precaution (EBP)-an infection control intervention designed to reduce transmission of major multidrug-resistant organisms (MDROs) which includes Methicillin-resistant Staphylococcus aureus (MRSA), (Extended-spectrum beta-lactamases (ESBL), (Vancomycin-resistant Enterococcus (VRE) and Carbapenem-resistant Acinetobacter Baumani. a.) involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDROs as well as residents with wounds, and/ or indwelling medical devices. Facility policy dated 06/30/2025 titled Incontinence and perineal care documents in part; procedures: 4).perform hand hygiene before the procedure, put on gloves and appropriate personal protective equipment if indicated. Facility job description titled Certified nursing assistant with no date documents in part that; main duties: C). carry out assignments for resident's care including bathing, grooming, R). assure that established infection control and standard precaution practices are maintained when performing nursing procedures. R33's medical diagnoses include but are not limited to essential hypertension, tracheostomy status, atrial fibrillation, respiratory failure. R147's medical diagnoses include but are not limited to acute and chronic respiratory failure, cutaneous abscess, essential hypertension, tachycardia. On 03/24/26 at 8:30am V19 (Registered Nurse/RN) observed administering medication through R33's gastrostomy tube (GT). V19 then observed administration of a subcutaneous injection into R33's left upper arm without performing hand hygiene or changing gloves. On 03/24/26 at 11:09am V19 RN observed administering medication through R147's gastrostomy tube (GT). V19 then observed administering a subcutaneous injection into R33's left upper arm without performing hand hygiene or changing gloves. On 03/24/26 at 11:31am V19 (Registered Nurse/RN) stated that she didn't think about changing gloves because she did not leave the room. V19 stated that she should have performed hand hygiene and changed gloves after administering medication into the resident's gastrostomy tube and before administering the residents subcutaneous injections. On 03/25/26 at 1:32pm V35 (Infection Preventionist/IP) stated that hand hygiene should be performed, and gloves should be changed between different routes of medication administration. V35 stated that a nurse should not go from administering medication through a gastrostomy tube to administering an injectable medication without performing hand hygiene. V35 stated that she is not sure if not changing gloves and performing hand hygiene before administering an injectable medication could cause an infection. Facility's policy titled Medication Pass revised 07/02/25 documents in part, Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Procedures: 1. G-tube Medications: a. Perform hand hygiene before and after administration of meds. 5. Injectables: a. Follow hand hygiene procedure. Facility's policy titled Hand Hygiene revised 06/30/5 documents in part, Policy Statement: Hand hygiene is important in controlling infections. Hand Hygiene consist of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Centers for Disease Control) Guidelines in regards to hand hygiene. Procedures: 1. Hand Hygiene using alcohol-based rub is recommended during the following situations:. b. Before and after performing aseptic task such as insertion of indwelling catheter or before handling invasive medical devices such as during insertion of peripheral IV (intravenous) catheter, fingerstick blood sampling, etc. (etcetera). g. Before moving from work on soiled body site to a clean body site on the same resident.

Based on observation, interview, and record review, the facility failed to administer residents' prescribed medications in a timely manner according to the physician orders. These failures have the potential to affect 145 residents residing in the facility. Findings include: On 02/28/2026 at 10:11AM, surveyor located on the fifth floor of the facility with V7 (Registered Nurse/RN). V7 observed at the medication cart preparing medications for residents. V7 states to surveyor that she started her shift at the facility at 7:00AM and began administering medications to residents at approximately 7:30AM. V7 states she has not completed her medication administration pass yet. V7 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple residents' eMARs were red in color. V7 states the red color on the resident's eMAR indicates that the medication to be administered is considered late. On 02/28/2026 at 10:26AM, surveyor located on the fifth floor of the facility with V8 (Licensed Practical Nurse/LPN). V8 states to surveyor that he started his shift at the facility at 7:00AM and began administering medications to residents at approximately 7:30AM. V8 states he has not completed his medication administration pass yet. V8 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple residents' eMARs were red in color. V8 states the red color on the resident's eMAR indicates that the medication to be administered is considered late. On 02/28/2026 at 10:30AM, V9 (Assistant Director of Nursing/ADON/RN) states she is assigned to care for residents on the third floor of the facility today. V9 states she has completed her medication administration pass. V9 states if medications are not given on time, then this is considered a medication error. V9 states all medications should be given on time according to the physician orders. V9 states depending on the type of medication, residents can experience adverse effects if their medications are administered late. V9 states examples of these medications include heart medications, blood pressure medications, and insulin. On 02/28/2026 at 10:32AM, surveyor located on the second floor of the facility with V10 (Registered Nurse/RN). V10 observed at the medication cart preparing medications for residents. V10 states to surveyor that she started her shift at the facility at 7:00AM and began administering medications to residents at approximately 8:00AM. V10 states she has not completed her medication administration pass yet. V10 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple residents' eMARs were red in color. V10 states the red color on the resident's eMAR indicates that the medication to be administered is considered late. V10 states she has administered some of the late medications already but has not documented them yet. On 02/28/2026 at 10:39AM, surveyor located on the second floor of the facility with V11 (Licensed Practical Nurse/LPN). V11 states to surveyor that she started her shift at the facility at 7:30AM and began administering medications to residents at approximately 8:00AM. V11 states she has completed her medication administration pass. V11 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple residents' eMARs were red in color. V11 states the red color on the resident's eMAR indicates that the medication to be administered is considered late. V11 states there are some mediations that she still has to administer to residents which is why their eMARs are red in color. V11 states she has administered some of the late medications already but has not documented them yet. On 02/28/2026 at 2:59PM, V5 (Director of Nursing/DON) states the time frame to administer resident's medication is one hour before the scheduled time and one hour after the scheduled time. Facility census dated 02/28/2026 documents that 34 residents reside on the second floor, 57 residents reside on the fourth floor, and 54 residents reside on the fifth floor of the facility. Facility Medication administration audit reports dated 02/28/26 documents that multiple residents residing on the second, third, fourth, and fifth floors of the facility were administered their medications late. Facility policy dated 07/02/2025 titled Medication Pass documents in part, After medication s administered to each resident, sign MAR that it was given.

Based on observation, interviews and records review, the facility failed to follow its call light policy for one (R1) of four residents reviewed in a sample of seven.R1's medical diagnosis in current face sheet includes but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, recurrent, moderate, dysphagia following cerebral infarction.MDS (Minimum Data Set) section C-Cognitive patterns dated February 16, 2026, documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive abilities. Section GG- Functional Abilities document R1 requires set up and cleaning assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, and shower/bathe self, partial/moderate assistance with upper body dressing.02/28/2026 at 12:26PM R1 was observed to be clean sitting on mechanical chair placed on the right side of his bed. R1's call light was observed placed on R1's bed far from R1's reach. R1 stated I cannot reach the call light because I have weakness on my left side. I had a stroke. R1 tried to reach the call light with his left hand and was unable to. R1 stated if I need something, I would have to shout and hope staff will hear me. I would like to be able to use the call light when I need help. R1 said he keeps his cell phone near him because sometimes the call light is placed far from him, and he cannot reach it to call staff.On 02/28/2026 at 12:49PM V14 (Certified Nursing Assistant -CNA) and surveyor observed R1's call light placed on R1's bed far from R1's reach. V14 stated R1 has left side weakness and cannot stretch his hand far enough to reach the call light where it is placed on his bed. Call light needs to be closer to R1 so he can reach it to call staff if he needs help. If R1 cannot reach the call light when he needs help, he can fall, or choke and his need will not be met.On 02/28/2026 1:00PM V15(Registered Nurse-RN) stated call light should be within resident reach for the resident to access and call staff for help. If it is not accessible, the resident can fall out of bed trying to get help. R1 can be in an emergency and not be able to reach staff for help if he cannot access his call light.On 02/28/2026 at 3:4PM, V5(Director of Nursing-DON) stated call light should be placed close to residents where they can reach it to call for assistance. If the call light is far from a resident, the resident will not be able to call for assistance. I don't want to speculate specifically what can happen to the resident if call light is not within reach.Call light policy dated 6/30/2025 documents:-Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observations, interviews and record reviews, the facility failed to provide clean and odor-free shower rooms. This applies to 1 resident (R1) in the sample of 3 reviewed for clean shower rooms.Findings include:R1's Face Sheet documents R1's diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, weakness, dysphagia, severe protein-calorie malnutrition, and hypertension. R1's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. On 3/4/2026 at 1:55 PM, R1 stated the showers in the facility are dirty and contained soiled incontinence briefs especially on the 5th floor where R1 used to live. On 3/4/2026 at 2:07 PM, the 4th floor two shower rooms had strong feces and urine odors permeating throughout the air. The foul odors were neck jerking, and surveyor could not enter shower room located in the East wing. The second-floor shower rooms had similar strong permeating odors of feces and urine as the 4th floor shower rooms. On 3/4/2026 at 2:23 PM, the 5th floor shower rooms had strong feces and urine odors permeating throughout the air. The foul odors were neck jerking and there was a yellowish-brown substance smeared on the entry wall of the shower about 7 x 10 in diameter. The substance looked like feces and urine mixed and then smeared on the wall.V35 (Environmental Services Director) said that the yellowish-brown substance was new because V35 did not see it earlier. V35 agreed the odors in the shower rooms were unpleasantly strong and not acceptable. On 3/4/2026 at 2:43 PM, V2 (Assistant Administrator) of two years stated that it is expected that the showers look and smell clean without debris. Review of the facility's Public Areas Daily Cleaning Workflow undated policy documents Public areas, equipment, and high touch areas are regularly cleaned, disinfected and well-maintained to promote a healthy hygienic environment in the nursing home.

Based on interviews and records review, the facility failed to follow their policy on following physician orders related to diabetes blood sugars and lab monitoring for one (R5) of three residents reviewed in a sample of seven.R5's current face sheet documents R5 medical diagnosis to include but not limited to metabolic encephalopathy, bipolar disorder, current episode manic without psychotic features, unspecified, difficulty in walking, not elsewhere classified, chronic embolism and thrombosis of femoral vein, bilateral, schizoaffective disorder, bipolar type, type 2 diabetes mellitus with hyperglycemia.MDS (Minimum Data Set) section C dated 01/29/2026 documents R5's Brief Interview for Mental Status (BIMS) as 3/15 indicating R5 has severe cognitive impairment.On 02/28/2026 at 1:25PM, R5 was observed lying in bed, R5 stated she had a blood draw recently and finger blood tests. R5 showed her right-hand front elbow side and was observed with a bruise. R5 stated she drinks a lot of water, sugar free drinks therefore she does not have diabetes.On 02/28/2026 at 4:07PM, V5(Director of Nursing) stated the doctor gives orders for blood glucose monitoring parameters and when to notify the provider if the blood glucose levels go below or above a certain number. Blood glucose levels are done to monitor residents' blood sugars. If physician orders are not followed and the residents' blood sugars are high, it can lead to hyperglycemia (high blood sugars) which can lead to diabetes [NAME] Acidosis. Nurses should carry out physician orders as given. V5 said R5 was ordered blood work for A1c to be done on 2/20/2026. R5 refused on 2/20/2026.On 02/28/20 2:21PM V7 (Registered Nurse-RN) said she was R5's nurse today. V7 works part time one day a week. R5 is diabetic. Blood sugar is taken two times a shift. I took her blood sugars this morning and at 11: AM. I cannot find the blood glucose levels I documented. Nurses let the doctor know when a resident has high blood sugars. I don't know the parameters of R5 blood sugars and when to notify the doctor.R5's Physician Order Sheet (POS) dated 2/19/2026 documents A1c to be completed on 2/20/2026. If R5 refuses, send different technician in the morning.R5's progress notes dated 2/20/2026 05:56 AM document R1's refusal of A1c blood draw one time at 1:02AM. Does not document A1c blood draw was offered to R5 again.On 02/28/2026 at 4:07PM, V5(Director of Nursing) stated V5 stated If it is not documented, it is not done.No blood glucose monitoring parameters to be reported to physicians are documented. R5's blood glucose levels from 02/20/2026 to 02/27/2026 document blood glucose levels between122mg/dL to 230mg/dL.R5's blood glucose levels for 02/28/2026 ordered for 8:00AM and 11:00AM are signed as taken at 2:03PM. Documented time does not align with physician orders. Policy titled Physician Orders dated 7/3/25 documents:-It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS.-Medication orders entered in the POS (Physician Order Sheet) shall be reflected accurately in the MAR (Medication Administration Record).

Based on interviews and record reviews, the facility failed to provide on a consistent basis the dietary needs and food preferences of a resident. This applies to 1 resident (R2) in the sample of 3 reviewed for dietary preferences.Findings include:R2's Face Sheet documents R2's diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle wasting and atrophy, dysphagia, oropharyngeal phase, benign prostatic hyperplasia without lower urinary tract symptoms, hypertension, and depression. R2's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment.On 3/2/2026 at 2:50 PM, R2 was sitting in a chair beside R2's bed. He was alert, oriented and talkative. R2 confirmed complaints of wrong food orders were still valid. On 3/4/2026 at 2:55 PM, V19 (Dietician) V19 described R2's prescribed diet as receiving double-portions with scrambled eggs at every meal. V19 stated R2 was upset because R2 did not receive scrambled eggs with R2's breakfast on 2/28/2026. V19 said on 2/27/2026, R2 requested to have scrambled eggs for every breakfast. V19 stated the kitchen did not add the scrambled eggs to R2's breakfast on 2/28/2026 because R2's meal ticket was not updated. V19 added that R2 received double portions for meals, and the scrambled eggs were just R2's preference. V25, V26 and V27 (Certified Nursing Assistants/CNAs) interviewed consecutively on 3/3/2026 from 11:14 AM to 12:45 PM stated that R2's food orders were always incorrect because R2 would not receive R2's scrambled eggs with breakfast or R2 would not receive R2's double portion with R2's meal. The CNAs stated they would have to call kitchen staff for corrections. V25 said this morning R2 complained about not getting double the portion of eggs. The CNAs stated R2 did not look like R2 lost weight and they were not aware of the nursing staff giving R2 a hard time. V28 and V29 (Licensed Practical Nurses) interviewed consecutively on 3/3/2026 from 1:14 PM to 2:15 PM stated that R2 was prescribed double portion meals and often complained about not receiving double portions. V29 stated that R2 always had complaints about the scrambled eggs and not receiving enough. V28 said most of the time R2's meals were wrong and V28 could not understand why. Review of R2's diet order dated 3/5/2026 document R2 to receive a regular diet; double portions were not specified. V19's dietary and progress notes both dated 2/27/2026 documents R2's dietary preference for breakfast and V19's dietary notes specify to include scrambled eggs. There was no documentation of R2's diet order for double portions or the facility's required Food Preference Interview found in the facility's electronic medical records.

Based on interviews and record reviews, the facility failed to follow their Abuse and Neglect policy by failing to verify background checks of contracted staff, failing to obtain a copy of their professional licenses, and failing to train contracted staff on issues related to abuse and neglect. These failures have the potential to affect all 174 residents residing in the facility. Findings include: On 11/14/2025 at approximately 10:16 AM, V2 (Assistant Administrator) stated contracted security staff started working at the facility a couple of weeks ago. On 11/14/2025 at approximately 11:10 AM, V9 (Contracted Security) stated started work for facility on Wednesday (11/12/2025). V9 stated received training through contracted employer. Did not receive facility specific training on abuse and neglect. On 11/14/2025 at approximately 2:30 PM, requested contracted security staff's background checks, copies of the licenses or certificates, and training from V2, V3 (Director of Nursing), and V11 (Nurse Consultant).On 11/18/2025 at approximately 9:23 AM, V2 stated contracted security company did not provide background checks and copies of licenses or certificates yet. V2 stated [V2] was having a difficult time getting the information from the contracted security company. V2 stated they should be in the IDFPR (Illinois Department of Financial and Professional Regulation) portal. On 11/18/2025 at approximately 9:47 AM, V12 (Human Resources Director) stated did not run the background checks on V9 or V13 (evening Contracted Security) because they are from a third-party vendor (contracted). V12 stated did not verify the contracted security staff's background checks or licenses. V12 stated will verify and pull their licenses through IDFPR now. At approximately 10:08 AM, V12 returned with copies of V9 and V13's IDFPR 'Lookup Detail View.' Time stamps were 11/18/2025 10:00 AM on V9's sheet and 11/18/2025 10:06 AM on V13's sheet. Facility's contract with the security company documents in part that it started on 11/03/2025. It also documents in part that the facility can request background checks from the contracted company at any time.Facility did not provide copy of V9 and V13's Permanent Employee Registration Cards until 11/19/2025 at 1:54 PM. Facility provided a copy of V9's 'Security Orientation Checklist' on 11/19/2025 at 5:02 PM. V9 signed it on 11/17/2025 (after start of survey). Facility did not provide a 'Security Orientation Checklist' for V13. Facility's Abuse and Neglect policy (last revised 6/26/2025) documents in part: The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working in behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions, including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency, or academic institution. For licensed staff, obtain a copy of professional licenses. Train employees, through orientation and on-going sessions on issues related to abuse prohibition, neglect, exploitation, misappropriation of property such as: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Abuse identification and recognizing signs of abuse. How staff should report their knowledge related to allegation without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Understanding of behavior that increase risk of abuse.

