Every finding on record at Center Home Hispanic Elderly

Based on interview and record review the facility failed to have appropriate interventions and supervision in place to prevent residents (R1 and R2) from falling. This failure affected two (R1 and R2) of five residents reviewed for falls. This failure resulted in R1 sustaining a subdural hematoma (brain bleed) and R2 sustaining a right humerus fracture. 1. R1's face sheet dated 07/29/2026 documents, in part, that R1 was admitted to the facility on [DATE] with diagnoses of Dementia, Alzheimer's disease, aneurysm of the heart, insomnia, essential hypertension diabetes mellitus, orthostatic hypotension convulsions, altered mental status, left artificial hip joint, muscle weakness, and hyperlipidemia. R1's Minimum data set for Cognitive patterns and brief interview of mental status dated June 8, 2026, documents in part that R1 had a score of 03, which means that R1 was severely cognitively impaired. R1's Functional abilities section documents in part that R1 had a score of 03 which means that R1 required partial/moderate assistance from staff to complete the task of chair transfers and sit to stand. R1 had a score of 88 for ambulation which means that this task was not attempted because R1 was not ambulating due to her medical condition or safety concerns. R1's care plan dated 04/21/2026 documents in part that R1 is at risk for falls related to altered mental status, convulsions, diabetes mellitus, Alzheimer's, orthostatic hypotension, and dementia.[Interventions: staff to anticipate and meet R1's needs, complete the fall risk review per facility protocol]. R1's Self-care deficit care plan dated 04/20/2026 documents in part that R1 requires assistance with activities of daily living to maintain highest possible level of functioning due to cognitive status. [Interventions: staff to provide R1 with all activities of daily living as required per the residents need dependence: transferring, ambulation]. R1's order summary report dated 06/11/2026 documents in part that R1 had an order to Do not attempt resuscitation/DNR. On 07/29/2026 at 11:48 AM, V4 (Care manager) stated he used to be the care manager for R1 for her diagnosis of diabetes and hypertension diagnosis, V4 was informed by the hospital that R1 sustained a fall on 07/04/2026 and she was hospitalized for brain hemorrhage and V4 was mandated to complete an incident report and file the report with IDPH. On 07/29/2026 at 12:01 PM,V5 (Primary care physician) stated that the Brain hemorrhage resulted from the fall which caused the death of R1. V5 stated that the family elected not to have surgery to evacuate the brain bleed which was the best decision for R1 related to her current condition. Facility reported initial incident completed by V2( Director of nursing) dated 07/05/2026 documents in part that R1 sustained a fall on 07/04/2026 which resulted in a laceration to right occipital area, R1 is self-ambulatory, and orders were received to send R1 to hospital for evaluation. Documents state that the hospital called the facility to inform the facility that R1's CT (computed tomography) scan of the head displayed that R1 has a Subdural, subarachnoid, and intraparenchymal hemorrhage and R1 was being transferred to another hospital for a higher level of care. (The facility's assessment noted R1 required partial/moderate assistance to transfer/sit/stand and supervision to ambulate) Facility reported final incident completed by V2 (Director of nursing) dated 07/10/2026 documents in part that upon completion of the facility's investigation it was confirmed that R1 sustained a fall and was observed sitting on the floor in the activity room. V2 documented that R1 was impulsive as a result of anxiety and status post head injury and after careful review the facility has concluded the investigation. V12 (Certified Nursing Assistant/CNA), written statement dated 07/07/2026, documented in part that on 07/04/2026 upon making rounds R1 had an unwitnessed fall. R1 was in dayroom hallway at 8:30 PM and that V12 did not witness R1 fall. V12 documented that she last saw R1 at 8:00 PM after snacks. V12 documented that R1 was more confused than usual and R1 was noncompliant with wheelchair. V13 (CNA), written statement undated, documented in part that on 07/04/2026 V13 did not witness R1's fall because V13 was taking other residents to their rooms to go to bed. V13 documented she last saw R1 at the nursing station. V13 documented that the fall occurred in dayroom on evening of 07/04/2026. On 07/30/2026 at 1:27 PM, V13 (CNA ) stated she worked on the 2nd floor on 07/04/2026. V13 stated R1 was a fall risk and had a fall risk band on her wrist. V13 stated that fall risks are not supposed to be left alone. V13 stated that her and the other aides normally switch out at all times to ensure that someone is always in dining room monitoring. V13 stated she was informed that R1 fell but she is not aware of what happened because it was not her monitoring time. V13 stated R1 liked to get up and move around daily and was a bit confused even after redirection. V13 stated that R1 was not combative. V13 stated that V14 informed her that V18 (CNA) was sent home early. V13 stated that V14 (Registered Nurse/RN) split up the assignment but that she (V13) did not have R1. The assignment was split up after R1 had fallen. V14 (RN), written statement dated 07/04/2026 documents in part that V14 was the nurse for R1 on 07/04/2026 and that R1 experienced an unwitnessed fall which resulted in bleeding laceration to right side of her forehead. V14 stated that V12 was who informed her that R1 was on the floor and when V14 arrived to the incident R1 was observed at the entrance of the dayroom in a sitting position. On 07/30/2026 at 12:33 PM, V14 (RN) stated I was the nurse on 2pm-10pm shift on 07/04/2026, and after dinner my aides were gathering other residents to place them in bed. R1 had an unwitnessed fall. R1 is not supposed to be left unsupervised. At the beginning of the shift everyone knows their section and their assignment. V14 stated she informs the aides verbally and we all agree with the assignments. V14 stated that V18 was responsible for monitoring the dining room when R1 had a fall. V14 stated that V18 was sent home on another issue after dinner. V14 stated V2 (Assistant Administrator) called V18 and sent her home. V14 stated she did not assign anyone else to monitor the dining room because V14 became busy. V14 stated R1 had a short attention span and has behavior of wanting to go to restroom. V14 stated it would have been ideal to bring R1 to the nursing station but at the time it was not possible because V14 states she was not made aware that R1 was left in dining room unattended. On 07/30/2026 at 12:53 PM, V18 (CNA) stated she worked on 07/04/2026 and was assigned to provide care to R1 but I was sent home by administration. V18 states she left the facility around 5-5:30 PM. V18 states R1 was in the dining room before she left. V18 states she was being questioned by V2, so she was not even in the dining room. V18 states normally she starts at 2pm and works to10pm and when V18 arrives she does walk through of unit and makes sure all residents are okay. V18 stated all staff is aware that someone is always supposed to be in dining room monitoring residents at all times. V18 states that sometimes the dining room time is written on the schedule but not always. V18 stated she did not sign off to any aide before she went home early, and that she cannot tell another aide to do her assignment that was on the nurse. V18 stated that R1 was a fall risk, R1 would like to get up from her wheelchair but her gait was very unstable. On 07/30/2026 at 1:09PM, V2 stated there was an allegation of abuse that was reported that day (07/04/2026) and I came to the facility per instruction of the administrator and did the report and interviewed the resident and sent V18 home pending investigation. The director of nursing was informed to call and make assignment rearrangements. Dinner time on the 2nd floor was being finished up and residents were coming out of the dining room. V2 stated she never went into the dining room. V2 states she expects the staff to monitor residents during meals and be present to watch the residents because of safety issues to decrease the risk of falls. On 07/30/2026 at 1:16 PM, V3 (Director of Nursing/DON) stated she was made aware that V18 was sent home by V2. V3 stated V2 texted her via phone on 07/04/2026 to inform her that there was an allegation that needed to be investigated and that V18's name was listed so she needed to be removed from the schedule. V3 stated she attempted to call some staff to come in to assist but since it was a holiday no one would pick up the shift. V3 stated she informed V14 that it would only be two aides on the 2nd floor unit and begin placing residents in bed early. V3 stated she was not sure of the time she informed V14 to begin helping the aides to place the residents in bed. V3 states that residents are not supposed to be left unsupervised in the dining room. V3 stated that someone should have stayed in the dining room while the nurse and aide helped to put residents to bed. V3 stated her expectation of the staff is to ensure all residents are monitored for supervision and to keep all residents safe. R1's hospital records dated from 07/04/2026-07/06/2026 documents in part that R1 has documented bleeding in brain from magnetic resonance imaging (MRI) dated 07/04/2026. R1 was transferred to another hospital for neurosurgery for higher level of care on 07/05/2026. On 07/05/2026 at 8:51 PM CT scan of head without contrast documents in part that R1's head demonstrates interval increase in the mixed attenuation hematoma involving the left temporal and occipital lobe with also increase in size of the layering fluid component. The hematoma has increased to 9.6 x 4.7 centimeters from 8.7 x 4.2 centimeters. Facility policy titled Supervision and Safety dated 3/15 documents in part Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility wide priorities. 4). resident supervision is a core component to resident safety.10). staff to make visual rounds more often, if necessary, based on residents' assessment needs. Facility policy titled Falls dated 6/14 documents in part: observed or unobserved and reported by staff member, licensed nurse should conduct assessment immediately to determine causative factors. Facility job description titled Registered Nurse job description undated documents in part Job summary: the primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities performed by the nursing assistants. essential Duties and Responsibilities:1).directs the day to day function of the nursing assistants;8).meet with you assigned staff to plan the shifts services;21).develop nursing assistants work assignment;22).make multiple daily rounds on your shift to ensure acceptable standards are met. 2. R2's face sheet dated 07/29/2026 documents, in part, that R2 was admitted to the facility on [DATE] with diagnoses of Essential hypertension, hyperlipidemia, syncope, displaced fracture of upper end of right humerus, occlusions and stenosis of bilateral carotid arteries. R2's Minimum data set for Cognitive patterns and brief interview of mental status dated June 17, 2026, documents in part that R2 had a score of 03, which means that R2 was severely cognitively impaired. R2's Functional abilities section documents in part that R2 had a score of 03 which means that R2 required partial/moderate assistance from staff to complete the task of chair transfers and sit to stand. R2 had a score of 04 for ambulation, which means that R2 required supervision or touching assistance from staff to complete the task of ambulation safely. The facility Final Reportable Incident to the local state agency dated 06/24/2026 at 6:02 pm, documents in part: It was concluded that R2 is self-ambulatory with wheelchair. Upon completing rounds R2 was observed with discoloration to the right arm. A head-to-toe assessment was completed; a purplish discoloration was noted on his upper right arm and shoulder with mild swelling; R2 denied pain. R2 is alert & oriented x 1-2 with bouts of confusion; R2 was interviewed, but he is a poor historian of how the discoloration was acquired. Staff were interviewed. R2 was sent to the hospital for evaluation and was informed that an X-ray was done which revealed a displaced and angulated fracture of the right proximal humerus diaphysis. R2 sustained a fall 3 days prior, due to right sided weakness. R2 has a diagnosis which includes but not limited to polyneuropathy and syncope and collapse. R2 Brief Interview for Mental Status (BIMS) dated 06/17/2026 shows a score of 3 which indicated that R2 is severely cognitively impaired. On 07/30/2026 at 12:06pm V17 (Licensed Practical Nurse/LPN) stated that on 06/15/2026 around 12:04 am she heard R2 yell for help. V17 stated R2 had an unwitnessed fall. V17 stated R2 was unable to explain what happened or how he fell. V17 stated she performed a head-to-toe assessment and R2 showed signs of facial grimacing upon assessment indicating pain. V17 stated she contacted V15 (Physician) but no new orders were given to send R2 to the hospital for further assessment. V17 stated the fall interventions that were in place for R2 were not effective due to R2's cognition. V17 stated that more effective interventions could be a 1:1 sitter, bed alarms, and floor mats. V17 stated potential risks of not having the proper interventions in place could be increased injuries. R2's progress note dated 06/15/2026 authored by V17 documents in part, Staff heard R2 yell for help. Upon entering the room, writer observed R2 lying on the floor with his head elevated. A small skin tear was noted on the right forearm on the elbow. R2 was alert but unable to explain how the incident occurred. Head to toe assessment completed. No other injuries noted at this time. Skin tear cleansed with NS (normal saline) and covered with a dry gauze dressing. R2 exhibited mild signs of discomfort during assessment. V15 and V3 notified. Family was notified. No new orders received. R2 assisted from the floor per facility protocol, tolerated well. Plan of care ongoing. On 07/30/2026 at 10:05 am V6 (CNA) stated on 6/19/2026 she was assisting R2 getting out of the bed when she noticed facial grimacing. V6 then stated she took R2's shirt off and noticed bruising from his top right shoulder down to his waist. V6 also stated she noticed this was a change in condition. V6 stated she notified V16 (LPN) at that time. V6 also noticed R2 was unable to lift his arm up. V6 stated that due to R2's cognition, the interventions that were in place for him were not effective. V6 stated a bed alarm could have been helpful in alerting staff members if R2 was trying to get up by himself. V6 stated R2 was not mentally capable of being educated or redirected. V6 stated potential risks of not having appropriate fall interventions in place could lead to more frequent falls and injuries for the residents. On 07/30/2026 V16 (LPN) stated she was notified of bruises on R2 by V6 on 06/19/2026. V16 stated she assessed R2's skin and noticed discoloration on one side of his body. V16 stated she called V15 to notify him of changes in R2's skin. V16 further stated V15 gave orders to send R2 out to the hospital. V16 stated she placed a follow-up call to the emergency department and was notified R2 had sustained a fracture. V16 then notified V3 (DON) about R2's fracture. V16 stated due to R2's cognition the interventions that were in place were not effective. V16 stated floor mats, frequent rounding, and bed alarms could have prevented frequent falls for R2. V16 stated potential risks of not having appropriate interventions in place could lead to increased falls and injuries for the residents. R2's progress note dated 06/19/2026 authored by V16 documents in part, At Approximately 10:45 am While CNA giving AM care Resident observed with redness to Right arm. This writer Observed redness to Right shoulder, arm underarm pit also, Swelling to Right arm. Resident unable to state what Happen. Resident AOx1-2 at baseline. Complete body assessment done. No other new bruises or [NAME] observed. Resident c/o (complaint of) pain when trying to raise up right arm. R2 unable to rate pain level. Tylenol given as orders. V15 order to send to hospital. On 07/30/2026 at 9:53 am, V11 (Restorative Director) stated she manages restorative care plans. V11 stated she reads the risk management every day and keeps a log of all falls and fall dates. V11 further stated if residents suffer 2 falls within 30 days, they qualify for the Fallen Star Program. V11 stated R2 was a part of the Fallen Star Program. V11 stated she adds interventions for falls in their care plans such as floor mats, bed alarms and keeping residents in common areas. V11 stated R2's care plan had not been updated to reflect changes in R2's condition. V11 stated according to R2's BIMS (Brief Interview of Mental Status) score of three, the interventions that were in place at the time of R2's falls were not effective. V11 further stated a bed alarm would have been a good intervention to have in place for R2. V11 stated potential risks of not having proper fall interventions could cause serious injury to the residents. On 07/29/2026 at 11:58 am, V3 (DON) stated R2's care plan consisted of fall interventions. Some of those interventions included for R2 to be educated to ask for help, and R2 was enrolled in the Falling Star Program. V3 stated the Falling Star program consists of residents having a star on the door and frequent rounding for residents. V3 stated V6 was doing morning personal care for R2 when skin discoloration was observed. V3 stated she notified V15 (Physician) and was given orders to send R2 to the hospital. V3 stated no bed alarms or floor mats were in place at times of R2's falls, nor were these interventions care planned for. V3 further explained the potential risks of not having the appropriate fall interventions in place for residents could lead to injury and death. On 07/30/2026 at 10:22 am V3 also stated R2 should have had a bed alarm to alert staff of residents trying to ambulate on their own, as well as other interventions. V3 stated the interventions that were in place due to R2's cognition score were not effective. On 07/30/2026 at 11:15am V15 (Physician) stated bed alarms and floor mats would have been more effective interventions to prevent R2 from frequent falls. On 07/30/2026 at 2:04 pm V1 (Administrator) stated he was notified of R2's multiple falls by V16 and V17. V1 then stated that R2 was not cognitively intact to use his call light. V1 stated based on R2's cognition and co-morbidities, the interventions that were in place at the time of R2's falls were ineffective. V1 stated some interventions that could have been more effective are getting R2 up out of bed, checking on him frequently, and having floor mats. V1 then stated potential risk for not having appropriate fall interventions in place are repeat falls, and residents could sustain injuries. R2's Care Plan dated 07/17/2026 documents in part, R2 is at risk for falls due to syncope and collapse. R2 will have a safe environment maintained. The undated facility policy titled Falls documents in part Observed or unobserved and reported by staff member. Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible and causative factors. The undated facility policy titled Care Plan documents in part All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status.When a change occurs in a resident's condition the Care plan Coordinator is notified by a member of the Interdisciplinary Team. The care plan is then reviewed and updated.The Interdisciplinary Team is responsible for the implementation of resident care management.The Care Plan Coordinator reads report books and makes rounds daily and updates care plan as needed.

Based on interview and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. This failure places all 118 residents in the facility at risk to be provided with inappropriate care and services.Findings include:On 01/20/2026 at 1:08 PM, V11 (Licensed Practical Nurse) stated that she is the assigned nurse for the whole third floor and there are 37 residents. V11 stated that she does not feel comfortable taking care of this many residents because it gets overwhelming. V11 stated I am late on medications all the time. There is no way to do blood pressure checks, blood sugars, administer due medications and assess the residents effectively within a two-hour window. V11 denied that management helps. This surveyor asked V11 which resident has she given medication late to? V11 stated R114. On 01/22/2026 At 9:36 AM, V19 (Staffing Coordinator) I try staffing two nurses per floor and there are three floors. V19 stated that today there is one nurse working on the third floor because they were not able to get another nurse to come in. V19 denied that any staff are complaining that they are short-staffed. V19 stated that she will provide surveyor with the requested nursing daily assignments with the names of the nurses that did work that day. On 01/22/2026 at 1:48 PM, V2 (Director of Nursing) stated we are never short-staffed. We always have a nurse. We are supposed to have only one nurse. We staff two nurses to give the nurses more support to be able to provide care to the residents. When we provide one nurse, we are at adequate staff. I will provide two nurses, so they are able to provide more of a better care such as TLC (tender, love, and care). V2 stated I am not saying that one nurse is not able to provide that care. V2 stated that she is not aware that residents are receiving their medications late. V2 stated I do medication review audits which includes checking to see if the medication administration was recorded the prior day. V2 stated that she checks the time the medication was given more than once a month. V2 denied that any nurses have brought up staffing concerns. V2 stated in general if a facility is short-staffed; medication administration can be late, you are not able to give the resident the extra care that you would be able to give if you were not short-staffed.R114's Medication Admin Audit Report dated 01/20/2026 documents in part Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth three times a day for muscle spasm was due at 8:00 AM but was administered at 12:00 PM.R114's Medication Admin Audit Report dated 1/20/2026 documents in part metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 500 mg by mouth two times a day related to type 2 diabetes mellitus with unspecified complications was due at 08:00 AM but was administered at 12:03 PM.R114's Medication Admin Audit Report dated 01/20/2026 documents in part Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day related to chronic respiratory failure with hypoxia was due at 8:00 AM but was administered at 12:03 PM.R114's care plan documents in part R114 has diabetes mellitus. Interventions document in part diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Facility document dated 1/22/2026 documents in part census 122.Facility's nursing daily staffing sheet dated 1/22/2026 documents in part one nurse for the 2nd floor and one nurse for the 3rd floor.Facility document dated 12/27/2025 documents in part census 118.Facility's nursing daily staffing sheet dated 12/27/2025 documents in part one nurse for the 2nd floor and one nurse for the 3rd floor.Facility document dated 12/22/2025 documents in part census 120.Facility's nursing daily staffing sheet dated 12/22/2025 documents in part one nurse worked on the 1st floor, one nurse on the 2nd floor, and one nurse on the 3rd floor during morning shift.Facility document dated 11/16/2025 documents in part census 115.Facility's nursing daily staffing sheet dated 11/16/2025 documents in part one nurse worked on the 1st floor, one nurse on the 2nd floor, and one nurse on the 3rd floor during morning shift.Facility document dated 11/15/2025 documents in part census 115.Facility's nursing daily staffing sheet dated 11/15/2025 documents in part one nurse worked on the 1st floor, one nurse on the 2nd floor, and one nurse on the 3rd floor during morning shift.Facility document dated 1/20/2026 documents in part resident listing report, 118 residents.Facility document dated 01/20/2026 titled facility assessment tool documents in part the average census for 2025 was 116. Current Census 118 residents as 1/20/2026. Staffing plan. Total number of Licensed Nurses staffed per shift on average: 6 per days, 6 evenings and 3 nights excluding treatment nurse, staffing but agencies if needed. Individual staff assignments will be based on the individual resident needs, preferences and acuity of care provided, and will be re-evaluated and adjusted accordingly to meet these needs. In general, the most independent clients reside on the first and third floors, with the highest acuity of care clients residing on the second floor. Additionally the clients of the third floor typically have greater behavioral symptom management than the clients of the first floor.