Based on interviews and record reviews, the facility failed to follow their 'Abuse and Neglect' policy and report an allegation of abuse to the Illinois Department of Public Health (IDPH) for one (R1) out of three residents reviewed for abuse. Findings include: R1's admission Record documents in part diagnosis of anxiety disorder.During interviews with R1 on 11/14/2025 at approximately 9:39 AM and 11:00 AM, R1 stated facility hired security to antagonize and intimidate R1. R1 stated V9 (Security) curls [V9's] lips and mean mugs R1. R1 stated V9 puts hand on the gun in front of R1 to intimidate R1. R1 stated [R1] had to call police a few days ago (11/11/2025) because V9 threatened R1 and held gun. R1 stated a receptionist (later identified as V7) and V12 (Human Resources) were present for the incident. On 11/14/2025 at 10:16 AM, V2 (Assistant Administrator / Abuse Coordinator) stated being aware that R1 called police because R1 alleged that V9 was threatening R1. V2 stated did not report the incident to Illinois Department of Public Health and there is no open reportable related to it. On 11/14/2025 at 11:10 AM, V9 (Security) stated R1 was recording staff without consent. V9 stated when staff reminded R1 of facility policy, R1 got mad and called the police. V9 stated R1 told the 911 dispatchers that V9 pointed the gun to R1. V9 denied pointing a gun to R1 or intimidating R1. V9 stated reporting the incident to V2. On 11/14/2025 at 1:36 PM, V7 (Receptionist) stated R1 called the police and informed the 911 dispatcher that security was threatening R1 with a gun. On 11/18/2025 at 9:47 AM, V12 (Human Resources) stated R1 was recording staff without consent. Staff reminded R1 that R1 cannot record, but R1 got more upset. V12 stated R1 kept pointing to the no gun sign at the front desk and saying facility wasn't allowed to have security. V12 stated R1 then called police.Facility's Abuse and Neglect policy (last revised 6/26/2025) documents in part: All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on interviews and record reviews, the facility failed to follow their 'Abuse and Neglect' policy and report an allegation of abuse for one (R3) out of three residents reviewed for abuse. Findings include:R1's admission Record documents in part diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder.R1's Care Plan documents in part that R1 presents with a difficult or troubled past secondary to severe mental illness. R1 presents with abuse risk factors related to acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history, and present mental health symptoms. R1 presents with behavioral symptoms including verbal aggression, agitation, and manipulative behavior (focus initiated on 10/24/2025). R1 displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers (initiated 10/17/2025). R1 has the potential to demonstrate verbally aggressive behaviors related to ineffective coping skills, mental illness, and poor impulse control (initiated 10/17/2025).R3's admission Record documents in part diagnoses of schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder.On 11/05/2025 at 1:11 PM, R3 was alert and oriented to person, facility, and date. R3 stated that the former roommate (R1) was violent. R3 alleged that R1 wanted to hit R3 in the face because R1 accused R3 of turning off R1's television. R3 alleged that R1 has been threatening R3 for the past three days with R1 also requesting money from R3. R3 described a staff member that was currently working on another floor (V7 - Nurse) as a witness. During a follow-up interview with R3 on 11/06/2025 at 9:40 AM, R3 stated R1's threats started over the weekend. R3 also alleged that R1 took R3's debit card. R3 requested to get it back but R1 threatened to hit R3. R3 stated notifying staff but R1 continued to be R3's roommate until R1 was sent out to the hospital Tuesday evening.On 11/05/2025 at 1:40 PM, V7 (Nurse) stated on Monday evening (11/03/2025), a CNA (Certified Nurse Aide) notified V7 that R1 was threatening to hit R3. V7 denied witnessing or hearing the threats firsthand. V7 stated the CNA (who facility assumes is V16) mentioned R1 was upset that R3 was pressing the television volume down. V7 stated informing the social worker (V9) who then went to speak to R1 and R3. When asked if V7 reported the abuse allegation to the abuse coordinator (V1), V7 stated reporting it to V9.Attempted telephone interviews with V16 (CNA) on 11/06/2025 at 10:10 AM and 1:22 PM and again on 11/07/2025 at 9:03 AM; however, V16 did not answer or return the calls. V16 was scheduled to work 11/06/2025 afternoon/evening; but did not present to work during surveyor's allotted work time.During an interview with V9 (Social Service Director) on 11/05/2025 at 2:47 PM, V9 described R1 as attention-seeking, manipulative, and very behavioral. V9 stated on Monday evening, V9 received a text message from V10 (Restorative Nurse) that R1 was having behaviors but no mention of abuse. V9 stated [V9] was no longer in the facility at the time. V9 stated sharing an office with V10 and it was V10 who went to speak with the residents.During an interview with V10 (Restorative Nurse) on 11/05/2025 at 3:01 PM, V10 stated V7 called Monday evening to report that R1 was acting up. V7 did not mention any allegation of abuse between R1 and R3. When V10 arrived on the floor, R1 was in the hallway speaking loudly that R1 could not find the tv remote. V10 went to the room and R3 assisted V10 look for R1's remote. V10 stated R3 did not mention any allegation of abuse while they searched. V10 stated R1 and R3 remained roommates afterwards.On 11/06/2025 at 9:48 AM, V5 (Nurse) stated R3 reported an allegation of abuse around noon yesterday while surveyor was speaking with the roommate (11/05/2025 at approximately 12:30 PM). V5 stated R3 was very broad and stated that R3 got hit in the face. When asked if V5 reported the abuse allegation, V5 stated It was already reported.On 11/05/2025 at 2:05 PM, V2 (Assistant Administrator) and V3 (Director of Nursing) brought in the abuse and injury reportables. There was no reportable for R3. Both stated they did not receive any allegations of abuse from R3 or from staff regarding R3's allegation that R1 was threatening R3. During a follow-up interview on 11/06/2025 at 1:59 PM, V2 and V3 stated V5 did not report R3's allegation that R3 got hit in the face. V2 stated if the staff hears any potential abuse, they are to report it to V1 (Administrator/Abuse Coordinator) or V2 (Abuse Coordinator designee when V1 is not available). Both stated that even with any roommate disagreement such as the tv being too loud, the facility is to look into it and evaluate whether the residents are roommate compatible. Both stated they were not informed of the allegations until the surveyor notified them.Facility's Abuse and Neglect policy (last revised 6/26/2025) documents in part: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee.

Based on interview and record review, the facility failed to follow their abuse policy and procedure to ensure that abuse allegation was reported no later than two hours to the State Agency (SA) for one (R1) out of three residents reviewed for abuse. Findings Include:R1's clinical records revealed an admission date of [DATE] with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living.On [DATE] at 9:42 AM, interviewed R1 regarding his out on pass incident on [DATE]. R1 stated, I had a pass with an escort. That day somebody signed me out. It was my cousin [V3 (R1's Cousin)]. It was Friday he [V3] signed me out around 4:30 PM. We went out to dinner with family. We went down past Diversey. There were so many people outside. It was Labor Day weekend. After dinner we were separated. My phone kept dying. I ran out of battery. It was too crowded. My phone died. Eventually I got on the train to come back here. I ended up going South. I got surrounded by 4 colored men. I remembered 2 people raped me. I can't remember exact details. I was drugged. I got back in the facility Saturday night. What I remember is being under a Metra. Two people were doing it. I can't remember. I can't remember the full details. The next morning, I got on a bus. Still no power on my phone. I went to my old apartment complex. Charged my phone. Got back on the train. I got a hold of [V11 (Assistant Director of Nursing)] around 4:00 PM. Told her [V11] I'm on my way back to the facility. At 4:47 PM I texted [V11] I said I'm going to be back soon. Not thinking correctly, I took the wrong train. [V11] told me to get back to the facility. I told [V11] that I was sexually assaulted. I texted her [V11] at 6:02 PM that I was sexually assaulted. I think I got back here in the facility around 7:30 PM. I came back on my own. They allowed me upstairs and changed my clothes and washed my face. They let me eat. They gave me my medications which include Xanax, Briviat, and Olanzapine. The ambulance came within 45 minutes to an hour. No police came. I get to the hospital I don't remember anything that was said and done in the ER [Emergency Room]. I remember I had discharged in my pants. They did not report the sexual assault in the hospital. The rape kit was not done. Then the next morning [V16 (Registered Nurse Supervisor)] says okay we need to call the police. After the police report was done [V16] had to do a body assessment. I consented for the body check, but I felt humiliated. After that they told me to go back to the hospital. I said no. I told them that I want my outside social worker with me. Monday, I went back to [hospital]. They did the rape kit. The result of the rape kit is still pending. It will take a couple of months. Right now, I can't go out on pass anymore.On [DATE] at 11:38 AM, V11 (Assistant Director of Nursing) stated that on [DATE] at around 6:00 PM, R1 texted V11 informing her that R1 got sexually assaulted while out on pass. V11 stated R1 went out on pass with a family member. V11 stated that she informed V1 (Administrator) right after (no more than an hour) R1 told her about the sexual assault allegation. On [DATE] at 2:02 PM, V1 (Administrator) stated that she is the abuse coordinator and the facility's abuse policy is to report any abuse allegation to IDPH (Illinois Department of Public Health) no later than 2 hours. V1 stated that V11 reported to her that R1 had texted V11 that he was sexually assaulted in the community. V1 stated that V11 called her over the weekend on a Saturday ([DATE]), but V1 does not remember the exact time. V1 stated she did not do the initial reporting to IDPH within two hours and did it the next day because there were conflicting stories. V1 stated that R1 refused to tell V23 (Registered Nurse/Nursing Supervisor) anything when R1 came back in the facility. V1 stated R1 did not disclose the sexual assault to the hospital. V1 stated the next day ([DATE]), V16 questioned R1 specifically. R1 did tell V16 that he was sexually assaulted and that's when V1 did the initial report to IDPH. The facility's Abuse Report Initial Form for R1's sexual allegation shows date and time the report was sent to IDPH: [DATE] at 4:00 PM. Date and time the alleged incident occurred: [DATE] at 7:30 PM. Allegation details documents in part: [R1] stated that when he went out on independent pass yesterday with his cousin [V3] he was drugged and sexually assaulted in the community on the south side of Chicago on the street at a bus stop by 2 individuals unknown to him [R1]. A nursing assessment was done with no new injury noted, no swelling, bruising noted. [R1] complains of pain on bilateral upper extremities and dorsal aspect of the toes of both feet. The police were called, an officer came to interview [R1] and a police report was filed with report number JJ396568. [R1] is being sent to the ER [Emergency Room] for evaluation. A final report will be sent to the state within 5 working days.The facility's Abuse and Neglect policy dated [DATE] documents in part: All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on interviews and record reviews, the facility failed to follow their policies and procedures to ensure (a) the police were contacted to assist with finding a resident who was on supervised community pass and did not return as indicated on the sign out sheet, (b) a resident was reviewed for risk for elopement concerns upon admission, and (c) a person-centered care plan was initiated timely to address community pass privilege. These failures affected one (R1) out of three residents reviewed for community pass privileges.Findings Include:R1's clinical records revealed an admission date of 7/24/25 with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living. R1's electronic health records (EHR) revealed no risk for elopement was completed upon admission. R1's physician order shows R1 may go out on pass with his family ordered on 8/26/25. R1's outside pass privilege care plan was initiated on 9/3/25.R1's RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENSE (OUT ON PASS) signed by V3 (R1's Cousin) on 8/29/25 at 4:30 PM reads in part: I, [V3], here to accept complete responsibility for [R1] while away from [The facility], and absolve the management of said nursing home, its personnel and the attending physician of responsibility for deterioration in condition, or accident that may happen while the patient is away. I understand that a bed will be reserved for the above - named patient when he/she returns on or before 8:00 PM.R1's progress notes dated 8/30/25 at 7:40 PM revealed R1 came back in the facility on 8/30/25 at 7:35 PM.On 9/7/25 at 9:42 AM, R1 stated he went out on pass on 8/29/25 at around 4:30 PM with V3. R1 stated V3 signed him out. R1 stated they went out for a family dinner. R1 stated after dinner, he got separated from V3 and that his phone ran out of battery. R1 got back at the facility on his own on 8/30/25 at 7:30 PM.On 9/7/25 at 11:38 AM, V11 (Assistant Director of Nursing) stated that R1 can go out on pass with escort. Family member or facility staff. They just have to sign [R1] out. V11 stated residents can go out on pass from 10:00 AM to 8:00 PM. V11 stated that if a resident does not return the facility by 8:00 PM, the nursing supervisor on duty informs administration and they contact whoever was listed as emergency or whoever sign them out. V11 stated that administration will make determination when to call 911 if resident does not return in the facility by a certain period. V11 stated that on 8/30/25, around 4:00 PM, [R1] called [V11] that his phone was about to die and that [R1] was on his way back to the facility.On 9/7/25 at 11:58 AM, V18 (Social Service Designee) stated that the risk for elopement assessment was not completed for R1 on admission. It was completed on 9/1/25.On 9/7/25 at 12:48 PM, a phone interview was conducted with V19 (Registered Nurse). V19 stated that on 8/29/25, R1 went out on pass and did not return. V19 stated he contacted R1 but did not pick up. V19 stated he called V15 (R1's Brother) but does not know R1's whereabouts. V19 stated he did not call the police, but he informed V20 (Evening Registered Nurse Supervisor).On 9/7/25 at 12:54 PM, a phone interview was conducted with V20 and stated that on 8/29/25, V20 called R1 after 11:00 PM but was not picking up the phone. V20 stated he left around midnight and R1 was still not back in the facility. V20 stated he is not sure what is the facility's policy when to call the police if resident does not come back within the curfew. V20 stated that he posted to the facility's communication platform to notify management that R1 was out on pass with family and has not returned in the facility.On 9/7/25 at 1:38 PM, a phone interview was conducted with V23 (Registered Nurse/Nursing Supervisor) and stated that she was the nursing supervisor on 8/30/25 from 7:00 AM until 11:00 PM. V23 stated, I was notified that [R1] did not return the facility. At 8:00 AM, I started calling his [R1] cell phone multiple times. [R1] did not answer. I also tried calling [V3] he was the one signed him [R1] out but it was not connecting. I called [V3] multiple times. I informed [V2 (Director of Nursing)] and [V11] that [R1] has not returned. I also contacted his [R1] other responsible party they said that [R1] did not contact them. V23 stated that R1 returned in the facility on 8/30/25 at around 7:30 PM.On 9/7/25 at 3:04 PM, a phone interview was conducted with V25 (Receptionist) and stated that she worked on 8/29/25 PM shift. V25 stated, [R1] told me that he was going to head out. [R1] was waiting in the lobby area. [R1's] cousin [V3] came with another friend. They left the building around 4:30 PM. [V3] signed [R1] out. [V3] put his information on the sign out sheet. All three of them left the facility together at around 4:30 PM. When [R1] did not return at 8:00 PM, I called [R1] three times, and I called [V3] three times. [V3's] number went straight to voicemail. [R1] did not answer.On 9/7/25 at 2:45 PM, V1 (Administrator) stated that the facility calls the police if a resident does not return the facility from out on pass for more than 24 hours. V1 stated that R1 went out on pass with a family member on 8/29/25, did not return by 8:00 PM, but called at around 4:00 PM the next day informing the facility that he will be returning. V1 stated that all residents are allowed to go out on pass with escort or with family members. V1 stated that R1 is not allowed to go on independent pass because of R1's history of substance abuse and suicidal ideation.On 9/7/25 at 2:26 PM, V24 (Clinical Care Coordinator) stated that the out on pass privileges care plan is initiated after the order is obtained and the resident and the family have been informed that there's an order. V24 stated that the purpose of the comprehensive care plan is for the interdisciplinary team to be able to identify the active and potential problems and able to specify interventions to minimize or prevent or address the problems. V24 stated that if R1's out on pass privilege was ordered on 8/26/25 the comprehensive care plan should have been initiated between 8/26/25 to 8/29/25. V24 stated if it was initiated on 9/3/25, the care plan is late. The facility's Elopement policy dated 7/26/24 documents in part: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. If the case is that of a resident who went OOP [Out On Pass] and did not come back on the day and time indicated the resident is supposed to come back, the facility will wait for 2 more hours to allow time for resident to return (as in many situations, the delay in the resident's return is a result of traffic, [NAME] pick up, etc). One the 2 hour grace period has elapsed, the facility will contact the police to assist with finding the resident. The facility will also call possible places like hospital ERs, shelters, family and friend's houses, etc where the resident be at.The facility's Care Plan policy dated 6/30/25 documents in part: After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days.