Based on observation, interview and record review, the facility failed to follow their policies by a) not ensuring all food items in the kitchen were labeled/dated and b) not following manufacturer instructions to use the three-compartment sink. This failure has the potential to effect 113 residents that eat food from the kitchen.Findings include:1/20/26 at 9:36 AM, conducted initial kitchen tour with V23 (Head Cook). Observed one bag of diced turkey ham in freezer #3 with no label/date.1/21/26 at 1:47 PM, Observed V24 (Cook) prepare puree meal. Observed V24 cleanse the utensils, blender container, blade, top and spatula, in the three-compartment sink. Observed the middle rinse compartment with no water filled in it. V24 rinsed the utensils with running water from the faucet. V24 did not allow the utensils to remain submerged in the sanitizer for the manufacturer suggested time. V24 did not allow the utensils to air dry before reusing them for the next puree dish.Observed labeling on front of three-Compartment sink reading WASH WATER LINE, RINSE WATER LINE, SANITIZE WATER LINE indicating the water fill line/level for each compartment.1/22/26 at 12:23 PM, V23 (Head Cook) stated items should be labeled to know when the item needs to be discarded. Residents should not be served expired foods because they could get sick. The food could be messed up. I don't eat expired foods. I prepare puree meals. I wash the blender cup with soap, rinse with water and sanitize it in the 3-compartment sink. I also put it in the dishwasher. The first compartment, wash, is filled with water and soap. The second compartment, rinse, is filled with clean water. The third compartment, sanitize, has the sanitizer and water. All three compartments should be filled to the fill-line. Items are supposed to submersed in the water, not run under the tap. The items should be left in the sanitizer for at least 50 seconds. The amount of time for the chemical to sanitize. The items need to completely dry before reusing them. 1/22/26 at 2:03 PM, V8 (Dietary Supervisor) stated the bag of diced turkey ham should have been labeled upon entry. In the 3-compartment sink all three sections should be filled with water to the level point/water-fill line. Submerging is a more thorough process than just rinsing under the tap. Items should be submerged in the sanitize section for approximately 60 seconds to allow the sanitizer to be effective. Items should sit until completely dry because water is transient for bacteria. 1/22/26 at 4:20 PM, V1 (Administrator) stated food items in the kitchen should be labeled/dated so it is known when to discard them. Kitchen utensils should be washed and sanitized properly according to manufacturer instructions.1/20/26, Facility census was 118 with five residents NPO (nothing by mouth). Facility policy Labeling and Dating Foods, 2017, documents in part: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by.Facility policy Manual Sanitizing in Three-Compartment Sink, 2017, reads: Manufacturer's instructions on the wall poster above the three-compartment sink are followed. Utensils and equipment are air-dried.The wall poster above the three-compartment sink, Procedures for 3 Compartment Sinks, no date, documents in part: Fill WASH and RINSE sinks with hot water. Immerse utensils in RINSE SINK filled with clear, hot water. Immerse utensils in SANITIZER SINK for a full minute. Remove utensils from SANITIZER sink. Invert to drain. Let them air dry, do not wipe.

Based on observation and record review, the facility failed to follow their policy by not properly maintaining their dumpster area. This failure has the potential to effect all residents residing in the facility.Findings include:1/20/26 at 10:30 AM, Observed facility dumpster area. Observed one dumpster that was not covered by the lid. Observed two dumpsters that were overfilled with trash bags to where the lids could not close properly. Observed multiple latex gloves on the ground.1/22/26 at 12:23 PM, V23 (Head Cook) stated the dumpsters were full and not covered. The dumpsters should be covered because of mice, rats, dogs could be attracted to the area around the facility. There should not be trash on the ground around the dumpsters.1/22/26 at 2:03 PM, V8 (Dietary Supervisor) stated the kitchen disperses to the dumpsters. The lids should be closed even if the trash is overflowing. It is a community hazard. They should be covered to contain debris. If left open, it could attract rodents, bugs with the potential to pass germs.1/22/26 at 3:57 PM, V26 (Maintenance Director) stated dumpsters should not be overflowing so no mice, animals will come. The dumpster lids have to be closed at all times for mice, animals. The area around the dumpsters should be clean.Facility policy Waste Management, 5/25, reads in part: 4. Trash containers will be emptied when full but at least at the end of each shift. Plastic liners shall be tied and placed in outside dumpster, and dumpster lid kept closed. 5. Maintenance and Housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.

Based on observation, interview, and record review, the facility failed to review and update policies and procedures related to infection control prevention and failed to follow the facility policy for maintaining clothes and linen free off contamination in the laundry area. These failures have the potential to affect 118 residents living in the facility.Findings include:On 01/21/2026 V3 (Infection Control Preventionist) presented policies and procedures related to infection control and prevention that were not reviewed annually based on the dates that were written in the documents. General Infection Control Policy review date 12/2023Coronavirus (Covid-19) Policy review date 12/07/2023Antibiotic Stewardship Policy 05/2018Linen Storage and Transport Policy dated 07/2014Linen and Laundry Policy 03/2014Linen Handling Policy dated 11/2014On 01/21/2026 at 11:29 AM, V3 (Infection Control Preventionist) after review of facility's policies and procedures. V3 stated that policies and procedures are reviewed when they change. New infection control policies and procedures are sent by nursing director, consultant or corporate. Nursing consultant sends us the policy letting us know that it changes. V3 stated that she understands the need to review infection control policies and procedures at least annually. V3 said, I can see what you mean, policy changes often that it needs to be reviewed.On 01/21/2026 at 01:10 PM, laundry room was reviewed with V18 (Housekeeping Director) at the area where washing machines are located. V18 stated that all clothes and linens are being washed by facility's washing machines. A large fan was seen attached to the wall visibly with accumulation of dust and debris. V18 stated that she does not know how to turn it off. V18 stated, Even when it's on, I can see it needs cleaning. V18 stated that clothes and linen that are washed by these washing machines are still wet and need to be dry. That can attract dust coming from the fan. At the clean linen area, a table was seen full of linens with a portable fan (color orange and black) that was on directed to the linens. V18 stated that these linens are clean, and the table is used to fold clean linens. V18 stated, Yes, I can see that it is dirty. V18 stated that she will ask both fans to be cleaned.On 01/21/2026 at 1:28 PM, V26 (Maintenance Director) at maintenance office. V26 was asked about the water management program. V26 stated that water temperature needs to be checked Monday to Friday every week. V26 was asked to present log for current week that includes 01/19/2026, 01/20/2026 and 01/21/2026. V26 could not present any log stated that V27 (Assistant Maintenance Director) takes the water temperature. V26, after about 10 minutes presented a printout document with water temperature records for 01/19/2026, 01/20/2026 and 01/21/2026. V26 stated that V27 is currently out of the country for vacation, V27 brought water temperature log home and needed to call his wife because he left it in the car.Facility presented Water Management Plan dated 08/04/2021 that reads: This Water Management Plan expires on 08/01/2022 which was more than three (3) years ago.Housekeeping guidelines dated 07/2014: Purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. Housekeeping equipment should be kept clean and in good repair. Daily cleaning will be responsibility of the user. Linen and Laundry Policy dated 03/14: The purpose of the policy is to prevent further spread of microorganisms in the environment. Linen Handling Policy dated 11/2014: To ensure proper handling of soiled and clean linen and personal laundry prevent spread of microorganisms. Clean linen shall be stored in such a manner to prevent contamination. Per General Infection Control Policy dated 12/23: On environmental cleaning / disinfecting, a clean environment will minimize the presence and subsequent transmission of microorganisms. Regular cleaning activities using effective products and techniques are an important component of infection prevention and control. A regular schedule for periodic environmental cleaning shall be established minimal daily and as often as possible.

Based on review of records and interview the facility failed to follow infection control policies on offering vaccination for 4 out of 5 residents (R20, R90, R123, and R129) for a total sample of 24 residents reviewed for immunization, failed to include all facility staff in screening for Covid-19 vaccination, and failed to follow policy in offering Covid-19 vaccination to facility staff. Findings include:Resident records related to immunization reports are as follows:R20 does not have documentation of any vaccination.R90 documents receiving Mantoux skin test for TB (Tuberculosis), no Covid-19 vaccination recorded.R123 documents receiving Mantoux skin test for TB (Tuberculosis), no Covid-19 vaccination recorded.R129 documents receiving Mantoux skin test for TB (Tuberculosis), no Covid-19 vaccination recorded.On 01/21/2026 at 11:29 AM, V3 (Infection Control Preventionist) stated that there is no documentation that vaccination was offered. Any vaccination received by residents are documented in immunization report. V3 stated that she is still in the process of including R20, R90, R123 and R129 for flu, pneumococcal and Covid-19 vaccinations. Flu, pneumococcal and Covid-19 vaccinations should be offered upon admission. It is part of infection prevention that could benefit residents. V3 stated that she doesn't deal with staff Covid-19 vaccination screening. According to V3, HR (Human Resources) is in charge of Covid-19 screening for staff.On 01/22/2026 at 10:57 AM, V25 (Human Resources) presented document titled Covid-19 Staff Vaccination Status for Providers stated that document includes all staff Covid-19 vaccination status. V25 stated that for facility staff that does not have Covid-19 vaccination and would like to receive Covid-19 vaccine facility does not offer vaccination. V25 said, unfortunately, we don't offer (Covid-19 vaccines) that.Review of Covid-19 Staff Vaccination Status for Providers and List of all Active Employes documents show that there are fourteen (14) facility staff not included in Covid-19 Staff Vaccination Status for Providers screening. Facility staff are not included are as follows: Nine (9) Certified Nursing Assistants, one (1) Registered Nurse, one (1) Licensed Practical Nurse, one (1) Escort, one (1) Laundry Aide and one (1) Dietary [NAME] not listed as screened for Covid-19. Out of fourteen (14) facility staff, eleven (11) facility staff perform direct care to residents. One (1) facility staff (LPN) performing direct care to residents was not offered Covid-19 booster dose.Immunization Program Policy and Procedure dated 03/2025: the purpose is to eliminate or minimize the risk to residents who have been targeted as priority groups that are most vulnerable to influenza, pneumonia and other preventable diseases. It is the policy of this facility to provide for Immunizations for the Influenza virus, pneumococcal, coronavirus and other diseases. Residents and responsible parties are informed of the facility's vaccination prevention programs prior to or at the time of admission. The resident's immunization history shall be assessed and documented in the medical record at the time of admission within 72 hours.Policy and Procedure on Employees Immunizations dated 12/2023: Employees and physicians working in the clinic setting are at risk of exposure to communicable diseases or can potentially transmit a vaccine-preventable disease to others. Employees without documented immunity shall be offered recommended immunizations unless contraindicated.

Based on observation, interview, and record review, the facility failed to ensure residents were free from hazards. This failure has the potential to affect the 37 residents that reside on floor three.Findings include:1/20/26 at 12:45 PM, while touring floor three, accessed a room that was not locked, with no signage on the door. Observed two red bins. One red bin had one full Sharps container inside. One red bin had two full Sharps containers inside. Observed two grey bins with filled trash bags inside. Observed one tall, blue laundry container. Observed two sinks filled with more small bins, boxes, metal bed rails. 1/20/26 at 1:00 PM, accessed a room that was not locked with signage reading Clean Utility Room. Signs on the door read: DO NOT ENTER! Employees ONLY, Door Must be CLOSED, PLEASE make sure door is CLOSED. Inside of the room, observed four packs of ten blue stick razors, bottles of mouthwash, deodorant, shave cream, toothbrushes, toothpaste tubes, hairbrushes, adult briefs, gloves, gowns, urinals, two oxygen tanks and an IV (intravenous) pole.1/20/26 at 12:49 PM, accessed the rooms with V4 (Registered Nurse). V4 stated this is the trash room. Residents should not be able to get inside. Housekeeping comes in here. When full, we remove the Sharps containers from the carts and bring them in here. V4 stated residents should not have access to Sharps containers. It's a safety hazard. They could get cut, needle puncture. We put needles, and discarded medications inside them. Residents should not have access to discarded medications because they could take them or give to other residents. It is not safe. V4 stated residents should not have access to the razors. They have blades. They could harm themselves by cutting themselves, cause bleeding. V4 stated most residents on floor three have dementia.1/22/26 at 3:57 PM, V26 (Maintenance Director) stated I put a new lock on the clean utility room. The trash room was supposed to be locked so residents could not get in. The trash room has dirty linen, garbage, and sharps in it. I put a lock on it yesterday. There were two oxygen tanks, mouthwash, briefs, razors in the Clean Utility Room. Residents should not have access to the razors because they could cut themselves. 1/22/26 at 4:20 PM, V1 (Administrator) stated residents should not have access to sharps, razors, trash. It's a safety issue.1/20/26, Facility census on floor three was 37 with seven resident's dependent for mobility.Facility policy Needle Sharps - Handling and Disposal, 3/14, documents in part: 5. Used needles and other sharp objects, must be placed in a puncture-resistant biohazard container. 6. If the puncture-resistant containers are stored in an isolated room, they must be stored in an area that will not be considered a risk for the resident.

Based on observation, interview, and record review, the facility failed to a.) administer resident's prescribed medications in a timely manner according to the physician orders and b.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 9 out of 115 shifts. These failures have the potential to affect 54 residents residing in the facility. Findings include: On 01/20/2026 at 9:47AM, surveyor on the third floor of the facility with V11 (Licensed Practical Nurse/LPN). V11 states to surveyor that she started her shift at the facility at 6:00AM and began administering medications to residents at approximately 8:00AM. V11 states she has not completed her medication administration pass yet. V11 states she is the only nurse assigned to the third floor and is responsible for administering medications and caring for 37 residents. V11 states there is a staffing need for a second nurse to be assigned to the third floor to help care for the residents. On 01/20/2026 at 10:14AM, V11 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple resident's eMARs were red in color. V11 states the red color on the resident's eMAR indicate that the medication to be administered is considered late. V11 states the time frame to administer resident's medication is one hour before the scheduled time and one hour after the scheduled time. V11 states if medication is administered an hour after it is scheduled, then it is considered late. On 01/20/2026 at 10:58AM, V4 (Registered Nurse/RN) states she performed a narcotic drug count at the start of her shift, but she forgot to sign the shift change accountability record sheet. V4 states she is responsible for the 1st floor [NAME] medication cart. Review of the Shift Change Accountability Record for Controlled Substances Sheet for the month of January 2026 for cart identified as the West cart located on the 1st floor of the facility indicated for 9 shifts in January 2026, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 01/04/26, 3rd shift (10:00PM-6:00AM)On 01/06/26, 2nd shift (2:00PM-10:00PM), 3rd shift (10:00PM-6:00AM)On 01/08/26, 1st shift (6:00AM-2:00PM)On 01/10/26, 2nd shift (2:00PM-10:00PM), 3rd shift (10:00PM-6:00AM) On 01/18/26, 1st shift (6:00AM-2:00PM), 2nd shift (2:00PM-10:00PM)On 01/20/26, 1st shift (6:00AM-2:00PM) On 01/22/2026 at 8:01AM, surveyor located on the first floor of the facility with V6 (LPN). V6 states she has already completed her morning medication administration pass because she is used to working by herself, so she starts her medication administration pass early so that the residents will receive their medications on time. V6 states today, there are 2 nurses working on the first floor of the facility but prior to this, she has worked alone to care for all the residents on the first floor of the facility. On 01/21/2026 at 9:10AM, surveyor located on the third floor of the facility and observes that there are two nurses assigned to care for residents on the third floor of the facility. V4 (RN) states she is assigned to care for residents on the East wing of the third floor. V4 states another nurse (identified as V12/LPN) is assigned to care for residents on the [NAME] wing of the third floor. V4 states she has completed performing her morning medication administration pass. On 01/21/2026 at 10:49AM, V4 deploys the electronic medication administration/eMAR on the computer. Surveyor observes that multiple resident's eMARs were red in color. V4 states the red color on the resident's eMAR indicate that the medication to be administered is considered late. V4 states she administered medications to the residents but did not document, which is why the resident's eMARs are red in color. Facility census dated 01/20/2026 documents that 37 residents reside on the third floor of the facility, and 17 residents reside on the [NAME] wing of the first floor. Facility Medication administration audit reports dated 01/20/26 and 01/21/26 documents that multiple residents residing on the third floor of the facility were administered their medications late. Facility policy sated 02/2017 titled, Controlled Substance Medications documents in part, At each shift change, a physical inventory of specific medications, those selected by the facility, is conducted by two licensed nurses and is documented on an audit record.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for five (R13, R66, R77, R91, R108) residents reviewed for medication administration in a total sample of 24 residents reviewed, resulting in a 27.27% error rate. Findings Include: R66's electronic medication administration record/eMAR dated 01/22/2026 documents: Cholecalciferol Oral Capsule 25 MCG (1000 UT) (Cholecalciferol) Give 2 capsule by mouth one time a day scheduled at 9:00AM. On 01/22/2026 at 7:54AM, surveyor observed V13 (Registered Nurse/RN) administer Cholecalciferol 25 MCG (1000 UT) 1 tablet to R66. R91's eMAR dated 1/22/2026 documents: Ergocalciferol Tablet 50 MCG (2000 UT) Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 01/22/2026 at 8:29AM, surveyor observed V14 (Registered Nurse/RN) administer Cholecalciferol 25 MCG (1000 UT) 1 tablet to R91. R91's eMAR dated 1/22/2026 documents: Mucus Relief ER Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) Give 600 mg by mouth every 12 hours for cough for 7 Days scheduled at 8:00AM. Surveyor observed that this medication was not administered to R91 during the medication administration pass with V14 (Registered Nurse/RN). V14 states the medication is not available for administration to R91. V14 states R91's medication was already reordered on 01/20/2026 and she is awaiting it to be delivered from the pharmacy. R13's eMAR dated 1/22/2026 documents: Clotrimazole External Cream 1 % (Clotrimazole (Topical)) Apply to Bilateral plantar topically one time a day for prophylaxis at 9:00AM. On 01/22/2026 at 8:36AM, surveyor observed that this medication was not administered to R13 during the medication administration pass with V14 (Registered Nurse/RN). R108's eMAR dated 1/22/2026 documents: Docusate Sodium Oral Capsule 50 MG (DocusateSodium) Give 50 mg by mouth two times a day scheduled at 8:00AM. On 01/22/2026 at 8:45AM, surveyor observed V14 (Registered Nurse/RN) administer Docusate Sodium 100MG 1 tablet to R108. R77's eMAR dated 1/22/2026 documents: Calamine-Zinc Oxide External Lotion 8-8 % (Calamine-Zinc Oxide) Apply to topical topically two times a day scheduled at 8:00AM.On 01/22/2026 at 8:54AM, surveyor observed that this medication was not administered to R77 during the medication administration pass with V14 (Registered Nurse/RN). R77's eMAR dated 1/22/2026 documents: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain. Surveyor observes V14 administer Acetaminophen 325MG 1 tablet to R77. R77's eMAR dated 1/22/2026 documents: Cholecalciferol Oral Tablet 25 MCG (1000 UT) (Cholecalciferol) Give 2 tablet by mouth one time a day scheduled at 9:00AM. Surveyor observes V14 administer Cholecalciferol 25 MCG (1000 UT) 1 tablet to R77. R77's eMAR dated 1/22/2026 documents: Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour (Venlafaxine HCl) Give 150 mg by mouth in the morning for MDD/GAD scheduled at 9:00AM. Surveyor observed that this medication was not administered to R77 during the medication administration pass with V14 (Registered Nurse/RN). V14 states the medication is not available for administration to R77 and she has to reorder it. Facility policy dated 09/2025, titled Medication Administration Policy documents in part, Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview, and record review the facility failed to a.) label house stock medications that had been open and b.) remove and discard expired medications in two of five medication carts reviewed. These failures have the potential to affect 37 residents residing in the facility reviewed for medication labeling and storage.Findings include: On 01/20/2026 at 9:57AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart identified as the East cart. Surveyor observes the following: 1 open house stock medication bottle labeled Diphenhydramine HCL 25mg inside of the medication cart. Diphenhydramine medication observed with an expiration date labeled 07/2025. On 01/20/2026 at 10:08AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart identified as the West cart. Surveyor observes the following: 1 open house stock medication bottle labeled Diphenhydramine HCL 25mg inside of the medication cart. Diphenhydramine medication observed with an expiration date labeled 07/2025 1 open house stock medication bottle labeled Sodium Chloride 1GM inside of the medication cart. Sodium Chloride medication does not have a visible expiration date labeled. 1 open house stock medication bottle labeled Acetaminophen 325mg inside of the medication cart. Acetaminophen medication observed without an open date labeled. 1 open house stock medication bottle labeled Melatonin 3mg inside of the medication cart. Melatonin medication observed without an open date labeled. 2 open liquid medication bottles labeled R9's name, Megestrol Acetate 40mg/ml inside of the medication cart. Megestrol Acetate medications observed without an open date labeled on both bottles. On 01/20/2026 at 10:14AM, V11 states the Diphenhydramine medication should not be stored in the medication carts and should have been discarded once they expired on 07/2025. V11 states it is not safe to administer expired medications to residents and they could experience adverse reactions if given expired medications. V11 states the Sodium Chloride medication would not be safe to administer to residents since she is unsure of when the medication expires. V11 states all opened house stock and liquid medications should be labeled with an open date. Facility census dated 01/20/2026 documents that a total of 37 residents reside on the 3rd floor of the facility Facility policy dated 09/2025 titled, Medication Administration Policy documents in part, Multi-use vials and house stock liquids must be dated when opened. Expired medication may not be administered to the resident.