Based on observation, record review, and interviews, the facility failed to ensure and include medical diagnosis and medication regimen in providing preventive interventions to prevent falls/accidents, failed to utilize fall assessment in providing effective fall interventions in the fall care plan, and failed to identify and address the resident's hypotensive state after the fall to prevent recurrence of similar accidents. These failures affected 1 resident (R2) out of 3 residents reviewed for the right of every resident to be free from injury resulted by accident. As a result, 1 resident (R2) sustained a forehead laceration due to fall that required suturing and a laceration to the left arm that required medical attention. Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's diagnosis includes hypotension (upon admitted d 08/29/2024), abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy. R2's cognition is intact with BIMS score of 15 dated 02/13/2025. R2's bed mobility and transfer is supervision and touch assist. R2 is ambulatory based on MDS assessment dated [DATE]. On 04/29/2025 at 01:30 PM, R2 was seen with female visitor. R2 was having hard time to communicate verbally. R2 uses cellphone to communicate by typing texts. R2 typed he slid and fell , did not elaborate what happened. R2's forehead shows skin scar. Facility Reported Incident related to R2's fall documents as follows: R2 fell on [DATE] around 08:00 AM, R2 was seen sitting on a chair in his room bleeding from a laceration to his forehead and left lower arm. R2 returned to facility on 03/12/2025 with sutures on his forehead. R2's vital signs taken after the fall are as follows: blood pressure 85/63, heart rate 103, oxygen 90%, temperature 97.3 Fahrenheit, blood sugar 245. Per final investigation, R2 stated that he was attempting to pick something up from the floor, he fell and scrapped his head in the process. Clinical notes of V12 (Licensed Practical Nurse) dated 03/09/2025 documents that when R2 fell R2 was noted to have a decreased level of consciousness, confused and disorientated. Review of R2's blood pressure records documents that R2 maintains systolic blood pressure of over 100 as his baseline. There are days that R2's systolic blood pressure drops below 90 mm/Hg. Normal blood pressure for systolic is 120 and diastolic is 80 or 120 over 80 (120/80 mm/Hg). Review of R2's Medication Administration Records (MAR) documents that R2 was prescribed medication Midodrine 10 MG (milligram) to be given when systolic blood pressure is below 95 mm/Hg. Midodrine is a medication that treats orthostatic hypotension or drop of blood pressure when a person changes position from lying to sitting to standing. Per R2's MAR and blood pressure log there are days when R2's systolic blood pressure drops less than 95 mm/Hg and Midodrine was not documented as administered per physician's order. Per blood pressure log, the day before R2 fell (03/08/2025), R2's blood pressure was recorded once with result of 124/70 mm/Hg. R2 has an order for vital signs check every eight (8) hours equivalent to three (3) checks a day. R2 fell on [DATE], when V12 took R2's vital signs, R2's systolic blood pressure result was 85/63 which is lower compared to R2's baseline. Fall happened around 08:00 AM when R2 got up went to the bathroom and attempted to pick up something on the floor that resulted to R2's injury. On 04/30/2025 at 12:12 PM, V9 (Restorative Nurse/Licensed Practical Nurse) and V10 (Restorative Nurse/Licensed Practical Nurse) stated that all fall care plans, fall assessments and prevention of fall is done by V11 (Fall Coordinator/Registered Nurse). On 04/30/2025 at 12:19 PM, V11 (Falls Coordinator/Registered Nurse) stated that R2 fell on [DATE] when he was trying to pick up something on the floor. V11 stated that R2 was independent in standing up and walking. V11 stated that prior to the fall, R2 has two (2) interventions in the care plan on position teaching and asking for assistance. After the fall, 1 intervention was added monitoring was done one and a half (1.5) hour intervals instead of two (2) hours. V11 stated that she does not do quarterly assessments for falls and only does assessments when a resident falls. V11 stated that restorative does fall assessment and cannot locate any fall assessment in R2's electronic health records. V11 stated that she does not remember if restorative coordinated to her their quarterly fall assessments. V11 stated that care plan is also done by restorative including interventions. And she (V11) only does fall interventions when a resident falls. V11 was asked if she based her plan of care interventions to prevent fall on any assessment. V11 answered that she based her fall plan of care interventions on the resident's mental status, mobility, diagnosis, what medication the resident is taking. V11 was asked if R2's care plan interventions were based on R2's medication and medical diagnosis? V11 said, I don't remember if I checked his (R2) current medication. V11 was made aware that during the fall R2's blood pressure was low with a result of 85/63 mm/Hg as shown in the incident report. V11 stated that was low, that R2 maintains systolic blood pressures over 100. V11 said, I never see it that low. It could be orthostatic hypotension that he fell . R2 likes to lie down much. When he gets up it can be a problem. V11 asked the writer if a resident has hypotension that led to a fall, should the hypotension be addressed in the falls care plan? On 04/30/2025 at 01:29 PM, V12 (Licensed Practical Nurse) stated that she found R2 on the floor. R2 stated he slipped when he was coming from the bathroom with his walker. R2 was found next to his bed on the floor. R2's forehead was gashing with blood to his face. V12 stated that she thought she needed to do code blue because R2 stopped breathing and looked discolored. V12 stated that she was not able to check R2's vital signs prior to the fall. V12 stated that R2's blood pressure result was hypotensive because R2 usually has a normal blood pressure and that R2 has medication for hypotension. V12 stated that hypotension causes confusion, lightheadedness that can contribute to fall. V12 stated that R2's vital signs needed to be taken twice on her shift and that she (V12) usually takes vital signs during medication pass or when she gives medication to residents around 08:00 AM. V12 stated that she was doing medication pass when R2 fell . V12 clinical notes dated 03/09/2025 at 08:09 AM when R2 fell , documents that R2 was noted to have decreased level of consciousness, confused and disoriented. On 05/01/2025 at 11:01 AM, V2 (Director of Nursing) stated that Restorative Nurse and Falls Nurse work overlaps but as to fall concerns it will be the Falls Coordinator that will do the assessment. Restorative Nurses focus on activities of daily living and range of motion. V2 stated that V11 (Fall Coordinator/Registered Nurse) is having a hard time with the computer. V2 stated that R2 went to the washroom bent down and fell . V2 stated that he does not know R2's blood pressure baseline he cannot say if blood pressure is a concern for R2. V2 stated that signs and symptoms of hypotension includes syncope (fainting or passing out), body shaking and disorientation. V2 stated that R2 has medication Midodrine that increases the blood pressure and it needs to be given when blood pressure is low as prescribed. V2 was asked if it would help to check R2's blood pressure prior to the fall? V2 replied, It does not matter what time to check. One nurse taking care of many residents. What if other residents have hypotension too? Then V2 stated that it would be a good intervention to monitor R2's vital signs. V2 was asked if hypotension or blood pressure record of R2 were reviewed to prevent recurrent falls? V2 said, I don't have to have hypotension to feel dizzy. I have to check if hypotension is one of R2's diagnosis. V2 stated that R2 went to the hospital for suture of laceration on the forehead and have left lower arm laceration due to the fall. Per hospital records R2's laceration needs repair via suture. R2's fall care plan interventions dated 09/09/2024 prior to fall are as follows: First, teaching how to position. And second, instruction for assistance. No revision was made until after R2's fall dated 03/09/2025. R2 fall care plan intervention after fall dated 03/10/2025 added one (1) intervention monitoring of R2 every one and a half (1.5) hours. All interventions do not identify that R2 has medical diagnosis of hypotension upon initial admitted d 08/29/2025 that R2 has medication for low systolic blood pressure/orthostatic hypotension. The blood pressure of R2 at the time of the fall was hypotensive 85/63 mm/Hg. R2's blood pressure record documents drop of systolic blood pressure lower than 95 mm/Hg on certain days which requires medication to increase systolic blood pressure as prescribed by physician. Fall Occurrence Policy dated 07/26/2026: It is policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. A fall risk assessment form will be completed by the nurse or the Falls Coordinator upon admission, readmission, quarterly, significant change, and annually. Ultimately, the Falls Coordinator may change the intervention provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. The Falls Coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary. Federal Drug Agency (FDA) information on Midodrine reads: INDICATIONS AND USAGE ProAmatine(R) (Midodrine) is indicated for the treatment of symptomatic orthostatic hypotension (OH). Centers for Disease Control and Prevention National Center for Injury Prevention and Control program STEADI (Stop Elderly Accidents, Death and Injuries) dated 2017 reads: Postural hypotension-or orthostatic hypotension- is when your blood pressure drops when you go from lying down to sitting up, or from sitting to standing. When your blood pressure drops, less blood can go to your organs and muscles. This can make you more likely to fall. These symptoms can differ from person to person and may include: dizziness or lightheadedness, feeling about to faint, passing out, or falling Headaches, blurry or tunnel vision Feeling vague or muddled Feeling pressure across the back of your shoulders or neck Feeling nauseous, or hot and clammy Weakness or fatigue.