Based on review of records and interview the facility failed to follow immunization program policy and procedure on offering vaccination for 4 out of 5 residents (R20, R90, R123, and R129) for a total sample of 24 residents reviewed for immunization. These failures are not in accordance with facility's immunization program policy and procedure which 4 residents (R20, R90, R123, and R129) did not receive influenza and/or pneumonia vaccine(s) that may help in preventing infection(s).Findings include:Resident records related to immunization reports are as follows:R20 does not have documentation of any vaccination.R90 documents receiving Mantoux skin test for TB (Tuberculosis), no influenza and pneumococcal recorded.R123 documents receiving Mantoux skin test for TB (Tuberculosis), no influenza and pneumococcal recorded.R129 documents receiving Mantoux skin test for TB (Tuberculosis), no influenza and pneumococcal recorded.On 01/21/2026 at 11:29 AM, V3 (Infection Control Preventionist) stated that there is no documentation that vaccination was offered. Any vaccination received by residents are documented in immunization report. V3 stated that she is still in the process of including R20, R90, R123 and R129 for flu, pneumococcal and Covid-19 vaccinations. Flu, pneumococcal and Covid-19 vaccinations should be offered upon admission. It is part of infection prevention that could benefit residents.Immunization Program Policy and Procedure dated 03/2025: the purpose is to eliminate or minimize the risk to residents who have been targeted as priority groups that are most vulnerable to influenza, pneumonia and other preventable diseases. It is the policy of this facility to provide for Immunizations for the Influenza virus, pneumococcal, coronavirus and other diseases. Residents and responsible parties are informed of the facility's vaccination prevention programs prior to or at the time of admission. The resident's immunization history shall be assessed and documented in the medical record at the time of admission within 72 hours.American Healthcare Association Summary of CMS Vaccine Regulations for LTC 2025-2026: Before offering influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of immunization. Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunizationInterim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities dated 09/16/2024: The benefits of vaccination should be discussed, educational materials should be provided, and an opportunity for vaccination should be offered to the new resident as soon as possible after admission to the facility. Since October 2005, the Centers for Medicare and Medicaid Services (CMS) has required nursing homes participating in Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines and to document the results. According to the requirements, each resident is to be vaccinated unless contraindicated medically, the resident or legal representative refuses vaccination, or the vaccine is not available because of shortage. This information is to be reported as part of the CMS Minimum Data Set, which tracks nursing home health parameters.

Based on observations, interviews and record review, the facility failed to monitor one (R66) resident of six reviewed in a sample of 24. This failure led to R66 wandering into other residents' rooms.R66 is a [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to: dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, delusional disorders, depression, unspecified, and anxiety disorders. R66's MDS (Minimum Data Set) C-Cognitive Patterns dated [DATE], documents R66''s Brief Interview for Mental Status (BIMS) as 1/15, indicating severe cognitive impairment.On 01/20/2026 at 11:00AM, R66 was observed in another resident's room sitting on one of the beds and remained sitting for forty minutes. R66 was not able to answer questions.On 01/20/2026 at 11:25AM, V5 (Certified Nursing Assistant-CNA) observed R66 in another resident's room and stated R66 wanders in other resident's rooms. V5 stated the room R66 was currently in was not her room and the bed R66 sitting on was not her bed. V5 stated nursing staff are supposed to monitor R66 to prevent R66 from going into other residents' rooms which can upset other residents, and to keep R66 safe but staff are usually too busy to keep monitoring R66.On 01/20/2026 at 12:55PM V6 (Licensed Practical Nurse-LPN) stated R66 wanders in other resident's rooms and needs constant redirection. V6 stated R66's unit has residents with dementia and forgetfulness; residents can be friends one minute and next minute forget who the other resident is. V6 stated this can lead to R66 being hurt and found in other residents' room. V6 stated staff can redirect R66 but cannot stop R66 from entering other residents' rooms. V6 stated R66 should not be wandering into other residents' rooms because other residents can get agitated if they find R66 in their rooms and can hurt R66. V6 stated R66's room is far from the nursing station around the corner on the right side of the nursing station. V6 stated nursing staff do not always see R66 since her room is far from the nursing station.Surveyor and V6 reviewed R66's care plan dated 4/23/2025 which documented, a picture of R66 is to be placed on a discreet place in the nursing station and by the front reception to notify staff R66 is an elopement risk.V6 stated R66 is an elopement risk and looked for a picture of R66 by the nursing station. V6 looked behind computers, in binders, on the walls inside the nursing station. No picture of R66 was found. V6 stated a picture of R66 by the nursing station is to notify all nursing staff that R66 is a wanderer and an elopement risk. V6 stated care plans are for nursing staff to follow and give each resident care as documented in the care plan.On 01/20/2026 at 1:00PM, V6 checked R66 on the arm, neck and legs, no wander guard was observed. V6 stated R66 should be wearing a wander guard because R66 wanders and is an elope risk.On 1/20/2026 at 12:38PM, V7(Receptionist) stated names of residents who are on elopement risk are placed in the binder and stored by reception for safety to alert the receptionist if the resident tries to leave the facility. V7 stated if an elopement risk resident leaves the facility without permission, the resident can get lost or get injured while out in the community. V7 showed binder with elopement risk residents. Binder did not have R66 information on it. On 01/22/2026 at 2:12PM, V2 (Director of Nursing) R66 wanders in other residents' rooms and can be hit by other residents if she goes into their rooms and touches the other residents' belongings. V2 stated nursing staff should monitor R66 to keep her safe. V2 further stated R66's room is further away from the nursing station and around the corner where nurses cannot see her room from the nursing station. V2 stated R66 is at risk for resident-to-resident abuse because of wandering.Policy titled Resident Rights dated 11/18 documents:1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:-The right to an environment that preserves dignity and contributes to a positive self-image.Policy titled Supervision and Safety dated 3/15 documents:- Our facility-orientated approach to safety addresses risks for groups of residents such as wanderers, behaviors, aggressiveness, confusion, etc.- Resident supervision is a core component to resident safety.