Based on interviews and record reviews, the facility failed to a.) evaluate a high-risk resident's (R285) nutritional status within 14 days of admission; b.) implement a person-centered comprehensive care plan with nutritional interventions and goals addressing R285's nutritional risk factors; c.) follow their policy to obtain resident's weights monthly for 4 (R40, R49. R91, R106); d.) identify and address weight loss in a timely manner when significant changes occurred for 5 (R40, R49, R 91, R106, R285). These failures resulting in significant/severe weight loss for 4 (R40, R49, R106, R285) out of 4 residents reviewed for nutrition in a sample of 39. Findings include: 1. R40 was admitted to the facility on [DATE] and has diagnosis which includes but not limited Dysphagia, Dementia, Age-Related Osteoporosis, Respiratory Failure with Hypoxia, Unspecified Abdominal Pain, Fatigue, Major Depressive Disorder, Post-Traumatic Stress Disorder, Chronic Pain. R40's MDS (Minimum Data Set) from 02/01/24 BIMS (Brief Interview for Mental Status) was 08/15 indicating moderate cognitive impairment. R40's MDS dated [DATE] section K- Swallowing/Nutritional Status K0300 for Weight Loss 5% of more in the last month or low of 10% or more in the last 6 months yes, not on prescribed weight-loss regimen. R40's Weight Summary undated documents in part, R40's weights as follows: (02/20/2023) 205 pounds; (08/15/2023) 196.6 pounds; (09/20/2023) 186.2 pounds; (11/21/2023) 177.8 pounds; (01/25/2024) 167.6 pounds; (02/22/2024) 166.6 pounds. R40's Order Summary Report printed 03/13/24 documents in part, fortified pudding two times a day for supplement with order date of 05/16/23 and 03/13/24 and Glucerna after meals if not consuming >75% of meals ordered on 05/11/23, meal monitoring: record percentage eaten after meals ordered 05/02/2023, and Mirtazapine 7.5 mg by mouth at bedtime for depression ordered 05/01/2023. R40's Dietary Evaluation completed by V25 (Registered Dietitian) dated 11/09//23 documents in part R40's November 2023 weight pending, October 2023 weight not available, September 2023 weight 186.2 pounds, and August 2023 weight 196.6 pounds. with 5.3% weight loss times one month with recommendation to obtain current weight and continue with oral nutritional supplement. V25 Dietary Evaluation documents in part R40 receiving Glucerna after meals and fortified pudding twice a day. No changes to dietary interventions made. R40's Weight Warning progress note completed by V25 dated 12/21/23 documents in part R40's November weight 177.8 pounds and 9.6% weight loss in 3 months, 12.8% weight loss in 5 months, resident with decreased intake consuming approximately 50% of meals on average and varied acceptance of oral supplements, goal changed to no further weight loss. No changes to dietary interventions were made. R40's Dietary Evaluation completed by V25 dated 01/31/24 documents in part R40's January weight 167.6 pounds, 14.8% weight loss x5 months, weight loss related to varied intake per staff resident will skip some meals if she's sleeping or feeling depressed with recommendation to obtain current weight. No changes made to dietary interventions. R40's Weight Warning progress note completed by V40 (Registered Dietitian) dated 03/06/24 documents in part -10.5% weight change in six months, usual body weight 200-220 pounds, weight loss related to varied intake per staff resident will skip some meals if she's sleeping or feeling depressed, staff to provide oral supplements if resident is skipping meals. No changes made to dietary interventions. On 03/14/24 at 10:35 AM, V25 (Registered Dietitian) stated a significant weight loss trigger is defined as a weight loss trigger of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. V25 stated residents at high nutritional risk are residents who have had a weight loss, have wounds, change in appetite/intake, or are on tube feedings. V25 stated V25 documents on residents monthly if they trigger for weight loss and/or if they are on tube feedings. V25 stated V25 follows residents on tube feedings and those who trigger for a weight loss more often because they are at a higher nutritional risk and more susceptible to change in condition. V25 stated a resident receiving tube feedings who also has a wound(s) would place that resident at a higher nutritional risk so V25 sees them monthly rather than waiting to see them quarterly because V25 wants to do interventions more often on them and follow them more closely. V25 stated if a weight loss trigger occurs V25 would add or adjust nutrition interventions and notify the nurse practitioner and/or physician. V25 stated if a resident is receiving tube feedings as their only source of nutrition, then they should not be losing weight. V25 stated sometimes this may happen if they need more calories than accounted for and their nutritional needs would need to be re-adjusted. V25 stated if a resident receiving tube feedings has had a weight loss, then V25 would need to recalculate the resident's needs based on the current weight. V25 stated the goal for residents receiving tube feedings and/or with pressure wounds is not for them to lose weight. V25 stated V25 wants their weight to be stable, so they have proper nutrition for the wound(s) to heal. V25 stated if a resident is not receiving adequate nutrition there is a potential for malnutrition to occur and wounds to get worse, poor wound healing and furthering weight loss. 2. V25 stated in August 2023, R91 weighed 196.6 pounds and at that time V25 had a care plan for desired gradual weight loss. In September 2023 R91 weighed 186.2 pounds. V25 stated from August 2023 to September 2023 R91 lost 10.4 pounds (-5.3% weight change) and this triggered as a significant weight loss. V25 stated V25 spoke with staff who reported that R91 was eating the same, no change so V25 was not concerned and thought R91's September 2023 weight was an error and requested a reweight. V25 stated V25 did not document on R91's reported weight loss trigger in September 2023 or implement any interventions because V25 thought the weight loss reported was an error. V25 stated R91's reweight was not done in September 2023 and in October 2023 R91's weight was not done or available. V25 stated that in November 2023 R91's weight was 177.8 pounds and that R91 had lost an additional 8 pounds since September 2023. V25 stated from August 2023 to November 2023 R91 lost a total of 18.8 pounds (-9.6% change) in 3 months and this triggered as a significant weight loss. V25 stated in November 2023 is when V25 found out R91 was skipping meals related to feeling more depressed and sleeping more often. V25 stated because of the weight loss and change in eating habits V25 recommended for R91 to start on oral supplement after meals and fortified pudding twice per day with lunch and dinner. V25 stated this weight loss was preventable because R91 did not have any supplements ordered because V25 did not think R91 had any issues with calorie intake. V25 stated the goal at this time was to stabilize R91's weight, and for R91 not to have any further weight loss. V25 stated there was no weight done for R91 in December 2023. V25 stated V25 does not know why R91 was not weighed but should have been weighed because V25 uses weights to track to assess if the dietary interventions are working. V25 stated in January 2024 R91 weight was down to 167.6 pounds. V25 stated R91 lost an additional 10 pounds from November 2023 to January 2024 (two-month period) and from July 2023 to January 2024 R91 lost 35.4 pounds (-17.4% change) six months. V25 stated this weight loss over 6 months triggered as a significant weight loss and it was not a planned weight loss. V25 stated that this amount of weight loss puts a resident at higher risk for malnutrition, and wound development. V25 stated she assessed R91 on 01/31/24 and recommended to obtain another weight and continue with the same interventions. V25 stated in February 2024 R91's weight was 166.6 pounds and a significant weight change happened from August 2023 to February 2024 because R91 lost 30.3 pounds in six months which was a -15.4% change. V25 stated six months ago R91's care plan was for gradual weight loss based on obesity however since R91 started to lose weight because of skipping and sleeping through meals related to depression R91's weight loss was not planned and R91's nutrition care plan goal was updated. V25 stated there is no nutrition assessment addressing this weight loss in February 2024. V25 stated V25 cannot always get to all the assessments because there are so many to do that V25 cannot always address the weight issue in the month it occurs. V25 stated V25 does not have any of the monthly weights for March yet and that V25 is still waiting on reweights for February 2024. V25 stated all weights are entered into the resident's electronic health record and there are no separate weight binders. 44103 3. R285's clinical records show an initial admission of 1/10/24 with listed diagnoses not limited to Anoxic Brain Damage, Anemia, Type 2 Diabetes Mellitus with Unspecified Complications, Gastrostomy Status, and Dysphagia Oropharyngeal Phase. R285's Minimum Data Set (MDS) dated [DATE] shows R285 has severe cognitive skills. R285's physician order sheet (POS) with active orders as of 3/12/24 documents in part: Enteral feeding- Tube type: (gtube), Jevity 1.5, Rate: (65 ml/hr), start at (7am) and Turn off @ 5am during ADLs and PRN and NPO (Nothing by mouth) diet, NPO texture, NPO consistency. R285's electronic health record (EHR) documents the following weights: 2/21/2024 09:41 137.6 Lbs 1/11/2024 11:06 158.0 Lbs 1/10/2024 20:45 158.0 Lbs On 3/14/24 at 11:55 AM, observed V29 (Restorative Aide) and V28 (Restorative Licensed Practical Nurse) re-weighed R285 using a total body mechanical lift and R285's weight read 134.0 Lbs. R285's electronic health records (EHR) do not show any dietary notes or nutritional assessments were completed since admission of 1/10/24 to 2/13/24. R285's EHR shows R285 was not evaluated by V40 (Registered Dietitian/RD) until 2/14/24. V40's note dated 2/14/24 at 1:09 PM documents in part, Resident is at risk for malnutrition r/t NPO [Nothing by Mouth] status, dependence on TF [Tube Feeding]. R285's progress notes show that R285's severe weight loss on 2/21/24 was not addressed by V40 until 3/6/24. R285's progress notes from 2/21/24 to 3/8/24 show no documentation of R285's weight loss was communicated to V37 (R285's Physician), V38 (In-house Nurse Practitioner), or V39 (R285's Nurse Practitioner). R285's EHR does not show a person-centered comprehensive care plan with nutritional interventions addressing R285's medical nutrition therapy and risks for nutritional needs since admitted [DATE]. R285's EHR shows R285's weight loss was not addressed in the care plan until 3/14/24. On 3/14/24 at 10:24 AM, V25 (RD) was interviewed. V25 stated V25 is the full time RD in the facility and V40 is helping out. V25 stated that R285 was NPO which means nothing by mouth and all of R285's nutrition is coming from the tube feeding. V25 stated that R285 is at high nutritional risk based on tube feedings for nutrition and wounds. V25 stated that R285 was admitted in January and was not assessed by V40 (RD) until February. V25 stated that R285 was not triggered in the system as a new admission, and therefore was not seen by a Dietitian until after a month. V25 stated R285 was admitted on [DATE] and was seen by V40 on 2/14/24 and again on 3/6/24 for the weight loss. V25 stated R285 weighed 158 Lbs on 1/10/24 and 137.6 Lbs on 2/21/24. V25 stated that the admission weight could have been an inaccurate weight. V25 stated that R285 was not re-weighed. V25 stated that R285 has significant weight loss from January to February and that the weight loss could have been caused by R285 not getting enough calories from the tube feeding and/or increased nutritional needs due to wounds. V25 stated that the goal for R285's nutritional status would be for stable weight and not for R285 to lose weight. V25 stated that R285's weight loss was unplanned. V25 stated that there is no order for R285 to receive weekly weights. V25 stated that V25 uses weights as a tool to determine if residents are meeting their nutritional needs. V25 stated that if V25 had evaluated R285 on admission, V25 would have ordered weekly weights, supplements, and re-evaluate the tube feeding if R285 is getting enough calories. V25 stated that if residents are losing weight, then that would suggest they are not getting enough calories. V25 stated that R285's tube feedings were not held, and there is no report of R285 refusing or not tolerating the tube feedings. V25 stated that R285 was reassessed In March two weeks after the weight loss was identified. V25 stated that R285 was not seen earlier because it was a busy month, and V25 was getting a lot of weight triggers. V25 stated that R285's doctor was not notified but should have been notified about the weight loss. V25 stated that R285 does not have a nutrition care plan but there should be one and the weight loss should be care planned. V25 stated that it is important to have a nutritional care plan to track and make sure everyone taking care of the resident is aware of the weight loss and to implement nutritional interventions. On 3/15/24 at 10:31 AM, a phone interview conducted with V39 (R285's Nurse Practitioner). V39 stated, I don't think I have been notified of [R285's] weight loss. I would ask for a re-weigh because sometimes the scales are different, a Dietician eval and blood work to look for any causes of weight loss such as thyroid issues. If weight loss occurs, at least there should be an evaluation as soon as possible. 39779 4. R49 was initially admitted to the facility on [DATE], hospitalized four times with the most recent readmission on 09/18/23 with diagnosis not limited to Chronic Obstructive Pulmonary Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Anemia, Constipation, Severe Protein-Calorie Malnutrition, Retention of Urine, Contracture of Muscle, Unspecified Lower Leg Contracture of Muscle, Unspecified Upper Arm, Schizoaffective Disorder, Dysphagia, Vitamin D Deficiency, Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Hip, Stage 4, Pressure Ulcer of Left Hip, Stage 4, Abnormal Weight Loss, Hypo-Osmolality and Hyponatremia. Review of the Annual Minimum Data Set (MDS), an assessment tool, reflected R49 had a Brief Interview for Mental Status (BIMS) of 09 indicating moderate cognitive impairment. R49's Physician order document in part: Regular diet Puree texture, thin liquids consistency date 09/20/23. 1:1 feeding dated 09/18/23. On 03/12/24 at 12:17 PM, R49 was observed in bed being fed a pureed diet by staff. R49 consumed 100% of meal. Braden score 13 dated 05/17/23. Braden score 10 dated 03/08/24. R49 weights dated 02/21/24 89.6 Lbs., 01/15/24 89.0 Lbs., 09/22/23 113.0 Lbs., 09/19/23 114.0 Lbs., 08/15/23 115.0 Lbs. R49's weight summary did not reflect any weights noted after 09/22/23 until 01/15/24 which reflected a 21.24% weight loss in 4 months. R49's Physician order document in part: Mirtazapine Oral Tablet 7.5 MG (milligram) 1 tablet by mouth at bedtime for Antidepressants -Start Date- 09/18/23 2100. Multivitamin-Minerals Oral 1 tablet by mouth one time a day for Supplement -Start Date- 09/19/23 0900. Thiamine HCl Oral Tablet 100 MG 1 tablet by mouth one time a day for treatment -Start Date- 09/19/23 0800. Arginaid two times a day -Start Date- 09/18/2023 1700. Vitamin C Oral Tablet 500 MG (Ascorbic Acid) 1 tablet by mouth one time a day for Supplement -Start Date- 09/23/23 0900. House Supplement after meals 120 ml (milliliter) if Medpass -Start Date- 10/04/23 1800. Vitamin D3 50, Vitamin D3 Tablet 50000 UNIT 1 tablet by mouth one time a day every Monday, Friday for vitamin D def (Deficiency) -Start Date- 01/15/24 0800. Fortified Pudding with meals -Start Date- 01/17/24 1200. Dietary Evaluation dated 01/17/24 document in part: Weight/Medications: 1. Most Recent Weight: 89.0 (Lbs.). 5b. Weight loss during the last 3 month: Weight loss greater than 3 kg (6.6 lbs.). Significant Change Nutrition Note: Diet: Regular diet, puree texture, thin liquids 1:1 Feeding Assist Supplements: Arginaid BID (twice a day); House Supplement after meals. Labs: 1/9 hct (hematocrit) 26.8, hgb (hemoglobin) 8.6, alb (albumin) 2.5, vit. D 16.2. Skin: See wound rounds for full assessment - PU (pressure ulcer) x 8, Weight: 89.0# 1/15, 113.0# 9/22, 114.0# 9/19, 115.0# 8/15, 115.0# 6/15, 116.0# 5/28, 117.0# 5/16; BMI (body mass index): 14.4 (underweight) desirable BMI for age >65: 23-29.9 kg/m2 Per staff, resident's, appetite varies. R49 will sometime skip a meal if he doesn't like the taste and may request snacks instead. Continue house supplement after meals for weight management. Sometimes accepts ONS (oral nutritional supplements). Continue Arginaid BID to support wound healing. More wounds have opened since last assessment- resident likely not meeting needs orally to support wound healing. Weight loss noted, undesirable. Likely r/t (related/to) resident's varied intake of meals, but resident's weight is also taken with a wheelchair which may be inconsistent. RD (Registered Dietitian) added fortified pudding with meals to add a preferred food with extra calories. Continues to meet criteria for malnutrition r/t inadequate energy intake as evidenced by intake <75% of estimated needs, observed muscle wasting and fat loss, significant weight loss. Goals: no further weight loss, intake >/=50% of 3 meals daily, supplement acceptance, wound healing. Continue monitoring meal intake, weight monthly, and labs as available. Follow up PRN (as needed). 49's Dietary Evaluation dated 12/28/23 document in part: Weight/Medications: 1. Most Recent Weight: 113.0 (Lbs.) 9/22/23. Progress note dated 02/21/24 13:33 document in part: Weight Change Note Data: Weight Warning: Value: 89.6 Vital Date: 24-02-21 09:25:00.0 -10.0% change [ 21.4% , 24.4 ] Action: Resident triggered significant weight loss Weight: 89.6#, 2/21, (-21.4% x 6 mo (months)) 89.0#, 1/15, 113.0#, 9/22, 114.0#, 9/19, 115.0#, 8/15, 115.0#, 6/15, 116.0#, 5/28 117.0#, 5/16, Height: 66 BMI: 14.5 (underweight) desirable BMI for age >65: 23-29.9 kg/m2 Diet: Regular diet, puree texture, thin liquids 1:1 Feeding Assist Weight loss x 6 mo, stable x 1 month. Per staff, resident's appetite varies, but recently is good. He (R49) will sometime skip a meal if he doesn't like the taste and may request snacks instead. Appetite may also fluctuate with abdominal pain and sometimes feeling down. Continue house supplement after meals for weight management and fortified pudding. Sometimes accepts ONS. Continue Arginaid BID to support wound healing. Resident likely not meeting needs orally to support wound healing. Encourage oral intake to support wound healing and no further weight loss. Goals: no further weight loss, intake >/=50% of 3 meals daily, 50% supplement acceptance, wound healing. Continue monitoring meal intake, weight monthly, and labs as available. Follow up PRN. R49's Care Plan document in part: Focus: Actual Weight Loss: R49 has experienced weight loss and is at risk for continued weight loss. Date Initiated: 01/17/24. Interventions: Make a referral to the MD (Medical Doctor)/Registered Dietitian if there is a 5% weight loss over 30 days, or a 10% weight loss over 180 days. Date Initiated: 01/17/24. Provide one-to-one staff intervention and attention. Date Initiated: 01/17/24. Provide/serve the resident's nutritional diet as ordered. Prescribed diet is [Regular diet, puree texture, thin liquids]. Monitor/record intake with every meal. Date Initiated: 01/17/24. Weight will be obtained as ordered by MD Date Initiated: 01/17/24. Focus: R49 has an actual impairment to skin integrity related to Left ischial tuberosity - Stage 4 PI (pressure injury), Right ischial tuberosity -Stage 4 PI, Sacrum - Stage 4 PI, left lateral foot- Stage 3 PI, Right, Trochanter - Stage 4 PI, left trochanter/hip - UTS (unstageable) PI Date Initiated: 05/30/23. Interventions: Skin: Low air loss mattress for wound management and prevention of pressure injuries Date Initiated: 05/30/2023. Focus: R49 has the potential for further impairment of skin integrity. On 03/12/24 at 12:17 PM, R49 was observed in bed being fed a pureed diet by staff. R49 consumed 100% of meal. On 03/13/24 at 12:09 PM, surveyor observed R49 lying in bed on a low air loss mattress with the setting on 160 pounds. R49's food tray was observed on the overbed table. R49 was asked by the surveyor if he was trying to lose weight. R49 responded, I was not trying to lose weight, I don't know what happened. Surveyor asked if R49 has any wounds, R49 responded, yes, I have wounds and they changed my dressings today. On 03/13/24 at 09:37 AM, V25 (Registered Dietician) stated I have worked here for 2 years. Restorative takes the residents weights, gives them to me and I input them in the computer to see if there were any discrepancies and ask for reweights. The residents are supposed to be weighed once a month unless there are orders for weekly weights. The residents are weighed when we get the admission, and they should be reweighed when they are readmitted . There is no way for me to verify if the weights are done once a month. During Quarterlies or once a month usually I will catch missing weights when they give me the list and I don't see a weight. I see all the residents in the facility, do the MDS (Minimum Data Set) and care plans. I will talk to the NP (Nurse Practitioner) when I see a weight loss and get consult. I would want the resident weights to be stable and proper nutrition for their wounds to heal. For a resident with wounds, I would not want for them to have weight loss because of Malnutrition, worsening wounds and further weight loss. I was requesting R49 weights and was not receiving them. Surveyor asked V25 if the weights were requested and not received what is done, V25 responded I continue to ask for them. R49 had a weight loss of 21.2% over 4 months, which is a very significant weight loss. If the weights were being done monthly per policy the weight loss should have and could have been caught prior to the weight loss occurring. The weight loss could have caused R49 wounds to get worst or R49 developing new wounds. R49 is receiving House supplements 120 ml (milliliter) of med pass after meals, fortified pudding with meals and Arginaid twice a day. R49 is accepting some of the supplements. On 02/21/24 R49 weight was 89.6, that was his last weight and R49 was weighed with a mechanical lift. R49 initial weight was 117. The Nurse practitioner already knew about the weight loss because they consulted me. R49's oral intake was good. R49's weight loss has contributed to wounds, nutritional requirements are higher with wounds, and they need more calories. On 03/14/24 at 10:39 AM, surveyor observed V33 (Restorative Aide) weigh R49 with the total body mechanical lift weight scale with a weight of 92 pounds. V33 stated I do all the weights on the fourth floor. I take the weights to the restorative supervisor, and they put them in the computer. On 03/13/24 at 10:56 AM, V25 (Registered Dietician) stated there is no documentation for the requested reweights. On 03/13/24 at 11:20 AM, surveyor informed V25 (Registered Dietician) that R49's weight was observed with a reading of 92.0 pounds V25 stated R49's current weight of 92.0 pounds there is a 2.68% weight gain in one month. On 03/14/24 at 11:24 AM, V28 (Restorative/Licensed Practical Nurse) stated The restorative aides take the resident weights, fill out the weights on the census sheet, I give it to the dietitian and the dietician enters the weights in the computer. If there are any missing weights the registered dietitian will email me and ask for reweights. I make sure that the residents are reweighed. The weight policy is the weights are done the first week of the month. We weigh all the residents in the facility, and it takes about a week to a week and a half to complete all the weights. 5. R106 has diagnosis not limited to Sick-Euthyroid Syndrome, Abnormal Glucose, Dementia in other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance, Hypertensive Heart Disease without Heart Failure, Unspecified Protein-Calorie Malnutrition, Reduced Mobility, Long Term (Current) use of Aspirin, Skin Changes and Frequency of Micturition. Care plan document in part: Focus: Actual Weight Loss: R106 has experienced weight loss and is at risk for continued weight loss. Date Initiated: 12/22/23. Focus: Nutrition-Dementia Focused R106 is at risk for compromised nutritional status, related to dx (diagnosis) of dementia Date Initiated: 05/23/23. R106 weights 02/21/24 125.4 Lbs., 01/12/24 125.4 Lbs., 12/07/23 125.4 Lbs., 09/22/23 138.0 Lbs. R106 weight summary did not reflect any weights noted after 09/22/23 until 12/07/23 which reflected a 10.14% weight loss in 3 months. Dietary Evaluation dated 05/23/23 document in part: Weight/Medications 1. Most Recent Weight: 143.0 (Lbs.). Date: 5/18/23 22:35. Dietary Evaluation dated 08/16/23 document in part: Weight/Medications 1. Most Recent Weight: 140.0 (Lbs.). Date: 8/15/23 11:01. Dietary Evaluation dated 11/09/23 document in part: Weight/Medications 1. Most Recent Weight: 138.0 (Lbs.). Date: 9/22/23 11:56. Dietary Evaluation dated 01/03/24 document in part: Weight/Medications 1. Most Recent Weight: 125.4 (Lbs.). Date: 12/07/23 12:49. b. Weight loss during the last 3 month: Weight loss greater than 3 kg (6.6 lbs.). Re-admission Assessment Resident was sent to the hospital after a fall. Weight in Pounds: (01/24) pending, (12/23) 125.4, (10-11/2023) N/A (not applicable), (9/2023) 138, (8/2023) 140, (7/2023) 136, (6/2023) 134/135x2, (5/2023) 143, BMI: 26.2, within desired range for age. At risk for weight loss r/t (related/to) dementia. Actual weight loss occurred, see progress notes for details. Per staff, resident with good appetite and intake. Skin intact. At risk for malnutrition per MNA (mini nutritional assessment) score of 9/14. Goals: intake >/=75% of meals, intake >50% of oral supplements, no further weight loss. Monitor meal intake, labs, weight monthly. Follow up PRN. Dietary Evaluation dated 01/31/24 document in part: Weight/Medications 1. Most Recent Weight:125.4 (Lbs.). Date: 1/12/24 14:35. On 03/12/24 at 12:01 PM, was observed sitting on the bed eating lunch. Staff was observed at R106 bedside queuing and assisting with feeding R106 due to impaired vision. R106 consumed 100% of meal. On 03/13/24 at 09:37 AM V25 (Registered Dietician) stated R106 percentage of weight loss was 9.1% in three months and that is a significant weight change. I don't know why R106 was not weighed. I was requesting the weights from V28 (Restorative/Licensed Practical Nurse), and I started going to her (V28) for weights. The administrator and Director of Nursing are aware that there was a problem with getting monthly weights. R106 intervention are meal monitoring, fortified pudding with dinner dated 12/22/23 and R106 she already had house supplements. I requested reweights and the reweights were not in there. R106 intake was variable at times. On 03/14/24 at 10:25 AM, surveyor observed V33 (Restorative Aide) weighing R106 with a chair scale with a weight reading of 116.2 pounds. On 03/14/24 at 10:27 AM, V32 (Licensed Practical Nurse) stated R106 can be feisty, but I have never seen her refuse to be weighed. On 03/13/24 at 11:20 AM, surveyor informed V25 (Registered Dietician) that R106 weight was observed with a reading of 116.2 pounds. V25 stated R106 last weight on 02/21/24 was 125.4 pounds current weight of 116.2 pounds indicating a 7.3436% weight loss in one month which is another significant weight loss. Policy Titled Weights revised 07/28/23 document in part: It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. Procedures: 1. During the 1st week of the month, the restorative staff or designee will weigh each resident to fulfill the monthly weight requirement. 2. The monthly weights will be reflected on the resident's individual chart. 3. The significant weight changes (monthly (5%), quarterly (7.5%), and every 6 months (10%) will be assessed and addressed by the IDT (Interdisciplinary Team) which includes but not limited to the Dietician, Physician, Medical Specialist, Speech Therapist, Nutritionist, and Nurses. Titled Assessments undated document in part: Policy: Documentation of each individual's medical nutrition therapy (MNT) is the responsibility of the registered dietitian (RD) with assistance as assigned to the nutrition support staff. Recognize, evaluate, and address the needs of every individual, including but not limited to the individual at risk or already experiencing impaired nutrition. All documentation will be in accordance with state and federal regulations. Procedure: 1. Initial Assessment: The focus of the comprehensive medical nutrition therapy (MNT) assessment is to identify risk factors that may contribute to undernutrition, protein energy malnutrition, dehydration, unintended weight loss, pressure ulcers and other nutrition problems, as well as identifying other nutritional needs. For Subacute patients/residents, the initial MNT assessment for a new or readmitted individual is generally initiated and/or completed within 5 days of admission. Information for the MNT assessment will be gathered through interviews with individuals, family and staff, observations, and review of the medical record. The assessment form is filed in the medical record/electronic medical record. A new or re-assessment is completed each time an individual is readmitted , has a significant change in condition, and as deemed necessary by federal and state guidelines or the RD or designee. 2. Plan of Care: Each time an MNT assessment or re-assessment is completed, a care plan or care plan revision should be completed as appropriate. Care plans are to be completed within 7 days of completion of the assessment, and updated according to the facility's policy, state, and federal guidelines, and as needed due to any significant changes (i.e., weight status, food intake, diet order, etc.) Specific and measurable goals should be stated to maintain or achieve optimal nutritional status. Each time a care plan is updated, a re-assessment or progress note should be completed or revised as appropriate. Progress notes are completed according to facility policy and federal guidelines. When significant changes occur, notes should be updated. Significant changes can include but are not limited to changes in condition, diet order, food intake and weight. Generally, progress notes are written a minimum of every 90 days, and with each significant change in status. Individuals with high-risk conditions will need to be reviewed more frequently. Summary for Nursing Facilities: The initiation of the nutrition assessment is completed within 5 days of admission for Subacute residents and within 14 days of admission for all residents. The RD or designee assesses the nutritional status and completes the nutrition care process.