Based on interviews and records review, the facility failed to refer two residents (R40, R92) with newly diagnosed serious mental illness for PASRR (Pre-admission Screening and Resident Review) screenings in a total sample of 24 residents reviewed for PASRR.Findings include: R40 Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome, review date 5/14/24, has a determination of No Level II Required – No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/related condition). R40 face sheet, printed 1/21/26, documents diagnoses that include but are not limited to delusional disorder with onset date 3/24/25; generalized anxiety disorder with onset date 3/24/25; major depressive disorder with onset date 4/17/25. According to Psychiatry Note 2/13/25, Per staff patient (R40) has no changes in baseline behaviors. According to Psychiatry Note, 3/13/25, Per Staff patient (R40) frequently presents with paranoid delusions. Will start patient (R40) on quetiapine to manage delusional thinking. According to R40 Order Summary Report, printed 1/21/26, R40 has active orders for Quetiapine Fumarate oral tablet. According to MDS (Minimum Data Set), 12/22/2025, R40 has potential indicators of psychosis, delusions. According to R40 care plans, R40 requires psychotropic medication to help manage and alleviate anxiety and delusions, revision 7/29/25. 1/21/26 at 2:12 PM, V16 (Social Services Director) stated PASRR (Pre-admission Screening and Resident Review) is to identify people who have a severe mental illness, intellectual disability and serve as a guide for services. It helps to determine correct placement. The Level one is done at admission. Level two is done depending on what information is recorded in the level one, mental health symptoms, cognitive issues, substance abuse, medical conditions, psychotropic medications. Upon admission, to determine if another level one is needed, I use the level one information and the hospital records. A new level one is warranted if they are in house and show indicators of needing a level two, mental health symptoms, substance abuse, self-reporting of psychiatric issues. If there are significant changes, new diagnoses then a new level one is warranted. I am alerted to significant changes and new diagnoses when the MDS (Minimum Data Set) triggers a significant change, or when I do a progress notes review. We check for MDS triggers weekly. New psychiatric diagnoses are discovered through Psychiatry progress notes twice monthly. Medical diagnoses are discovered upon hospital readmissions. I am familiar with R40. Because of the major Depressive Disorder and Delusional disorder diagnoses R40 should have been referred for another PASRR screening. R40 was not referred due to oversight. R40 does verbalize delusions sometimes. Facility policy Pre-admission Screening and Resident Review (PASRR), 12/23, documents in part: 6. The facility will consider submitting a new PASRR L1 screen if there is a suspected psychiatric condition and/or a new psychiatric diagnosis is added by a physician. R92 is a [AGE] year-old individual with medical diagnosis included in R92's current face sheet includes but not limited to: delusional disorders, unspecified dementia, moderate, with psychotic disturbance. Section C - Cognitive Patterns documents R92's Brief Interview for Mental Status (BIMS) as 7/15 indicating R92 has severe cognitive disabilities. R92's medical records document R92's PASRR screening was completed on January 23, 2025. R92's current face sheet documents R92's mental health diagnosis of delusional disorders dated 07/30/2025 and unspecified dementia, moderate, with psychotic disturbance dated 06/06/2025 were diagnosed during R92's During Stay at the facility. On 1/22/2026 at 3:45PM, V16(Social Services Director) stated PASRR 1(Preadmission Screening and Resident Review) potential skilled nursing home (SNF) residents are screened for mental illness (MI), intellectual disability (ID), or developmental disabilities (DD) prior to admission. This screening helps the SNF determine if a resident requires a referral for a PASRR 11 screening by a specialized screener. V16 stated PASRR 11 is a person-centered evaluation that helps the facility develop a person-centered treatment plan. V16 stated it is his responsibility to check all residents' medical records for new mental health diagnosis, complete a new PASRR 1 and trigger a PASRR 11 to be completed by an outside specialized screener. V16 stated he missed R92's new diagnosis of Dementia with delusional disorders and dementia, with psychotic disturbance which R92 was diagnosed with during R92's stay at the facility. V16 stated failing to complete PASRR 11 for R92 can lead to R92 not receiving the specialized care R92 needs. R92's Physician Order Sheet dated 08/21/2025 documents R92's medications to include Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate)-Give 2 tablets by mouth two times a day for dementia with psychosis, paranoid delusions. 2/18/2025 -Melatonin Oral Tablet 10 MG (Melatonin). Give 1 tablet by mouth at bedtime for Insomnia. R92's Nursing Progress Note dated 1/7/2026 22:21documents R92 was noted upset throughout shift, wanted a shower at exactly the time she was requesting which was during dinner. When informed she would be given a shower latter, R92 started yelling and cursing at staff, taking and oxygen off. PASRR screening policy dated [DATE] documents: -Facility staff, as indicated, will provide information to help Maximus compete the level 2 interview/screen.

Based on review of records and interview facility failed to acquire preadmission screening and resident review for 1 out of 5 residents (R63) in a total sample of 24 resident reviewed for resident assessment. These failures affect 1 resident (R63) in determining correct care settings for a resident with serious mental illness. Findings include:R63, a [AGE] year-old resident, initially admitted in the facility on [DATE]. R63 was diagnosed with bipolar disorder and alcohol use upon admission.On [DATE], facility received notice of PASRR level 1 screening that documents R63 referred to PASRR level 2 screening with suspected or confirmed mental health disability. Under PASRR level 1, R63 has mental health diagnosis of bipolar disorder, substance related diagnosis which is alcohol abuse or dependency and currently on Lurasidone 60 MG which is an antipsychotic. Outcome of PASRR level 1 documents that a PASRR level 2 evaluation must be conducted.On [DATE], facility received notice of PASRR level 2 screening that documents R63 was determined for short term approval without specialized services. Date of short-term approval ends on [DATE]. Per PASRR level 2 instructions this determination allows R63 a limited number of days in the facility. The short-term approval will end on the date short term approval ends which was [DATE]. If R63 or care provider thinks R63 needs to stay after [DATE], a nursing home facility staff member must submit a new PASRR level 1 screen. The new PASRR level 1 screen must be submitted no later than 10 days before the short-term approval date ends ([DATE]).On [DATE] at 10:44 AM, V16 (Social Service Director) stated that R63 has diagnosis of bipolar, alcohol abuse and is currently taking antipsychotic. R63 was admitted on [DATE] and was given short-term approval that already expired on [DATE]. V16 stated that he missed requesting a new PASRR screening for R63 because it did not trigger in the system on his computer. V16 stated he should do a new screening because it expired [DATE]. V16 stated PASRR screening is important to determine the right setting or placement for R63.Pre-admission Screening and Resident Review (PASRR) policy dated 12/2023 reads: it is the policy of this facility to comply with Federal, State and the appointed screening agency. Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help resident function at his/her maximum level of well-being.

Based on observation, interview, and record review, the facility failed to assist a resident in maintaining their vision by not following physician orders to obtain corrective lenses for one (R94) resident in a total sample of 24 residents reviewed. Findings include: On 01/20/2026 at 1:17PM, R94 states he has visited the eye doctor twice already and the eye doctor prescribed him eyeglasses. R94 states he gave the prescription to the nurses in the facility, and they lost his prescription both times. R94 states he is still without the eyeglasses that he needs.On 01/22/2026 at 10:01AM, V20 (Social Services Assistant) states R94 informed her last month and a few months ago that when he went to the eye doctor, he received a prescription for corrective lenses. V20 states that R94 told her that he gave his prescription to the escort who accompanied him to the eye doctor. V20 states R94 also told her that the escort gave his prescription to the social services department. V20 states no one in the social services department received a prescription for eyeglasses for R94. V20 states she attempted to follow up with this matter by trying to find out who the assigned nurse or escort was on the day R94 went to the eye doctor. V20 states she was unable to figure out who the nurse or escort was and R94 did not remember the name of the eye doctor that he went to. V20 states the resident's doctor appointments are posted on the facility's electronic bulletin board to inform staff of the resident's upcoming and past outside doctor's appointments. V20 states the bulletin board lists the resident's name, the doctor's office address and telephone number, the date and time of the office visit. V20 states the nurses are responsible for inputting resident appointments in the bulletin board because they are the ones who makes the appointments. V20 states she can search back at least one year to see a list of resident's doctor's appointments. V20 states she searched back approximately 3-4 months and could not locate a doctor's appointment scheduled for R94. On 01/22/2026 at 10:45AM, V21 (Eye Care Clinic Receptionist) states R94 visited their eye care clinic on 09/25/2025 and was seen by an eye doctor. V21 states R94 was given a prescription for eyeglasses to help with reading and for seeing at a distance. V21 states the escort who accompanied R94 to his appointment was also made aware of R94's prescription and the need to contact R94's insurance company regarding payment for R94's eyeglasses.R94's progress note dated 09/25/25 at 4:40PM, written by V22 (Licensed Practical Nurse/LPN) documents Back from eye center with Dr without any order. A reappointment scheduled for 3/26/26 at 1pm.Facility document dated 01/22/2026, titled Clinical Communications, Facility Bulletin Board documents that on 09/25/2025, an eye doctor appointment was made for R94 at an eye care clinic.A document dated 09/25/2025 shows that a prescription for corrective lenses was written and prescribed for R94 by an eye doctor outside the facility. Ombudsman Resident's Rights for People in Long Term Care Facilities dated 11/2018, documents in part, Your facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview, and record review the facility failed to implement infection control measures during storage of oxygen tubing for one resident (R114) out of five residents reviewed in a total sample of 24 residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs.On 1/20/2026 at 12:43 PM, R114's oxygen concentrator's oxygen tubing not covered and, on the floor, next to R114's bed.On 01/21/2026 at 12:47 PM, V2 (Director of Nursing) stated that the facility does have an oxygen equipment policy. V2 stated that for oxygen tubings, staff change the oxygen tubings weekly, and when not in use, staff keep them in bags. V2 stated that the tubing should not be on the floor because of infection control and the residents can place the oxygen tubing back in their nose.R114's current face sheet documents R114 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: chronic obstructive pulmonary disease, unspecified, acute and chronic respiratory failure with hypercapnia.R114's active physician order set documents in part, oxygen at 2-4 liters/min (minute) per n/c (nasal cannula).R114's Transfers and Bed Mobility/Limited lift review (Nursing/restorative) assessment documents in part transfer recommendation, Resident will be designated as Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 1 = One Person Assistance.Facility provided document titled Oxygen Equipment documents in part, to administer oxygen in conditions in which infection control is maintained. Oxygen tubing/nebulizer masks will be covered when not in use.

Based on observation, interview, and record review, the facility failed to follow their policy to ensure appropriate wound care treatment is met and carried out for one (R1) out of 3 residents reviewed for pressure ulcers in a sample of 9.Findings Include:Section C documents in part BIMS (brief interview of mental status) of 11 which indicates that R1 is moderate cognitive impaired.On 12/23/2025 at 9:49 AM, surveyor observed R1 laying down on her bed, in an upright position while watching television. R1 seemed comfortable, under no pain or distress. R1 is alert and oriented to person. R1 is not alert and oriented to place and time, and has frequent confusion. Surveyor observed R1 holding the call light with her right hand. Surveyor observed a catheter bag; it was secured and off the ground. Surveyor observed a wheelchair and a walker at the bedside. There were no odors present, and the room was clean and free clutter. On 12/23/2025 at 10:01 AM, R1 stated she went to the hospital a few months ago and was told she had infection. R1, stated she developed the infection while being in the facility. Surveyor asked R1 what type of infection she developed in the facility, but R1 was unable to recall the name and location of the infection. R1 stated she did not have an infection before coming to this facility. R1 stated she has not had her wound care done today. On 12/23/2025 at 11:45 AM, surveyor observed the wound doctor and wound nurse going into R1's room. On 12/23/2025 at12:46 PM, V17 (Wound Nurse) stated she has been working in the facility for 3 years and she is familiar with the R1. V17 stated when she first started caring for R1, she had existing wounds that had healed, but then she developed the sacral wound while being in the facility. V17 stated R1 requires weekly wound care with the wound care doctor. V17 stated the doctor will assess the wound on a weekly basis, and depending on the assessment the doctor will either change the wound care order or leave it as it is. V17 stated the wound care order has not changed, it is still the same for weekly wound care; apply Santyl ointment to sacrum once a day. V17 stated R1 did not have MRSA in the sacral wound when she began treatment with her 3 years ago. V17 stated R1 went to the hospital one day for wound care, and when R1 returned to the facility she had a diagnosis for Methicillin-resistant staphylococcus aureus (MRSA) of sacral bone. During record review, surveyor asked what it means when there is an empty square shown on the treatment administration record (TAR). V17 stated if it is empty that means it was not documented or it was not done for that day. Surveyor asked V17 what can potentially happen if treatment is not being done daily, V17 stated the wound will not heal properly.On 12/23/2025 at 1:21 PM, V2 (Director of Nursing/ DON) stated R1 was treated for MRSA when she was diagnosed in the hospital on August 27, 2025. V2 stated the MRSA was found in the sacral bone. Surveyor asked V2 if R1 was admitted with MRSA. V2 stated the MRSA was developed here and was discovered in the hospital.On 12/23/2025 at 2:00 PM, V19 (Infection Preventionist) stated R1 was sent to the hospital for wound care, and upon return to the facility she was diagnosed with MRSA in the sacral bone. V19 stated when R1 returned to the facility from the hospital she was placed on contact precautions and was taking antibiotics. V19 stated R1 is currently not taking any antibiotics, and she is no longer a candidate for contact precautions per their new policy. V19 stated she is currently on enhanced barrier precautions due to her wounds.Reviewed R1 treatment administration record, R1 did not receive any wound care treatment on 11/7, 11/9, 11/15, and 11/30.Policy titled Pressure Ulcer with no review date documents in part, It is the policy of this facility that pressure injury and other ulcers, (diabetic, arterial, venous) will be assessed and measured at least every (7) days by licensed nurse and recorded on the facility approved Wound Assessment Form. A notation will be made in the nurse notes, Treatment Administration Record, or on weekly bath sheet when NO skin problems are observed for the skin check.