Based on interview and review of records, facility failed to follow their policy to ensure appropriate interventions are in place to prevent falls for 1 of 3 (R9) residents reviewed for accidents and hazards. This failure resulted in R9 sustaining a subdural hematoma and being hospitalized . Findings include: On 01/17/2023 at 11:35 AM, R10 stated that she was R9's roommate. R10 stated that the first night (R9) moved into this room (R9) had fallen. That was on 11/13/2023. R10 stated that (R9's) wheelchair was by the window, (R9) said that she was trying to get into her wheelchair and (R9) slipped. R10 stated that (R9) was not sent out to the hospital. R10 stated that (R9) fell a week later trying to get into (R9's) chair. R10 stated that (R9's) falling woke (R10) up from sleep. This happened between 11:00 PM and 12:00 AM. The next day (R9) fell again trying to get to (R9's) wheelchair. After the third time (R9) had fallen, (R9) did not come back to the facility. After all three times, R10 stated that she called the nurse by pressing the call light. R10 stated no one came in and checked in on (R9) all night before (R9) fell . R10's MDS Section C (1/17/2024) documents in part: R10's BIMS score is 15 which means R10 is cognitively intact. On 1/17/2023 at 12:45 PM, V20 (R9's POA) stated that R9 had fallen several times. V20 stated that she had her last fall there on 11/2023. V20 stated that, R9's roommate witnessed three falls and she just called the staff and the staff members put her back in bed. V20 stated that the dates when they were notified when R9 had fallen was 6/10/2023, 9/23/2023, 11/17/2023, and 11/26/2023. V20 stated that the most recent fall was really bad and it put her in the hospital for a hemorrhage. That was on 11/26/2023. On 01/17/2023 at 2:35 PM V14 (Fall Coordinator/Psychotropic Nurse) stated fall risk assessments are done upon Admission, resident falls, quarterly and annually. V14 stated that she is familiar with R9. In 2023 R9 fell on ,d+[DATE], 6/9, 6/10, 7/5, 9/23 and 11/16. V14 stated that on 11/16/2023 she sustained an acute subdural hematoma. On 11/16/2023, R9 stood up from the bed, she fell right away. V14 stated that resident fell at 10:30 PM. R9's Progress note on 11/13/2023 documents in part: During the start of the shift round, resident noted to have left eye redness with swelling in the left peri-orbital area. No discharges noted, no indication of non-verbal pain. The resident is unable to provide information regarding the aforementioned redness and swelling d/t cognitive impairment. In-house NP notified with order to send to local hospital for CT-scan of the head. DON made aware and examined the resident. Contacted the resident's POA and informed the resident's current condition and order to send to outside hospital. R9's progress note by nurse practitioner on 11/20/2023 documents in part: Patient is a [AGE] year old female seen and examined today to follow up in regards to recent fall. patient had a fall on 11/16 and was sent to the hospital for evaluation, patient was admitted for subdural hematoma. Reviewed R9's care plan. No updated interventions after fall on 11/13/2023. Multiple interventions are repeated for multiple falls. R9's POS (11/13/2023) documents in part: Send to hospital for CT scan of the head related to left eye swelling and redness. Facility's Fall Prevention Program policy (12/5/2021) documents in part: All fall incidents shall be monitored, analyzed, root causes identified by the DON or designee. An incident report will be completed by the nurse each time a resident falls. The falls coordinator will review the incident report and conduct his/her own fall investigation to determine the reasonable cause of fall.

Based on interview and record review the facility failed to perform a two person assist for repositioning in bed for a dependent resident (R5), who was assessed as a two person assist for bed mobility. This failure resulted in R5 sustaining an acute, mildly displaced proximal left humeral fracture. Findings include: R5 has a diagnosis which includes but not limited to hypoxic ischemic encephalopathy, localized swelling mass, and lump left upper limb, osteomyelitis, colostomy, chronic respiratory failure with hypoxia, tracheostomy, dependence on respirator, flaccid neuropathic bladder, presence of urogenital implants, gastrostomy, dysphagia, type 2 diabetes. R5's Brief Interview for Mental Status (BIMS) dated 10/14/23 documents a BIMS of 00 which indicates that R5 is not cognitively intact. On 10/30/23 at 11:35 am, R5 was observed in bed awake, alert, and was able to nod R5's head and blink R5's eyes to yes and no questions however, R5 was not able to answer open ended questions. R5 was also observed with a sling to R5's left arm area. On 10/30/23 at 12:04 pm, V8 (Registered Nurse, RN) stated, on 09/27/23 V8 was the oncoming nurse for the 7:00 am to 3:00 pm shift on the third-floor unit. V8 stated, V8 and V33 (RN) from the 11:00 pm to 7:00 am shift, performed walking rounds on the third-floor unit, on 09/27/23. V8 stated, V8 and V33 observed R5's left arm stretched out, swollen with greenish bluish discoloration. V8 explained, R5's arms are usually observed in a contracted formation. V8 stated, V8 and V33 then called V2 (Director of Nursing, DON) to assess R5's left arm. V8 stated, V33 stated that V33 did not observe R5's arm swollen when V33 gave R5, R5's morning medication. V8 then stated, V2 came to R5's room and assessed R5's left arm swelling and discolored and V2 then called V38 (R5's nurse practitioner) to inform V38 of R5's swollen left arm. V8 stated, V38 came into the facility around 9:00 am on 09/27/23 and assessed R5's left arm and ordered a STAT (urgent) X-ray and a Doppler for R5's left arm to be performed. V8 stated, the results of R5's X-ray did not arrive during V8's shift. V8 stated, when V8 returned to work in two days, R5 had a sling to R5's left arm and V8 was informed that R5 had a fractured left arm. On 10/30/23 at 12:16 pm, V9 (Certified Nursing Assistant, CNA) stated, on 09/27/23 when V9 arrived on the third-floor unit V8 and V33 were in R5's room assessing R5's left arm before V9 was able to provide any care to R5. V9 stated, V9 did not work on 09/26/23. On 10/31/23 at 1:20 pm, V33 (Registered Nurse, RN) stated, on 09/27/23 during walking rounds with V8, V8 observed R5's left hand swollen. V33 stated, V8 called V2 to assess R5's hand and V33 then went home. V33 also stated V33 last saw R5 around 6:00 am when V33 gave R5, R5's medications through the gastrostomy (GT) tube, that R5's left hand was underneath R5's covers and that R5's left hand was not visible to V33. V33 explained, V33 only observed R5 to see if R5 was breathing okay during the night and V33 did not provide R5 with any care that allowed V33 to see R5's left hand. V33 also explained, V34 (Certified Nursing Assistant, CNA) provided patient care and repositioning to R5 and did not report any abnormalities to V33 regarding R5 during the shift. When V33 was asked if V33 helped V34 with repositioning or providing care to R5 during the night shift on 09/27/23, V33 stated, The CNA (V34) provided care by herself (V34). If she (V34) needs help. She (V34) would go to get the other CNA (V32). On 10/31/23 at 1:36 pm, V32 (Certified Nursing Assistant, CNA) stated, V32 is not familiar with R5 and that V32 has never provided care to R5. V32 explained, V34 did not ask V32 for any assistance with providing R5 care or repositioning on 09/27/23. On 10/31/23 at 2:42 pm, V34 (Certified Nursing Assistant, CNA) stated, V34 was R5's CNA on 09/27/23. V34 stated, on 09/27/23 V33 assisted V34 every two hours with providing care and repositioning R5. V34 stated, V34 and V33 used a sheet to turn and reposition R5. V34 stated, V34 last provide care to R5 with V33 around 5:00 am on 09/27/23 and V34 did not observe R5's arm swollen or discolored. On 11/01/23 at 10:23 am, V38 (R5's Nurse Practitioner) stated, V38 recalls being called regarding R5's having a left arm injury a few weeks ago. V38 stated, V2 called V38 and stated, R5 had swelling and purplish discoloration to R5's left hand. V38 stated, V38 assessed R5's left arm and ordered an x-ray of R5's left arm that showed that R5 had a left arm fracture. V38 then stated, V38 gave orders for R5 to go to the local hospital. V38 explained, R5 is a resident that requires total care from staff and R5 cannot reposition himself (R5). V38 stated in V38's professional opinion to safely reposition R5, R5 should have two staff members for repositioning. V38 explained, if one staff member provides repositioning for R5, the staff can potentially injury the resident, themselves (the staff member) and that R5 may not be effectively repositioned. V38 stated, during repositioning of R5 one staff member should be on each side of the R5's bed to assist with effectively repositioning R5. When V38 was asked regarding how R5 could have sustained R5's left arm fracture if R5 is a resident that cannot move or repositioning himself (R5), V38 stated that R5 cannot move himself (R5) and R5's injury could have potentially happened during repositioning or during care that was being provided to R5. On 11/01/23 at 10:41 am, V39 (Restorative Nurse, Licensed Practical Nurse, LPN) stated, R5 is a resident that has been assessed as totally dependent on staff for care and requires two persons assist at all times for transfers and bed mobility. V9 was asked regarding if a resident who is assessed for two persons assist for bed mobility should ever have one staff member for repositioning. V39 stated, No. That is not safe for the resident. V39 explained if a resident is assessed for two persons assist for bed mobility and repositioning and one staff member repositions the resident alone, the resident and the staff can get hurt. V39 was asked regarding how R5's left arm fracture occurred if R5 cannot move or reposition himself (R5). V39 stated, Even with two persons assist, R5's contractures and limitations, I (V39) would have to say R5's arm fracture happened when staff was moving R5. On 11/01/23 at 12:04 pm, V2 (Director of Nursing, DON) stated, R5 depends on staff for all of R5's care. V2 stated, R5 is alert and eyes are open but cannot answer open ended questions. V2 stated, about one month ago during the morning shift V2 was notified by V8 (RN) that R5's left hand was swollen. V2 stated, V2 assessed R5's left arm and observed swelling to R5's left arm and called V38 (R5's Nurse Practitioner). V2 stated, V38 ordered and x-ray to be performed on R5's left arm and the results of R5's left arm x-ray was a fracture. V2 stated, V38 then gave orders for R5 to be sent to the local hospital. V2 explained, R5 cannot move any of R5's extremities and that R5 has been assessed as a dependent resident that requires two-persons assist from staff. V2 also stated during R5's two persons assist for repositioning one staff member should stand on each side of R5's bed for support and a sheet should be used during turning. V2 also explained, the expectation of the facility is for staff to follow the assessment of the resident at all times and R5 has been assessed as two persons assist and should never have one staff providing care such as repositioning. V2 explained, if one staff member is providing care to R5 for repositioning there is a possibility of R5's arm to get stuck and injured when turning R5. V2 was asked regarding how R5's left arm fracture occurred. V2 stated, V2 concluded in V2's final report investigation to the local state agency regarding R5's left arm fracture that R5's injury happened during repositioning. R5's Minimum Data Set (MDS) dated [DATE] documents in part that R5 is dependent for staff care, two persons assist for bed mobility. Helper does all of the effort. Resident does none of the effort to complete the activity, the assistance of 2 or more helpers is required for the resident to complete the activity. R5's progress note authored by V8 (Registered Nurse, RN) documents in part that: During morning round, the writer noticed that skin discoloration and swelling on the residents left arm. V2 (Director of Nursing, DON) and V38 (R5's Nurse Practitioner, NP) was notified and STAT (immediate) Doppler test and X-ray of left shoulder, humerus, elbow radius and ulna after assessing the resident. The order was carried out. R5's radiology results report dated 09/28/23 at 05:08 am, documents in part that: Findings: Mildly comminuted, displaced fracture of the surgical neck of the humerus. Adjacent soft tissue swelling. The facility's document dated 10/31/20 and titled ADL (Activity of Daily Living) Care documents in part: ADL care is provided for each resident in the facility in accordance to the residents comprehensive assessment and care plan in order to identify, evaluate, and intervene to maintain, improve, or prevent an avoidable decline in ADL's . i. Other ADL support and assistance in accordance to the restorative nursing assessment and/or comprehensive resident assessment reviewed. R5's hospital record dated 09/28/23 documents in part: R5 was seen in the emergency department for an arm fracture. R5 was placed in a sling and recommended to be non-weight bearing per orthopedic surgeons. R5's Facility Reported Incident initial report to state agency dated 09/28/23 at 8:27 am, documents, in part: R5 noted with left arm edematous. V38 made aware with orders for duplex scan of the left upper extremity and x-ray of the left shoulder, left humerus, left elbow, and left forearm. X-ray. R5's Facility Reported Incident final report to state agency dated 10/03/23 at 4:38 pm, documents, in part: From the staff interviews conducted and the review of R5's medical records, it is concluded that no abuse had occurred, there is high possibility that the acutely mildly displaced fracture of the humerus could be caused by unintentionally and unknowingly due to positioning the resident on the affected arm while providing care.

Based on interview and record review, the facility failed to ensure a resident was free from Sexual Abuse for 1 (R2) of 4 residents reviewed for abuse. This failure resulted in R2 who is cognitively impaired being found in R11's room naked from the waist down, requiring hospital evaluation and R2's laboratory result from the hospital affirming male DNA (Deoxyribonucleic Acid) was found in the vaginal specimen. This was identified as an Immediate Jeopardy situation which began on 11/19/2022. On 09/28/2023 at 12:56 PM, the administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy Plan was removed on 10/02/2023 at 10:23 AM. However, the deficiency remains at the second level until the facility determines the effectiveness of the implementation of the removal plan. Findings Include: R2 Abuse assessment prior to 11/19/22 is inaccurate, R2 was scored as low due to numerous questions being answered wrong. The Facility does not have an effective Abuse Policy and V1 (Administrator) failed to identify the allegation as abuse. R11 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Anemia, Presence of Right Artificial Shoulder Joint, Localized Edema, Chronic Postprocedural Pain, Major Depressive Disorder and Cardiomyopathy. R11 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating cognitively intact. R2 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Hyperlipidemia, Dysphagia Following Cerebral Infarction, Gastrostomy Status, Anemia, Aphasia, Pseudobulbar Affect, Presence of Aortocoronary Bypass Graft, Major Depressive Disorder, Dermatitis, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Cough. R2 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating the resident was unable to complete the interview. [R2's diagnosis of Pseudobulbar Affect is defined as: pathological laughter and crying. Inappropriate laughing and crying due to a nervous system disorder. This condition is characterized by an involuntary and uncontrollable reaction of laughter or crying that's disproportionate to an event.] Reportable dated 11/19/22 and 11/23/22 was presented to the surveyor on 09/12/23. Facility's Final Reportable to the state agency regarding R2 and R11 dated 11/23/22 documents in part: On 11/19/22 at 04:45 PM V4 (Licensed Practical Nurse) went to R11's room when V24 (Agency Certified Nurse Assistant) asked the nurse to validate occupants in the room during the dinner tray service. When V4 opened the door, she noted R2 standing in R11's room by the door with no garments on her (R2) lower half, R11 was fully clothed. The two residents were immediately separated. R2 was unable to express what happened. R11 stated Nothing happened. R11 was moved to the 5th floor and placed on 1:1 supervision. R2 was placed on 1:1 supervision as well. Nursing assessments done for both residents with no evidence of injury noted. The physicians for both residents were called, and orders obtained to send R2 to the ED (Emergency Department) for a forensic exam and R11 to be sent out for a psych evaluation. Since no bed was available in the psych unit, R11 was sent to the ED. The police were called, came to the building and made a report. Interview with R11 which stated that he (R11) was in his room and R2 came to his (R11) room by herself. R11 stated that R2 gestured to me (R11) that she (R2) wanted to do something, and R2 seemed like she (R2) liked me. I took off R2 pants, but I thought better of it and stopped before anything happened. Interview with R2 was done by V15 (Social Worker). R2 was unable to state what happened and was smiling and laughing as is R2 usual demeanor. No evidence of physical injury noted during nursing evaluation or in hospital emergency department notes. R2's behavior remains at baseline, R2 presents as cheerful, interactive, relaxed and is wheeling her (R2) wheelchair around the unit as is R2's usual activity. R11 no longer resides in the facility. (Facility's reportable does not specify abuse was substantiated, even after R11 admitted he took R2's pants off) R2's Physician order dated 11/19/22 document in part: Send the patient to Hospital for forensic examination due to potential sexually abuse. R2's Physician orders document in part: Doxycycline Monohydrate Oral Capsule 100 MG (Milligrams) Give 100 mg by mouth two times a day for prophylaxis for 7 Days -Start Date- 11/21/22 2100. Flagyl Oral Tablet 500 MG (Metronidazole) Give 500 mg by mouth two times a day for prophylaxis for 7 Days -Start Date- 11/22/22. R2's Hospital Record dated 11/19/22 documents in part: Chief Complaint: R2 was seen in another patient's room with the diaper and underwear down to the floor. History of Present Illness: R2 presenting with possible sexual assault. Unknown exactly what happened but R2 was found in another patient's room with her diaper and underwear on the floor and the other resident in a state of undress. Medical Decision Making: R2 with possible sexual assault. Prophylactic azithromycin, ceftriaxone given. Will continue with 10-day doxycycline. Will give hormonal post prophylaxis for pregnancy. Assessment/Plan: Sexual Assault of adult. R2's Care Plan document in part: Need for Guardianship or Surrogate Decision Making: R2 demonstrate cognitive impairment, have a diagnosis of mental illness, impaired, compromised decision making, inability to understand course of treatment, compliance with care and prognosis/likely outcome. R2 is in need for V6 (R2 Family Member) to make health care and/or financial decisions or my (R2) behalf. V6 (R2 Family Member) is my Surrogate Decision maker per MD (Medical Doctor). Date Initiated: 11/02/21. R2 will acknowledge and respect that decisions made on my behalf reflect my best interest (to the best of their ability) and accept on-going communication between decision maker and facility staff, through next review Date Initiated: 11/02/21. Staff will contact the guardian/decision maker for appropriate treatment consent/authorization Date Initiated: 11/02/21. Communication Impairment: R2 presents with an alteration in ability to communicate related to or as evidenced by: Impaired speech (nonverbal). Date Initiated: 10/25/20. R2 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to limited ability with Dressing and Grooming such as: Put on or take off clothing, Unable to obtain or replace article of clothing, Unable to fasten clothing. R2 is at risk for pressure injury development and other skin breakdown due to factors that include but is not limited to incontinence of bowel and bladder. History of suspected abuse: R2 comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase my susceptibility to abuse/neglect. Date Initiated: 11/23/22. Wandering: I demonstrate movement behavior that may be interpreted as Wandering, Pacing or Roaming. I become agitated when redirected. I Demonstrate signs and symptoms of mood distress, i.e., continued wandering. Date Initiated: 11/23/22. I am to be frequently monitored. Substance Abuse/Chemical Dependency: R2 has a history of substance abuse/chemical dependency to include alcohol, marijuana, and tobacco. Date Initiated: 10/25/20. R2's Quarterly: Section VI. Abuse, Neglect, Exploitation & Trauma dated 08/25/22 document in part: I. Abuse, Neglect, Exploitation and Trauma 4. Does the resident have a history of substance abuse/chemical dependency. (no): Care plan documents R2 has a history of substance abuse. 5. Does the resident have a psychiatric history and/or mental health diagnosis (no). 7. Does the resident have a diagnosis of depression and/or history of depressive illness and/or present signs/symptoms of depression/mood distress; (no). Neglect/Abuse [R2 has a diagnosis of Major Depressive Disorder.] 10. 0-1 Low Risk. (R2 was scored as low due to numerous questions being answered wrong) R2's Progress Note dated 11/19/22 19:47 (7:47 PM) document in part: Health Status Note Text: Between 17:00 (5:00 PM) and 17:15 (5:15 PM) CNA (Certified Nurse Assistant) rushed to the assigned nurse to inform that she (CNA) saw a female patient in a male resident's room. The staff immediately went to room and observed both patients standing. The supervisor was notified immediately, and both were separated. Body assessment done on the (R2) female patient, and no evidence of injury noted. R2's Progress Note dated 11/19/22 20:01 (8:01 PM) documents in part: Health Status Note Text: Between 1700 and 1715 this patient (R2) was noted in a male patient's room. She (R2) unable to express what happened to her due to her (R2) medical condition - aphasia following cerebral infarction. She (R2) was immediately removed from the male patient's room and taken to her room and placed on one-to-one supervision. Nursing assessment done; no evidence of injury noted at 17:20. At 17:58, the patient's (R2) primary physician was notified, and he ordered the patient to be sent to the Hospital for evaluation. The assigned nurse called the Police to make a report and they arrived at the facility around 18:16. R2's Progress Note dated 11/22/22 10:24 document in part: Physician Progress Note Text: Patient (R2) Seen and examined. Patient (R2) was sent to Hospital ER (emergency room ) on 19 November for alleged sexual assault. Rape kit was performed at Hospital ER and patient (R2) was given 5 mg of Rocephin, 1000 mg of azithromycin and a prescription for doxycycline 100 mg twice a day for 10 days. Patient (R2) was also given 2 tablets of low overall, and she (R2) was also given 2 tablets to take with her (R2) to the nursing home to be given in 12 hours. Patient (R2) was also given a supply of doxycycline 100 mg twice a day to complete the course for 10 days. However, patient (R2) was not given metronidazole for trichomonas. I did prescribe metronidazole on 22 November when I saw her (R2) at the nursing home, and this was conveyed to the nurse practitioner question and to director of nursing. Examination reveals persistent left-sided hemiplegia. R2's Progress note dated 11/22/22 13:35, document in part; Discussed with doctor. Will add Flagyl 500mg (Milligram) bid (Twice a day) x 7 days to cover prophylaxis for trichomoniasis. R2's Progress note dated 12/30/22 09:55 document in part: Social Service Note Text: Quarterly Note: R2's mother, is R2 surrogate decision maker. Staff BIMS assessment indicates severe cognitive impairment. R2's Laboratory Report DNA-Outsourcing Report dated 04/20/23 document in part: Description: Sexual assault evidence collection kit from R2. List of evidence received on 01/06/23 for possible DNA analysis: 1B Vaginal Swab(s): Male DNA Screening Conclusion: The evidence was screened to identify samples containing sufficient male DNA expected to produce data suitable for comparison. STR (Short Tandem Repeat Analysis) Processing, Results and Conclusions: 3. The partial DNA profile obtained from the epithelial fraction of 1B Vaginal Swab(s): sample is consistent with a mixture of two individuals including R2 and one male contributor. R2 is expected to be present in the mixture obtained from the epithelial fraction of sample and was subtracted from the mixture for interpretation purposes. On 09/12/23 at 10:47 AM, V6 (R2 Family Member) stated the Rape incident happened on 11/19/22. It took a while for the DNA (Deoxyribonucleic Acid) test to come back, and I was waiting for the results. V31 (Detective) called and told me that there were five rape kit swabs done at the hospital. V31 said she did not know about the additional swabs that were taken and one of the swabs came back containing male DNA. I was told by the facility that R2 was found in a male room, nude from the waist down and they are sending R2 to the hospital. I did not receive any additional information. On 09/12/23 at 02:35 PM, V4 (Licensed Practical Nurse) stated I think that day after med pass at 3 something R2 was in the wheelchair. During dinner time the Agency Certified Nurse Assistant was passing trays and notified me that there is one tray for that room, and she saw 2 people in the room. When the agency CNA (Certified Nurse Assistant) reported to me, I went to the room, and I saw R2 standing half naked. We saw both of them standing. The other resident was fully dressed. We separated the residents, notified the physician, then got an order to send R2 to the hospital for evaluation. R2 just smiles but is nonverbal. On 09/13/23 at 09:48 AM, R2 was observed in the second-floor lounge room in a wheelchair unsupervised. R2 is nonverbal and smiles when spoken to. On 09/13/23 09:57 AM, V16 (Certified Nurse Assistant) stated R2 is an extensive care, nonverbal and not able to undress herself. On 09/13/23 at 10:25 AM, V10 (Certified Nurse Assistant Supervisor) stated R2 is a wanderer and goes from room to room. R2 is friendly and boy crazy, if there is any man speaking, R2 smiles. R2 is in a wheelchair and propels herself with her legs. On 09/13/23 at 10:40 AM, V15 (Social Worker) stated On 11/19/22 I was the manager and staff reported R2 was in the room with R11. R2 was immediately separated. We attempted to interview R2. R11 said nothing happen, R2 was just visiting. R2 was sent out for an exam and R11 was sent out for a psych evaluation. On 09/13/23 at 12:19 PM, V19 (Nurse Practitioner) stated I recall the allegation of R2's sexual abuse. R2 went to the hospital. I talked to V23 (Medical Doctor) and added the Flagyl to cover for trichomonas in case there was any sexual abuse that occurred to cover that for prophylaxis. On 09/13/23 03:32 PM, V32 (Licensed Practical Nurse) stated R2 wonders in other residents' rooms and is not able to take off her clothes by herself. The Certified Nurse Assistant was trying to go in R11's room and noticed the lady (R2) was in the room according to the CNA. We separated R2 and R11. R2 was sent to the hospital for evaluation. On 09/14/23 at 09:20 AM, Per telephone interview V24 (Agency Certified Nurse Assistant) stated I was passing trays and I saw 2 residents in a room. R2 was using a wheelchair and they were behind the curtain, but I never saw R2 and R11 getting sexual. On 09/14/23 at 09:53 AM, Per telephone interview V22 (Registered Nurse) stated R2 was in R11's room. R2 was immediately removed from R11's room and placed on 1:1 supervision. The doctor was called and ordered to send R2 out for an evaluation. On 09/14/23 at 10:17 AM, V3 (Director of Nursing) stated I got the call that day R2 wandered into R11's room. They were immediately separated and R2 was sent out to the hospital to be evaluated because they found R2 in the room with the male (R11) and we believed something sexual. R2 was behind the door and the guy (R11) was standing in front of her (R2). The rape kit test takes a long time to be processed. We did not follow-up to check if the rape kit test was negative or positive. On 09/14/23 at 10:59 AM, V1 (Administrator) stated the rape test is sealed in the emergency room . On 09/14/23 at 11:02 AM, Per telephone interview V23 (Medical Doctor) stated R2 was given the antibiotics in the hospital. The medication that R2 received was the standard of care in any alleged sexual abuse. The medications are given for chlamydia, gonorrhea, trichomonas and recommended 2 tablets for birth control. If the rape kit came back positive, it would be the police department to follow up. On 09/14/23 at 11:32 AM, V1 (Administrator) stated I was called at home to inform me that R2 was found in R11's room. R2 had her undergarments down and R11 was fully dressed. R2 and R11 were separated and R2 was sent to the hospital for evaluation. We were not able to determine what happened. R11 claimed adamantly that nothing happened. The detective closed the case and said that it was unfounded about 2 - 3 months later. On 09/15/23 at 09:37 AM, per telephone interview V31 (Detective) stated, R2's lab result did show male DNA. The swabs were taken at the hospital for criminal sexual assault. A complete kit was done. The lab report shows the vaginal swab that they took showed male DNA. While looking at the actual report V31 (Detective) read the results to the surveyor. R2 was treated at the hospital however V31 (Detective) stated that she cannot release the actual test report to the state agency however R2's results documents male DNA. On 9/22/23 at 1:49 pm, V31 (Chicago Police Detective) said, the rape kit collected from R2's vaginal canal came back with male DNA. V31 said, the male DNA could be from semen or fingers, however it is enough to compare the DNA to the male offender. V31 said, the DNA will be compared to R11's DNA. V31 said, the facility provided a video footage outside of R11's room. V31 said, on 11/19/22 at 3:17 pm, R2 wheeled herself to R11's room, the door was open. V31 said, after R2 entered the room, someone closed the door, unsure who (either R2 or R11) as the footage did not show who closed the door after R2 entered the room. V31 said, at 4:40 pm, a staff member during meal pass entered the room and discovered R2 also present in R11's room, and that staff member left and got help and numerous staff started to enter R11's room. V31 said, R2 was in R11's room for 1 hour and 23 minutes. On 09/26/23 at 09:36 AM, per telephone interview V24 (Agency Certified Nurse Assistant) stated we were working, and it was 2-3 CNAs (Certified Nurse Assistant). One of the CNA's, I don't know her name because I was agency, asked me to pass trays. She asked me how many trays I was passing in R11 room. I saw 2 people and she said there is only one resident in that room. I saw a female and a male in the room. The other CNA went to the nurse to tell them that there were two residents in the room and that they should come see. There is a privacy curtain, and the two residents were behind the curtain beside the wall. On 09/26/23 at 09:58 AM, V39 (Social Worker) stated R2 is alert and oriented to self and place. The residents have choices, and they can make their own choice. I could not say if R2 and R11 were in a relationship with one another. R2 had never been in R11's room and R11 had never been in R2's room prior to this. I just came in on Monday and they told me R2 was in R11's room. R2 and R11 were alone in the room and the door was closed. R2 rolls around in the wheelchair and goes to the dayroom. R2 will go in a resident room if she (R2) is welcomed in or knows that she (R2) can go in. R2 can stand with assistance. and is staff assessment; meaning R2 remembers people, staff, her room and faces. I believe R2 would laugh, and I believe R2 would consent to sex. R2's mother is R2's surrogate decision maker. I go off resident rights, if R2 can somehow make decisions. Once R11 came back from the hospital R11 really wanted to leave and said he (R11) did not want to be here anymore. When R11 returned from the hospital R11 was on 1:1 supervision for I think it was a couple of days. We were told by the administrator just in case anything else were to happen, Precautions. On 09/26/23 at 11:57 AM, V4 (Licensed Practical Nurse) stated When sitting in the wheelchair R2 wheels herself around the unit. I was sitting at the nurse station and about thirty minutes earlier R2 rolled past in her (R2) wheelchair. The assigned V24 (Agency Certified Nurse Assistant) was the one that told me there were 2 people in R11's room but there was one food tray for the room. Right away I went to R11's room because as a nurse V24 told me 2 people were in the room. When I entered the room that was only assigned to one male resident there were 2 residents in R11's room. I entered R11's room by myself then I called the supervisor. When I entered the room, I saw a male (R11) and a female (R2) resident in R11 room, and we had to take action. When the door was opened to the right R11 was standing behind the door to the rear edge of the door with the wheelchair closer to him (R11) and R2 was standing to the left of the wheelchair. The wheelchair was behind both of them, but I did not check the direction of the wheelchair. R2 and R11 were both standing facing the entrance. R2 can walk with assistance but that was the first time that I saw R2 standing. The door was closed but just open with a little crack. R11 was just standing there doing nothing when I opened the door, I could immediately see R2. R11 was fully dressed and R2's shirt covered the front and back so I could not see R2's private area. The leggings that R2 was wearing were around R2's calf area and I pulled R2 pants up. I am not sure if R2 had on a pull up or diaper, but I know for sure I pulled R2's pants up. I went and paged the supervisor, and the CNA took R2 to R2's room. Some staff, the supervisor and the social worker came to R11's room. The CNA may have seen R2's pants down. I asked R11 what was going on and R11 said nothing. I asked R2 also and R2 was just smiling. I have never seen R2 in R11's room before and I have never seen R2 and R11 interact with each other. To my knowledge R2 has never had any physical interactions with any other residents. R2 was put to bed fully dressed and I did R2's assessment with V22 (Registered Nurse) in the room. I removed R2's top, but I did not remove a diaper because R2 did not have a diaper on. R11 was in a 2-bed bedroom, the curtain for the second bed was closed where I could not see the second bed by the window. I can't say if it was abuse because we have to do an investigation before we can say that it is abuse. R2 is nonverbal. R2's facial expressions will let you know if R2 is not feeling well. I am not sure if R2 is cognitively impaired because I don't read all the care plans and I don't work on just one floor. I am not sure if R2 was care planned for wandering. The surveyor showed V4 (Licensed Practical Nurse) R2's care plan on the computer. V4 responded The care plan that I am now reading documents that R2 is cognitively impaired and R2 does not make her own decisions. On 09/26/23 at 12:46 PM, V1 (Administrator) Reviewed the reportable and stated based on my (V1) findings there was no evidence of physical injury noted during the nursing evaluation, emergency department notes, R2's behavior remain at baseline, R2 presents as cheerful, interactive and is wheeling her (R2) wheelchair around the unit as R2 usual activity. I did not put a statement of judgement (result of abuse investigation) in the reportable because it was hard for me to put a judgement statement. I could only put objective documentation of what was observed and told to me during the interviews. V24 (Agency Certified Nurse Assistant) was delivering lunch trays, saw two residents in the room and only had one tray. That is why V24 came out to get the nurse. That is what V24 told me, she (V24) only saw the legs and wandered why she only had one tray for the room. I did see the video footage and saw V24 go in R11's room then go to the food cart looking for the tray. V24 got V4 (Licensed Practical Nurse) and V4 went to R11's room. R2 was taken out of R11's room in the wheelchair. V15 (Social Worker) was called and lots of staff were [NAME] around the area. The police were called, came in and extracted the video on their own. I don't know how long R2 was in R11's room. V31 (Detective) called me after V31 talked to you (Surveyor) and told me R2 was in R11's room for over an hour. I talked to V31 about 2 months after the incident and was told that they were closing the case. R11 said that he (R11) took R2 pants off. The nurse told me that R2 was found in R11's room with her (R2) pants down. I could not substantiate or unsubstantiate the abuse. I have never written a reportable like this before. This is the first time that I have done a reportable without making a call in the end. There was no evidence of injury, we watched R2's behaviors, they remained at R2's baseline and that implies that R2 did not experience trauma. That is a great question as to why I did not unsubstantiate the abuse. It was a poor decision on how I worded it. I should have sent in an addendum after the detective closed the case. After the detective closed the case about 2 months later, I would have unsubstantiated the abuse. There was no evidence of injury, R11 denied that he had done anything to R2, the emergency room nurse on duty said there was no evidence so all those point to unsubstantiating the abuse. The reportable written the way I did; I would have definitely made an addendum to unsubstantiate the sexual abuse. I am unsubstantiating sexual abuse. I don't know how to answer the question if R11 pulled R2's pants down does he (R11) have the right to pull R2 pants down, absolutely not. The detective said the rape kit came back with male DNA to the outside of the vaginal area. The only way they can know if it was R11 DNA is if they get an oral swab from R11 and the results can take 9 months to a year. We don't have enough information because we have to wait for R11 buccal swab to come back. We are not sure if R2 was an active participant. Statements based on what I know is if R2 does not like anything R2 will cry and scream. R2 was not in R11's room screaming and I think that is important to note and consider. I think R2 BIMS cannot be assessed because of R2's aphasia. R2's care plan document R2 is cognitively impaired and cannot answer the BIMS questions. It is hard for me to make a statement about that. R2 has her mother as her surrogate decision maker. I think it is appropriate that R2 has a surrogate decision maker because R2 cannot verbally communicate to us. Seeing that R2 is cognitively impaired and cannot communicate verbally, how R2 can give consent to any sexual activity. I can't and don't know how to answer that question. R2 travels around the unit and decides where she is going. Closing statement, this is one of the most difficult as an administrator, hardest and most difficult situation going through the steps of the suspicion of abuse. There is so much gray and seeing that R2 cannot articulate words. I feel the facility did what they were supposed to do. We put R11 on 1:1 and may have been overcompensating. R11 was placed on 1:1 because I felt there would be a survey on this and to make sure I was doing everything that I possibly could. If R11 would have stayed here I would have continued the 1:1 supervision and decreased, it if R11 showed it was no longer warranted. If there is an allegation of sexual abuse, I would follow the abuse policy. On 09/26/23 at 01:38 PM, V15 (Social Worker) stated I was working as manager that weekend day. They called the nurse to inform her that they found R2 in R11's room with her (R2) pants down and they did not know what happened. V4 (Licensed Practical Nurse) told me when they finally got R11's door open, they saw R2 with her pants down. R2 is nonverbal, makes vocal sounds and R2 is pretty alert. R2 gets around with her wheelchair, is never really sitting still, if R2 gets bored in one spot R2 goes to the next spot. I am not sure if she (R2) is able to consent to any sexual activity. On 09/26/23 at 02:45 PM, per telephone interview R11 stated I was at the facility, but I never touched anyone inappropriately. I did not pull down R2 pants. I went to the hospital because I was having trouble with my back and the hospital transferred me to another facility. Am I in trouble? On 09/27/23 at 11:32 AM, per telephone interview V31 (Detective) stated my investigation is still ongoing. I watched the body camera of the investigators that were there at the facility and R11 first said R2 wanted me (R11) to do something then R11 said he did not do anything. R11 was changing his story back then. I never called V1 (Administrator) to tell her (V1) that the case was closed. We suspend them but never closed the case until it is investigated to the fullest extent. Suspended means that nothing is active until evidence start coming in. It would be confusing to a lay person. I would not have told V1 that the case was closed, how V1 interpreted it, V1 could have misunderstood me. On 09/27/23 at 01:09 PM, per telephone interview V40 (Forensic Scientist) stated The partial DNA profile obtained from the epithelial fraction of 1B Vaginal Swab(s): is consistent with a mixture of two individuals including R2 and one male contributor. R2 sample was outsourced. R2 was subtracted for epithelial purposes, and they would have done a differential. R2 would be taken out and see what is left over. There has to be a Y peak to say that there is one male contributor. On 09/27/23 at 02:18 PM, per telephone interview V23 (Medical Doctor) was asked by the surveyor if there was male DNA found in the vaginal sample of R2 what your interpretation is. V23 stated I'm not the expert but common sense, if there was male DNA in the sample there was sexual contact. As a physician if a sample was taken at the hospital and if there is DNA of a male there was sexual contact with a male. On 09/27/23 at 02:23 PM, per telephone interview V23 (Medical Doctor) stated the facility said that the sample was from the vaginal or pubic area. That could have come from anyone providing R2 care and changes the scenario. If the DNA is from the vaginal or pubic area it could have come from someone providing R2 care. V23 was asked as a Nurse the nurses and CNA's wear glove when providing care and if that is the case should another person DNA be found in the vaginal sample. V23 responded it should not happen from wearing gloves. V23 was asked by the surveyor if there were only female staff providing R2 care should male DNA be present. V23 responded If only females were providing care for R2 there should not be any male DNA present. On 09/28/23 at 12:28 PM, V3 (Director of Nursing) was asked by the surveyor the staff procedure when providing incontinent care to the residents. V3 responded they will do hand hygiene, gather supplies, go in the room, and start providing care. They are supposed to wear gloves and if something can cause a splash, they should wear a gown depending on the situation. They should at least always wear gloves for infection control, standard precautions. V3 was asked by the surveyor does the staff provide incontinent care without wearing gloves and V3 responded they are not supposed to touch the resident private parts, we use towels and put on gloves. On 09/28/23 at 12:56 PM, while in the facilities library the surveyor presented V1 (Administrator) the IJ (Immediate Jeopardy) Abuse Template with V3 (Director of Nursing) present. On 09/28/23 V1 (Administrator and V3 (Director of Nursing) exited the facility library and returned at 01:18 PM, V1 (Administrator) said I have a question/comment when I spoke with the detective, I was told that the male DNA was found in the vaginal area. Surveyors expressed that R2 was found in a male resident (R11) room for over an hour then asked can R2 consent to sexual activity and would that be a concern for sexual abuse with a resident (R2) having a BIMS score of 0. V1 (Administrator) stated I am uncomfortable signing it (IJ Template). The male DNA could be from staff providing care. The detective said it (Male DNA) was in the vaginal area. Surveyor asked how male DNA would be found in R2 vaginal area. V3 (Director of Nursing) responded the CNAs are dumb, and it could happen if the CNAs don't follow infection control. They will put the gloves in their pocket, and they could have left DNA on the gloves. V1 stated when I spoke with V31 (Detective), V31 said she did not tell me the case was closed and said that it was suspended. I never substantiated or unsubstantiated the abuse. All that I could put was my objective documentation. Surveyor informed V1 that there are 2 options of the abuse being substantiated or unsubstantiated. V1 responded I never made a result on the reportable. I was looking at penetration. I reviewed the video when the staff entered R11's room. The DNA will be compared with the male (R11). I am so uncomfortable that I can't sign this (IJ Template). Surveyors responded R2 was scored at low risk for abuse. R2 cannot speak, need care, and is assessed at a low risk for abuse. V1 responded I