Based on interviews and record review, the facility failed to provide adequate supervision during provision of ADL (Activities of Daily Living) care for 1 (R2) resident out of 3 residents reviewed for falls. This failure resulted with R2 falling while at the facility on 06/24/2025 and sustaining a facial laceration requiring sutures.Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) Type 2 Diabetes Mellitus, repeated falls, Alzheimer's disease, dementia, and laceration part of head (Onset Date: 06/25/2025). R2's (05/13/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section GG - Functional Abilities. GG0130. Self-Care. E. Shower/bathe self: 02 - substantial/maximal assistance - Helper does more than half of the effort. Helper lifts or holds trunk or limbs and provides more than half of the effort. R2's (Revision Date: 05/24/2025) care plan documented, in part Focus: has a Self-Care Deficit and requires assistance with ADL's to maintain the highest possible level of functioning. Goal: will maintain their current level of ADL functioning without a significant decline. Interventions: Provide assistance with all ADL's as required per the residents need dependence: Bathing.R2's (Revision on: 06/22/2023) care plan documented, in part Focus: is at risk for falls R/T (related to) Cognitive Impairments, Dementia. Goal: will remain free of injuries. Interventions: Staff to redirect resident when they see her bending over picking up anything off the floor (initiated: 09/13/2021). Anticipate and meet individual needs of the resident. (Date Initiated: 05/02/2017). R2's (06/24/2025) Fall documented, in part Person Preparing Report: V3 (Licensed Practice Nurse). Nursing Description: This writer was called by the CNA (Certified Nurse's Assistant) to the west side shower room, pt (patient) found lying on the floor leaning toward the left side, noted 2 lacerations on the left forehead above the left eye, bleeding, pressure dressing applied. 911 call was made, ambulance here to take pt to ER via stretcher. Predisposing Physiological Factors: confused, decreased safety awareness, and decreased strength. R2's (06/24/2025) CT Scan report documented, in part FINDINGS: Soft tissues: Swelling and laceration of the frontal scalp on the left side extending into the left periorbital area. R2's (06/30/2025) Final Reportable documented, in part Summary of Investigative Findings: While being showered by CNA (V4), the resident leaned forward, slipped off the shower chair, and fell, hitting her face on the floor. Resident has poor trunk control causing her to fall and sustain head injury, resident was sent out 911 and returned within 24 hours from ER (Emergency Room) with sutures.On 08/01/2025 at 10:32am with V17 (Licensed Practice Nurse) at the facility's first floor dining/activity room, R2 was seated on a wheelchair. R2 was leaning forward and V17 has to touch and guide R2's chin to show R2's face to the surveyor. R2 was observed with approximately 1mm x 2mm, 2mm x 2mm, and 3mm x 3mm scabbing above the corner of R2's left eyebrow. R2 was making noises, clenching her teeth. R2 failed to interact with the surveyor. V17 stated that she (R2) needs extensive assistance with bathing. That there should be 2 persons assisting her. That sometimes she (R2) is not redirectable and will not bear her weight. V17 stated, We need 2 people to safely give her a bath. On 08/01/2025 at 2:10pm, V4 (Certified Nursing Assistant) stated that if a resident is maximum assist with shower, there should be 2-person assisting the resident, that she (V4) took her (R2) to the shower; it was just her during that time and she did not ask other CNAs for assistance. V4 was in front of R2 while she was bathing her. V4 stated R2 tends to lean forward, and she (R2) leaned on her left side, and she (V4) tried to catch her. V4 stated R2 was too heavy for her and she grabbed her (R2) body, trying to protect her (R2) head from the impact but her head still hit the floor. V4 stated that even with the arm rest on both sides of the shower chair and positioned herself (V4) in front of her (R2), she still fell. V4 stated even before the incident on 06/24/2025, she (R2) always leans forward, and she (V4) should have asked for assistance when she gave her (R2) a shower to prevent her from falling. On 08/01/2025 at 12:03pm, V3 (Licensed Practice Nurse) stated that (R2) was being showered and fell; V4 tried to catch her but was unable to do so. That while in the shower room, she (V3) observed R2 with a laceration on the left side above her eyebrow. There were no other staff was present. V3 stated R2 is dependent on everything including shower and that R2 did normally well, but her (R2) trunk control was declining. R2 had poor trunk control prior to the incident. V3 added that there should be 2-person assisting R2 during shower to prevent falls.On 08/01/2025 at 12:31pm, V16 (Restorative Nurse/LPN) stated (R2) is coded substantial/Maximum assist with shower/bathing; that there should be up to 2 people assisting her with shower. R2 is alert only to herself and has a poor safety awareness and for safety, there should be 2 people assisting her with showers. On 08/01/2025 at 2:59pm, V9 (Therapy Director/Speech) stated for safety, she (V9) would recommend 2-person assist with shower. She (R2) has a very poor safety awareness and severe cognitive impairment. The likelihood of her falling could have been minimized. There is still a possibility she will fall with 2- person assist, but the incident of falls will be minimized. She has poor spatial awareness. She does not recognize leaning forward could cause her to fall.On 08/01/2025 at 1:22pm, V2 (Director of Nursing) stated V4 was disciplined for working in unsafe manner and R2 is 2-person assist with shower. V2 stated if a resident's MDS is coded 2 for Maximum Assist, ADL care should be performed with two people. V2 sated V4 did not follow the 2- person assist and if only she followed the 2-person assist, (R2) would have not fallen.V4's (06/25/2025) Corrective Action documented, in part Employee Name: (V4). Supervisor: (V2) Suspension. Reason for warning: No work shall be performed in an unsafe manner. The employee (V4) failed to follow safety precautions while giving a shower to a resident (R2) who was identified as a fall risk. Although the resident required the assistance of two caregivers, the CNA took the resident to the shower alone and did not ask for help. Disregard the company protocol led to the resident falling and sustaining an injury. The (06/25/2025) Inservice/Training Sheet documented, in part Topic: Resident that requires 2 (person) assist should always have 2 people/CNA present in the shower room. Presenter: V2 (Director of Nursing). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care facility resident in the State, you are guaranteed certain privileges according to rights, protections and State and Federal laws. You have the right to safety and good care. Your facility must provide services to keep you physical health.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for residents. As a result of these failures, R3 fell in the facility on 05/24/2025, while being showered by staff and sustained facial lacerations requiring 12 sutures. These failures affect three (R3, R4, R5) out of five residents reviewed for supervision and monitoring in a total sample of five residents. Findings include: On 06/07/2025, at 10:01 AM, V5 (Certified Nursing Assistant/CNA) states she is unsure of the name of the resident but heard that a resident on the first floor had stitches on their face. V5 states she heard this information approximately 1 week ago. V5 states since then, the facility has educated them on being careful when showering residents and not to leave them unattended during showers. On 06/07/2025, at 10:08 AM, V6 (CNA) states R3 was the resident who fell in the facility and has a scar on his face. V6 states she was not working in the facility that day. R3 fell but she heard of the incident when she returned back to work. V6 states she has cared for R3 and is aware of his behaviors. V6 states R3 moves around a lot, grabs things, and people when they walk past him. V6 states R3 is at risk for falls and wears a helmet in the facility. V6 states R3 needs to have his hand held for guidance and be watched at all times. V6 states she heard that 2 CNAs were showering R3 when he fell. V6 states she does not understand how R3 fell while in the care of 2 CNAs. R3 should not have fallen. V6 states R3's eye looked bad after he fell and R3 required stitches around his right eye. On 06/07/2025, at 10:10 AM, R3 was fully dressed and sitting in a chair located in the first floor hallway next to V7 (Licensed Practical Nurse/LPN). V7 observed with a medication cart and passing medications to residents with R3 sitting next to the medication cart. R3 observed with a gray helmet on his head and 3 steri strips on the side of his right eye. R3 is not verbally responsive and unable to make needs known. On 06/07/2025, at 10:14 AM, V7 (LPN) states she was not working in the facility the day that R3 fell. V7 states when she returned to work, she was informed that R3 fell while taking a shower. V7 states she was informed that there was a CNA (identified as V12) giving R3 a shower when R3 became agitated. V7 states another CNA (identified as V13) was called to the shower room for assistance. V7 states as V13 was putting on her gloves, R3 fell while in the shower. V7 states R3 had discoloration and lacerations above and below his right eye and required a total of 12 stitches. V7 states R3 is at high risk for falls and usually wears a helmet for safety in the facility. On 06/07/2025, at 10:48 AM, surveyor located on the second floor of the facility and hears a resident call out for staff assistance. V10 (CNA) observed inside of another resident's room without any residents inside. V10 observed with her phone in her hand looking at the screen. V10 states she is currently not on break and is responsible for caring for residents on the second floor. V10 states she should not be located inside of the resident's rooms operating her phone. Surveyor inquires to V10 if she is the CNA responsible for caring for the resident who called for assistance. V10 states that she did not hear a resident call for assistance while she was operating her phone. On 06/07/2025, at 11:12 AM, R4 and R5 observed sitting in a wheelchair inside of the third-floor activity room unsupervised and unattended. On 06/07/2025, at 11:13 AM, V15 (CNA) walks inside of the third-floor activity room and states she is responsible for monitoring the residents located in the activity room because it is her designated monitoring time. V15 states she is responsible for monitoring the third-floor activity room today from 11:00 AM-11:30 AM. V15 states there is supposed to be someone inside of the activity room monitoring the residents at all times. V15 states she is not certain of the resident's fall risk status but believes R5 is at risk for falls. V15 states if residents are not properly monitored, then they can potentially fall or injure themselves. On 06/07/2025, at 2:44 PM, V12 (CNA) states she was the nurse assigned to care for R3 the day he fell on [DATE]. V12 states the incident occurred at approximately 7:30 PM. V12 states she had just given R3 a shower. R3 was still located in the shower room sitting down in a shower chair. V12 states she then had R3 stand up and called her co-worker V13 (CNA) to come into the shower room to monitor R3 while V12 went to retrieve more towels. V12 states she saw V13 coming around the corner putting on gloves. V12 figured that V13 could see R3 from the angle where V13 was standing. V12 states V13 was standing approximately 2.5 feet away from R3 while V13 was putting on her gloves. V12 states she was standing at the shower room doorway getting more towels when she heard a loud boom. V12 states when she returned back to the shower room approximately 2 seconds later. She saw R3 lying face down on the shower room floor bleeding from his face. V12 states they then made the nurse (identified as V14) aware of R3's status and V14 went to the shower room to assess R3. V12 states she felt bad and was crying because R3 should not have fallen. R3's fall could have been prevented. V12 states R3's fall could have possibly been prevented if she had the towels closer to the shower room, or if V13 was standing closer to R3. V12 states R3 is at high risk for falls and requires a lot of 1:1 monitoring in the facility at times. V12 states R3 had a gash underneath his right eye and was sent out to the hospital to be evaluated. V12 states R3 returned back from the hospital the same day and had stitches in his right eye. V12 states R3's eye was also swollen and discolored blue and purple. On 06/07/2025, at 2:18 PM, V2 (DON/Director of Nursing/Fall Coordinator) states she handles the clinical reporting of falls to the state health department. V2 states she was on vacation when R3 fell and was made aware of R3's status. V2 states she followed up to ensure that R3's fall was investigated and reported by another staff member. V2 states she was made aware that V12 (CNA) was giving R3 a shower. V12 went to grab a towel and left V13 (CNA) with R3. V2 states V13 was putting on her gloves and she tried to catch R3 but R3 slipped and fell. On 06/07/2025, at 3:30 PM, V2 (DON/Fall Coordinator) states as a result of R3 falling in the facility, V12 (CNA) and V13 (CNA) were both suspended from work for a total of 3 days. On 06/09/2025, at 1:02 PM, V13 (Certified Nursing Assistant/CNA) states V12 (CNA) asked her for help while showering R3 because R3 was aggressive at that moment. V13 states R3 was irritated, aggressive, and trying to fight staff. V13 states V12 went to reach for towels. R3 attempted to walk while V13 was putting on her gloves. V13 states she tried to grab R3 but R3 fell face down in the shower. V13 states she feels really bad about R3 falling and cannot believe it happened. V13 states R3 fell within a matter of one second because they could not handle R3 in that moment. V13 states she was standing close to R3 but was trying to put her gloves on when R3 suddenly fell. V13 states R3 was bleeding close to his eye and V14 (LPN) called the ambulance. V13 states R3 was sent out to the hospital and needed stitches. V13 states she was suspended from work for 3 days and will be returning back to work this week. R3's Facesheet documents that R3 has diagnoses not limited to: Lacerations without foreign body of other part of head, unspecified injury of head, unspecified fall, history of falls, unsteadiness on feet, mild cognitive impairment, lack of coordination, seizures, and unspecified dementia. R3's MDS/Minimum Data Set, dated [DATE], documents that R3 has a BIMS/Brief Interview for Mental Status of 0/15, indicating R3 is cognitively impaired. R3 requires substantial/maximal assistance with showering/bathing. R3 is incontinent of bowel and bladder and ambulates via wheelchair. R3's Fall Risk assessment dated [DATE], documents that R3 is at high risk for falls. R3's care plan documents that R3 is at risk for falls with interventions to include Anticipate and meet individual needs of the resident. Facility Reported Incident dated 05/24/2025, documents that the facility reported to the state agency that R3 fell in the facility while in the shower and sustained injuries. R3's hospital records dated 05/24/2025, documents that R3 was evaluated in the hospital on [DATE], and diagnosed with complex lacerations of the face and required sutures. R3's nursing progress note dated 05/24/2025, at 7:20 PM, written by V14 (LPN) documents, This writer walked to the west side shower room. Writer noticed R3 was half sitting on the floor. Per the two aides who were showering R3, R3 slipped on the floor and fell. R3 was noticed with approximately two and half centimeter cut below the right eye (orbital area) oozing a moderate amount of blood. R3 was also noticed also with approximately 1 centimeter cut below right eye brow, oozing a moderate amount of blood. A pressure dressing was applied to both areas to stop the bleeding. R3 was assessed for any hip injury. Both extremities were equal in length and size. R3 denies any pain during movement of the both legs. R3 did not lose conscious, and was alert to name and situation. R3 was noted with base line mental status, and able to answer simple questions. R3 complained of pain on the forehead and right side of his face. R3 was noticed with swelling on the right facial area, swelling of the chin with bruising, right forehead swelling and purple discoloration, swelling and bruising of the right eye, right facial area edema with ecchymosis on and around the right side of the face. No bumps were noted on the head. R3 was able to grasp with both hands, and able to follow simple commands. R3's pupils were reactive to light. R3's right knee had a small cut, with a scrape. Redness was noted on the right hand by the thumb area with purple discoloration. No skin breaks. Redness was observed on the right side of the chest and abdomen area. 911 call was made and R3 was taken to hospital. R3's nursing progress note dated 05/25/2025, at 12:40 AM, written by V7 (LPN) documents Received R3 lying in bed with no signs of distress or discomfort. Writer noted R3 has 4 stitches below the right eyebrow that are intact. R3 has 8 stitches below the right eye (orbital area) that are intact. R3's right side of the face bruise along with swelling of the right eye. R3 right eye sclera redden, no drainage noted from the right eye. R3's chin on the right side has a small abrasion. R3's right knee had 2 redden scrapes with some right knee slight swelling. R3 has no active bleeding. R3 denies pain. No change in neurological status from baseline. Fall precautions implemented. R3 will continue to be monitored. R4's Fall risk assessment dated [DATE], documents that R4 is at high risk for falls. R5's Fall risk assessment dated [DATE], documents that R5 is at high risk for falls. Facility policy dated 03/2015, titled Supervision and Safety documents in part, Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. 1. Our facility-oriented approach to safety addresses risks for groups of residents such as wanderers, behaviors, aggressiveness, confusion, etc. 4. Resident supervision is a core component to resident risk factors. 9. Staff to decrease safety risk factors as much as possible. Facility policy dated 02/28/2014, titled Fall Prevention Program documents in part, 11. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. 22. Monitor gait, balance, and fatigue with ambulation.

Based on observation , interview and document review the facility failed to maintain all mechanical equipment in safe operating condition. This failure affected all residents in the facility by not providing hot water due to equipment failure. Findings include: On 4/30/25 the facility was toured and hot water accessible to the resident was measured with V5 (Maintenance Director) with a facility provided dial stem thermometer. 3rd floor mens common toilet at hanksink 11:10AM 90F . 3rd floor womens common toilet room. 11:13AM . No water supply at both handswashing sinks. 3rd floor womens shower and bathroom across room [