Based on interview and record review the facility failed to provide one of four residents [R1] with prescribed medications. This failure resulted in [R1] being hospitalized for shortness of breath, low oxygen levels, and left lobe pneumonia. Findings include: R1's clinical review documents in part; R1 is a [AGE] year-old admitted on [DATE], with medical diagnosis of pulmonary fibrosis, asthma, latent tuberculosis, and essential hypertension. R1's minimum data set [MDS] brief interview mental status score dated 6/20/23=15 indicates R1 is cognitively intact. R1's June 2023 EMAR [Electronic Medication Administration Record] noted Physician Order dated 6/13/23- Nintedanib Esylate 150 mg, give every 12-hours for pulmonary fibrosis was not administered from 6/13/23 thru 6/30/23. R1's July 2023 EMAR noted - Nintedanib Esylate 150 mg was not administered from 7/1/23 thru 7/6/23. [From R1's admission (6/13/23) to hospitalization (7/6/23) R1 did not receive any doses of Nintedanib Esylate]. R1's Physician Order dated 6/13/23-Rifapentine 150 mg (antibiotic), give 4 tablets one time a day every seven days (Wednesday) for latent tuberculosis, was not administered on 6/14/23, 6/21/23, or 6/28/23, [missing three weeks in total of the antibiotic Rifapentine]. R1's emergency room entrance form dated 7/6/23 indicates but not limited to; Nursing home staff reported sudden shortness of breath, increase in heart rate, and low oxygen levels. R1 presented to the emergency department with shortness of breath, hypoxic (low oxygen levels) with oxygen levels in the 80's, and respiratory rate of 35. R1's chest x-ray showed acute on chronic changes, pulmonary fibrosis, left lower lobe pneumonia, and elevated white blood count. Intravenous antibiotic started, and R1 admitted to the hospital. On 9/13/23 at 3:04 PM, V3 [Director of Nursing] stated, R1 was admitted to the facility on [DATE]. R1 was sent to the hospital on 7/6/23, due to increase in chest congestion and increase in heart rate of 113 beats per minute. R1 returned to the facility the next day on 7/7/23. On 7/8/23, R1 was noted with a high heart rate and low oxygen level and sent to the emergency department. On 7/8/23 was admitted with pulmonary fibrosis and has not returned back to this facility. I was made aware that R1's pulmonary fibrosis medication [Nintedanib Esylate 150 mg orally every 12 hours] was not available. R1 was admitted with that order from V21 [Pulmonologist]. I was made aware via email by our facility's pharmacy that the medication [Nintedanib Esylate] was not available and the medication required special procedure for dispensing. The facility's pharmacy could not obtain this medication [Nintedanib Esylate]. I called the specialized pharmacy all day on 6/15/23, no answer and no return call back, I did not document the phone calls made. I notified V19 [Facility Nurse Practitioner] and she told me to call R1's pulmonologist about the medication. On 6/16/23, I noted the number for V21 [R1's Pulmonologist] I called the office. I spoke with V21's nurse and asked for a temporary supply of R1's medication [Nintedanib Esylate], the nurse explained the office did not have any available sample medications, and I did not document the phone call to the V21's office. Then I went to R1 and asked if he had a supply of the medication at home, R1 said the medication Nintedanib Esylate was given to him during his hospital stay prior to coming to this facility. R1 also said that his lawyer is trying to have R1's previous employer pay for the medication. R1 is suing his previous employer, I did not document R1 and my conversation. On 6/17/23, I asked R1 for the status of the medication, R1 said that the former employer is responsible to pay and provide the medication and he [R1] would let me know what his [R1] lawyer says, I did not document R1 and my conversation, I did not call R1's lawyer. On 6/20/23, I sent an email to my corporate pharmacy office to let them know all my effort. That same day I received a response of a list of pharmacies that can supply the medication. That day I called all the pharmacies. All the pharmacies said they do not have R1's insurance information. One of the pharmacies said R1 should have been registered by the prescriber, or R1 can register himself. The pharmacist said she needs to talk to the prescriber or resident himself. I took the number and the name of the pharmacist to R1. I stood there and helped R1 get registered with the pharmacy. On 6/21/23, the pharmacy said R1's insurance did not cover the medication. I went to R1 and told the resident the medication was not covered under his insurance, and R1 said his lawyer will make the previous employer pay. I only called the pulmonologist office one time to see if the physician had any free samples of the medication. I did not request to speak with V21. R1 missed 23 days of Nintedanib Esylate to treat pulmonary fibrosis and three weeks of Rifapentine weekly dose of antibiotic to keep the level of bacteria down to prevent lung infection, which could potentially make R1's lung symptoms worse. On 9/13/23 at 12:25 PM, V19 [Nurse Practitioner] stated, I have been working here for seven years. I work with all the physicians here at the facility. I am familiar with R1. He [R1] is alert and oriented x 3. Some medical diagnoses are pulmonary fibrosis, asthma, latent hypertension, hyperlipidemia, and hypertension. R1 was ordered Nintedanib Esylate oral capsule 150 mg by mouth every 12-hours dated 6/13/2023, by V21 [R1's Pulmonologist]. I'm not sure when I was made aware R4's medication was not available. V3 [Director of Nursing] called the hospital to get the medication and was told the medication comes from a specialty pharmacy. I assisted with completing a prior authorization for Nintedanib, and it was denied, then I completed another authorization for the insurance company and the second time the authorization was approved. The specialty pharmacy was going to send R4's Nintedanib, but R4 went to the hospital. R4 went to the hospital around 7/6/23 due to heart palpitations, chest congestion and shortness of breath. R1 returned to the facility on [DATE]. On 7/8/23, R1 went back to the hospital due to fast heart rate and low oxygen level. The heart rate and low oxygen level was not documented. I do not know R1's admitting diagnosis. The medication Nintedanib Esylate helps slow the progression of the lung fibrosis. Overtime the scarring of the lungs will progress then eventually will become terminal. If a resident with the diagnosis of pulmonary fibrosis does not receive Nintedanib that was prescribed, it could potentially worsen the resident's health condition of their lungs. R1 was ordered (6/13/23)-Rifapentine oral tablet 150 mg, give 4 tablets by mouth one time per week for tuberculosis treatment. Rifapentine is an antibiotic. If a resident does not receive a prescribed antibiotic, it can potentially make their respiratory condition worsen. On 9/14/23 at 10:12 AM, V30 [R1's Former Facility Physician] stated, I was made aware of R1's pulmonary fibrosis medication [Nintedanib Esylate] was not available. I assisted with filling out the authorization forms with the insurance company and pharmacy. I did not instruct the facility director of nursing or nursing staff to notify V21, that R1 was not receiving the prescribed medication [Nintedanib Esylate], is for the treatment of pulmonary fibrosis. I was not made aware of R1 not receiving Rifapentine 150 mg tablet to give 4 tables by mouth once a week, is for the treatment of tuberculosis. R1 was sent to the hospital in July for increase in heart rate, and low oxygen saturation level. However, in my professional opinion, R1 being sent to the hospital for shortness of breath, was not related to him [R1] not receiving Nintedanib Esylate, or Rifapentine. R1 not receiving the lung medication or antibiotic did not make R1's lung condition worse, because R1 already has end stage pulmonary fibrosis. On 9/14/23 at 11:40 AM, V21 [R1's Pulmonologist] stated, I received a message that someone from R1's facility inquired about samples of Nintedanib Esylate. I forward another prescription to the specialty pharmacy, and R1 was made aware. When my nurse followed up with the pharmacy, the medication was filled. I was not made aware that R1 was not receiving his Nintedanib Esylate. No one from the facility phoned my office for a different medication or treatment plan. The medication Nintedanib Esylate is designed to slow down the pulmonary fibrosis disease process. Rifapentine is an antibiotic to help decrease bacteria in the lungs to prevent lung infections. I have not looked over R1's hospital medical chart, so I cannot say certainly that R1 was hospitalized because he did not receive his medications of Nintedanib Esylate and Rifapentine. I will say, due to R1 not consistently receiving all his prescribe medications it could potentially cause the pulmonary fibrosis to continually progress or worsen. [The facility did not call R1's V21 [Pulmonologist], to notify the medication [Nintedanib Esylate] was not being administered. The facility did not call V21 to request a different medication or a different treatment plan]. Policy-Documents in part: Physician Orders dated [7/28/23] -The facility shall ensure to follow physician orders as it is written in the physician order sheets [POS] -Upon admission and readmission, the facility will verify transfer orders from the hospital with the resident's attending physician

Based upon observation, interview and record review the facility failed to timely address change in condition for two of eight residents (R5, R7) in the sample, failed to document (R5) physical assessment, pain rating and/or vital signs and failed to administer (R5) pain medication. These failures resulted in R5 sustaining 3+ pitting edema and pain rated 10/10. The facility also failed to monitor R7's indwelling urinary catheter. This failure resulted in R7 sustaining altered mental status, low blood pressure, fever and UTI (Urinary Tract Infection) secondary to sepsis. Findings include: 1. On 4/4/23, IDPH (Illinois Department of Public Health) received allegations that facility staff ignore resident symptoms and fail to provide treatment. R5's diagnoses include SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone Secretion) and hyponatremia. R5's POS (Physician Order Sheets) include (1/24/23) Sodium Chloride 2 grams three times daily for electrolyte and (1/30/23) Tolvaptan (treats low sodium blood levels) 15 milligrams daily for SIADH. R5's (4/6/23) BIMS (Brief Interview Mental Status) determined a score of 11 (moderate impairment). On 5/3/23 at 1:30pm, R5 appeared to be distressed, teary eyed and calling out for assistance. Surveyor inquired if something was wrong R5 stated I need the Nurse, I press the button and nobody coming. My arms, they stay big, they're so big and I have pain (10/10). I got to go to the hospital and the manager or nurse not coming. They (staff) never coming, they never come because I have a problem. R5 appeared emaciated however both upper extremities were shiny with taut skin and notably edematous. On 5/3/23 at 1:36pm, surveyor inquired about R5. V24 (Licensed Practical Nurse) stated, She (V24) was notified of pain on the finger, so I offered her (R5) pain medicine, like Tylenol. Surveyor inquired if R5 received Tylenol today. V24 responded, I haven't given it to her right now. Surveyor inquired about R5's upper extremities. V24 responded, The CNA (Certified Nursing Assistant) told me she was complaining of pain, and I checked the hand and the vitals (R5's alleged assessment and/or vital signs were not documented). When I touched her, I asked if she had any pain she said yes, so I need to give Tylenol. Surveyor inquired why R5's bilateral upper extremities were notably edematous. V24 replied, She's on sodium, so I might be thinking from that sodium she might get swollen fingers. (R5's 5/3/23 Medication Administration Record affirms R5 received Sodium Chloride at 9am and 1pm). Surveyor requested the stage of R5's edema. V24 pressed the top of R5's left hand which was pitting and stated, I think it's a 3. Surveyor inquired if the physician was notified of R5's changes in condition (pain/edema). V24 responded, I haven't called yet. On 5/3/23 at 1:53pm, V3 (Assistant Director of Nursing) entered R5's room (as requested). Surveyor inquired about R5's change in condition. V3 stated, I know she (R5) was seen by the NP (Nurse Practitioner) today. I'm going to call the NP to let her know about the bilateral edema. R5 emphatically affirmed that the NP did not see her today. V17 (Social Service) subsequently translated for R5 and stated, She (R5) says everybody that comes to the room goes to her roommate. On 5/3/23 at approximately 2:05pm, V3 stated, I misspoke, the NP did not see her (R5) today, she saw the roommate. R5's electronic medical records affirm vital signs and pain level were last documented on 5/2/23 at 9:49am (the day prior). R5's (May 2023) Medication Administration Record affirms Tylenol was not documented. R5's (5/3/23) hospital history & physical states patient cachectic and edematous on exam. Suspect malnutrition as etiology of edema. 2. On 5/3/23 at 12:35pm, V23 (Family) stated, on 4/1/23 he contacted V12 (Agency Licensed Practical Nurse) via phone to report that R7 was not feeling well. He (V23) requested she (V12) check on (R7) however (V12) stated she was busy and would try to check on (R7) later. V23 immediately went to the facility and found R7 warm to touch and hallucinating. R7 also has a history of UTI (Urinary Tract Infection) and his urine was dark brown in the catheter bag therefore V23 requested an ambulance. V23 stated, R7's blood pressure was 66/30 when EMS (Emergency Medical Service) arrived. On 5/8/23 at 12:11pm, surveyor inquired about R7's (4/1/23) change in condition. V12 stated, The son came in (4/1/23) and asked me to come check his father, said he (R7) wasn't feeling well so I took his vitals. He (R7) felt warm and had a temperature. His son wanted him (R7) sent out and I sent him (R7) to the hospital. Surveyor inquired if R7's son (V23) called V12 (on the phone) prior to arrival. V12 responded, He (V23) did, he just said that his father sounded confused. R7's (4/1/23) progress notes state (11:45am) resident was noted with a urine output:300cc (cubic centimeters) with amber colored urine. Son came and requested that father be transferred to the hospital for evaluation. Vital Signs:121/64, 84, 20, 95% at room air, 103.5 axillary (therefore above 104F oral). Left message with doctors answering service at 12:38pm (53 minutes later). Spoke to nurse practitioner at 12:40pm, ordered for resident to be transferred to Hospital for evaluation. Resident is admitted to hospital due to sepsis and hyponatremia R7's (4/1/23) hospital records include chief complaint fever and altered mental status. Sent to emergency room with hypotension and temperature 103.5 at skilled nursing facility. Blood pressure as low as 61/33 secondary to sepsis, urinalysis dirty. Physician reports that he (R7) came with (indwelling urinary catheter) which was dirty and changed in the emergency department. White blood cells 12.8 (high). Urinalysis positive for UTI. On 05/08/23 at 1:33pm, surveyor inquired about staff requirements for resident change in condition V27 (Medical Director) stated, If there's a change in the patient's status after the nurse assesses the patient the primary physician should be notified. Surveyor inquired about a timeframe for reporting resident change in condition. V23 responded, I'm not sure that I can put a timeline on anything. If somebody becomes short of breath or has chest pain, then I think there is urgency and they should call the physician immediately. Surveyor inquired about potential harm to a resident with a temperature 103.5 (axillary) not addressed. V27 responded, I think in that situation and the temp is 103.5 then I would expect a call right after she took the temperature. Surveyor inquired about potential harm to a resident prescribed Sodium Chloride daily and Tolvaptan with (3+ pitting) upper extremity edema V27 replied Localized swelling in the arms would not happen from those medications, it would be a generalized edema not only upper extremities so there could be other reasons. It could be thrombosis, that would be something we would need to rule out or it could be nutritional. Surveyor relayed concerns with R5 & R7's delayed care at the facility. V27 responded, The nurses need to do a thorough and accurate assessment of the patient and address those issues. The notification for change in condition policy (revised 7/28/22) states the facility must immediately consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status (ie: deterioration in health). Per federal definition 483.10(g)(14), a need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (eg: an adverse drug reaction) or commence a new form of treatment to deal with a problem.

Based on observation, interview and record review, the facility failed to ensure that a resident (R89) that is dependent and cognitively impaired ingested medications prior to leaving the room. The facility also failed to provide care interventions to a resident (R27) that was diagnosed with multiple psychiatric disorders and was refusing medications and wondered. These failures resulted in R27 sustaining subdural hematoma that required hospitalization . Findings include: 1. Facility's (1/16/23) incidnet report regarding R27 documents in part: Resident with hx of dementia and schizophrenia was transferred to hospital via involuntary petition due to increased paranoid delusions and aggression. Resident pulled a grab bar off the wall in the bathroom and swung it at nursing staff while shouting I am going to kill you m .s and screaming incoherently. Staff was unable to redirect resident at that time and resident was petition out. Per updates from the hospital, she was noted with subacute left forehead hematoma. R27 is [AGE] years old, medical diagnosis that includes Diabetes (04/18/2022), Essential Hypertension (10/01/2015), Dementia (09/10/2022), Paranoid Schizophrenia (11/14/2018), Delusional Disorders (10/01/2015), Brief Psychotic Disorder (10/01/2015). R27 per resident record was transferred to hospital on 01/27/2023. On 01/31/2022 at 10:56 AM, V9 (Licensed Practical Nurse) stated, R27 is not here right now. She (R27) was transferred to the hospital last Friday, 1/27/2023. R27 was refusing medications all the time. I cannot really know when it started but she just refused her care. In the room where R27 used to stay, V9 showed the grab bar that was mentioned in the incident report. It was the metal bar that residents hang towel on it. V9 said pointing at the towel bar, This is the bar. Yes, it is not really a grab bar but the metal thing that holds the towel. Then after going out of the bathroom, V9 pointed at the door where a lot of markings where observed. Then V9 said, Yes, that was the markings when R27 became aggressive and was hitting the door with a bar we saw in the bathroom. I don't know where R27 got her forehead hematoma. But I noticed it after she became aggressive. V9 was asked about the incident that happened where R27 also sustained hematoma on the forehead on 1/9/2023. V9 stated, R27 wanders a lot and may have entered into the shower room. Because according to R27 she hit her head on the shower bar. R27 has problem with behavior, sometimes we cannot determine what she means to say. R27 refused a lot of her medications that is why she goes to the hospital often. At the shower room, multiple shower bars was seen on waist level. V9 was asked which shower bar did R27 said she hit her head? V9 said, I don't know, it can be one of those. R27 wanders around unattended. R27 refused to go to the hospital so we cannot determine the extent of injury on her (R27) head. V9 was asked since you cannot determine which shower bar R27 hit her head, did you ask her? V9 said, No, I am not sure if she (R27) really hit her head on the shower grab bar. On 02/02/2023 at 09:28 AM. V3 (Director of Nursing) said, I was not here on 01/9/2023, I was not here at that time. For what I can read, she (R27) has hematoma on her left forehead because she (R27) hit her head on the grab bar at the shower room. Then she (R27) refused to go to the hospital. Her (R27) brief interview for mental status (BIMS) was 15. There was no investigation done on the incident that happened on 01/09/2023. Yes, I agree because no diagnostic test was done, we cannot determine the extent of injury R27 has in her forehead. I think that is correct, R27 has multiple medical diagnosis including paranoid schizophrenia, delusion, and psychosis. I understand what you mean, that it would determine what happened if it was investigated. And may help prevent the similar incident that happened on 01/16/2023. V3 was asked to guide writer related to plan of care for both incidents that happened on 1/9/2023 and 1/16/2023. Or behavioral problems were being address on the care plan. V3 said, I cannot find it. And when R27's condition was not addressed, it will continue to get worst. V3 further said, Like what happened on 1/9/2023 and 1/16/2023. The injury on 1/16/2023 may be the same injury. But because R27 went to the hospital, and they saw subdural hematoma when they do CT scan. I reported it to State Agency. Yes, now that I think of it, R27's MDS (minimum data set) shows R27 needs limited assistance. And it would be helpful to investigate since she wanders without assistance and supervision. And on 1/9/2023 she refused to go to the hospital and have no diagnostic test done to determine R27's head injury. On 02/02/2023 at 10:07 AM, V24 (Restorative Nurse / LPN) said that he did MDS assessment for R27 on Functional Status. V24 said, R27 has poor safety awareness, she (R27) had fall incidents when she was out with her family. Left alone, R27 has a high risk of falling. Yes, R27 was assessed as needing 1-person limited assistance because although her brief interview of mental status (BIMS) score was 15 she poor safety awareness. Review on R27 minimum data set (MDS) dated [DATE] under Functional Status, in part reads: R27 needs 1-person limited assistance on bed mobility, transfers and walk in room and corridor. Under R27's CAA (Care Area Assessment) dated 12/22/2023 under Triggering conditions are as follows: Actual problem, affect function includes changing cognitive status, mood decline, recent hospitalization . Presence of any behavioral symptoms (verbal, physical or other), rejection of care occurred at least 1 day in the past 7 days and wandering occurred at least 1 day in the past 7 days are part of triggering conditions. R27's cognitive skills for daily decision making has a value of 0 through 2. On 02/02/2023 at 04:12 PM. V30 (Psychiatrist/Medical Doctor) said that R27 refused all her medications especially psychotropic medications. And because of not taking psychotropic medications her medical diagnosis that includes Paranoid Schizophrenia, Delusions Disorder and Psychosis caused those aggressive behavior like what happened on 01/09/2023 and 01/16/2023. V30 said, R27 has severe psychosis and does not comply with her medications specially with her psychotropic medications. R27 has also elevated blood pressure and does not take her medication for hypertension. R27 sometimes has more than 180 systolic blood pressure. V30 was asked if the incident that happened on 01/9/2023 and 01/16/2023 has a direct relationship with R27 not taking her psychotropic medication. V30 said, Absolutely, R27 has severe psychosis and is paranoid. Because of not taking psychotropic medication results to manifestation of her psychiatric disorder. And medication intervention will not be effective because R27 will refused it anyway. Fall is highly possible, but she (R27) even goes to the vending machine often by herself. From July 2022 to January 2023 residents Medication Administration Record (MAR) were reviewed. Starting July 2022, R27 started refusing medications including insulin, anti-hypertensive, and psychotropic medications. R27 refusal to take medication increased by January 2023 almost all medications including seizure medication, insulin, anti-hypertensive, and psychotropic medications. On 02/03/2023 at 10:35 AM. V3 (Director of Nursing) stated that R27's incident happened on the 14th of January, and it was reported on the 16th of January because the facility received the CT scan result on 1/16/23. The incident on 01/09/2023 was not reported although R27 sustained hematoma on her left forehead because R27 has a BIMS score of 15. V3 was asked if psychiatric disorders of R27 like delusional disorders, paranoid schizophrenia was considered during the incident. V3 said, No, we just rely on R27's BIMS score. V3 was informed that on R27's (Psychiatrist) notes, R27 multiple behavior concerns need to be considered and not only R27's BIMS score. V3 replied, I just considered R27's BIMS score. V1 (Administrator) stated, Facility did not report the injury of R27 in the forehead because we do not consider it to be injury. V1 said, When you (referring to the writer) say that R27 has an injury on the forehead on 01/09/2023 it has a bad connotation. We don't call it injury. V1 was asked if a hematoma on the forehead of a person is considered as injury. And since R27 refused to go to the hospital and CT scan was not done it cannot be determined the extent of injury. V1 did not answer and gave the phone to V3 (Director of Nursing). V3 said, Do we need to report if a resident fell and had a hematoma on the forehead? V3 was asked since no diagnostic test was done, how will the facility determine the extent of injury? Would it be beneficial if the incident was reported and investigated? V3 said, We will review this matter. R27's Notes are as follows: Notes dated 01/09/2023 by V9 (Licensed Practical Nurse) in part reads: R27 has a bump on her left forehead. R27 refused to go to hospital emergency room and no diagnostic test was done. Notes dated 01/09/2023 by V20 (Nurse Practitioner) in part reads: Reported to her (V20) that R27 sustained hematoma on the forehead. R27 refused CT scan. Notes dated 01/14/2023 by V9 in part reads: R27 became aggressive towards staff and other residents. R27 broke the bar from the bathroom and started hitting the door. R27 was transferred to hospital emergency room with petition for aggressive behavior. Facility submitted CT Scan of R27's Head dated 01/15/2023 in part reads: Under clinical indication: Subdural Hematoma. Left Frontal Scalp Hematoma. After review of R27's care plan multiple identified problems including R27's non-complaint with medications (Psychotropic, Hypertension, Diabetes, Seizure due to subdural hematoma) was not addressed. Incidents of 01/09/2023 and 01/14/2023 when R27 sustained hematoma on the forehead was not addressed. R27's activities of daily living (ADL) requirement of one-person limited assistance on transfers and ambulation was not followed. Per Care Area Assessment and V9 and V30's statements R27 remains wandering independently. And R27 also has difficulty of hearing per the same assessment. R27's wandering was not addressed although on 01/09/2023 R27 sustained left head hematoma that was unwitnessed. Facility policy on Care Plan dated as revised 07/27/2022, in part reads: The facility will put in place person-centered care plans outlining care for the resident. 45110 2. On 01/31/23 at 11:40 AM, observed R89 in bed laying across the bed. On the bed side table noted 3 medicine cups with medication in each cup. On 1/31/23 at 11:45 AM, V15 [Registered Nurse] stated, I have not administered any medication to R89 today, those three cups of medication did not come from me. Earlier this morning, R89 refused her medication so I will try to give her medication after lunch. On 1/31/23 at 11: 53 AM, V3 [Director of Nursing] and surveyor observed R89. V3 stated, I'm not sure which nurse left these 3 medication cups of pills, I will investigate. On 2/2/23 at 8:26 AM, V3 [Director of Nursing] stated, R89 does not have a physician order to self-administer medications. The nurse should identify the resident and administer the medication, stay there until the resident has taken all the medication. If the resident refuses the nurse should remove the medication and notify the physician. The nurse should document the refusal on the electronic medication record as well. Medications should never be left at the bedside. Medications left at the bedside with a resident of BIMS score of 7 potential of not taking the pills at all or taking all the pills at one time that cause an overdose. If not taking the medications at all could potentially cause R89 medical conditions to worsen. On 1/31/23 at 12:05 PM, surveyor and V3 compared the cups of medication to R89's medications in the medication cart. V3 identified the medications: Cup [1] Potassium 20meq, duloxetine 60mg, memantine 10mg, and aspirin 325mg. Cup [2] Levothyroxine 50mcg, memantine 10mg. Cup [3] potassium broke in half.

Based on observation, interviews, and record reviews, the facility failed to ensure safety for one resident(R1) while she was operating a motorized wheelchair (WC) inside an elevator. Three residents were reviewed for wheelchair safety. This failure resulted in R1 sustaining a right fibula fracture. Findings include: R1 was determined not to be safe operating a motorized wheelchair by Director of Rehab (V8) yet she was provided a motorized wheelchair and allowed to operate it. Facility Reported Incident dated 6/18/21, documents on 6/11/2021, R1 reported to have bumped her legs on the elevator door while operating her motorized wheelchair. Resident was transferred to bed by Hoyer lift with 2 staff while affected ankle was immobilized. Current Face Sheet documents, R1 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include: Vascular Parkinsonism Disease, Heart Disease, Chronic Kidney Disease, Stage 3, [CONDITION(S)] Disease of Nervous System, [CONDITION(S)], Depressive Episodes. Minimum Data Sheet (MDS) dated [DATE] section C documents R1's mental status was intact as noted in the Brief Interview for Mental Status (BIMS) score of 12 out of 15. Section G of MDS documents R1 requiring moderate to maximum assist for all functional activities screened. Hospital X-ray results dated 6/12/21 of R1's right ankle documents the following: IMPRESSION: Findings consistent with a nondisplaced fracture of the distal right fibula and additional possible fracture of the right medial malleolus. On 7/6/2021 at 12:05pm during an interview, R1 states I steered the motorized wheelchair myself it's hard to steer. Only 2nd day using it. My leg was caught between the walls and broke my ankle. V6 (Activity Aid) was supposed to help me. Observed R1 in bed with right side cast toes out to mid leg. On 7/8/2021 at 10:58 AM, V6 (Activity Aide) states he went downstairs to escort R1 back to her room after a visit with her family. V6 states he held the door for R1 and she came into the elevator. V6 states R1 entered the elevator while facing the back of the elevator. He let go of the door once R1 was inside. V6 states R1 turned to face the door and she hit her leg on the inside of the frame of the elevator (a non-moving part). Not the door. I saw it a little. V6 states that R1 said ouch when she hit her leg. V6 states R1 said she was okay. V6 states he was not aware that R1 required supervision while operating the motorized wheelchair. V6 states he came to assist R1 that day because it is the facility's policy to escort residents to and from visits. On 7/6/2021 at 12:15PM V7 (CNA Assigned to R1 today) stated, She (R1) has not been getting up lately. They (Physical Therapy) has been trying to teach her how to use the powered wheelchair. I have seen her bump the wall before, we verbally guide her. On 7/6/2021 at 12:38 V9 (Occupational Therapist) states, R1 has cognitive delayed response and is impulsive. We discussed various levels of speed for her while in the powered wheelchair. I was told she raises up the speed in the halls, she is speeding in the halls. Not always aware of her environment. She has had instances when she was told to go left or right or not respond to cues, her alertness is delayed. On 7/6/2021 at 12:28 PM, V8 (Director of Rehab) states, we started working with her in the power chair and she has been unsafe the entire time. She is not safe to use power chair as of discharge on 6/18/21. V8 reading from 6/11/21 Therapy notes states: motorized wheelchair requires moderate verbal cues to avoid obstacles. Surveyor asked what that means. V8 responded, it means resident is not safe to use if needs mod-max cues to avoid obstacles. Assistance should be provided by CNA, restorative, nurses. Clinically trained staff. On 7/8/2011 at 10:30 AM V8 states, resident (R1) was never safe to operate motorized wheelchair alone without supervision. It is communicated to all staff (nurses, CNA's, Restorative and it is in the computer) therapy's recommendations that R1 needed supervision to operate the motorized wheelchair safely. Physical Therapy Treatment Encounter note dated 6/10/2021 and signed 12:59 PM documents the following: Practice propelling WC throughout halls requiring Mod/Max verbal cues to avoid obstacles to increase safety and independence. Physical Therapy treatment encounter note dated 6/11/2021 and signed 01:17 PM documents the following: Propel motorized WC throughout facility requiring Mod verbal cues to avoid obstacles and stop when headed to barriers to increase safety. On 7/8/2021 at 10:38 AM V8 (Director Rehab) states, we worked with R1 periodically with the motorized wheelchair upon daughter's request or R1 preference to be in chair. R1 rarely uses wheelchair in the facility. After motorized wheelchair trials we would always say R1 needed supervision while operating the motorized wheelchair. Motorized Wheelchair Care plan dated 5/18/21, documents the following: Therapy Screen on 1/20/21, 2/25/21, 3/19/21, 5/18/21 and 6/18/21 for R1: Not appropriate for independent use Motorized wheelchair. Patient came back from hospital; patient is not appropriate for Motorized wheelchair use at this time. Facility will provide Regular Wheelchair and will store motorized wheelchair until it is next possible screen by Therapy. Review of Hazards policy dated 8/5/2020 documents the following: Policy Statement: It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents.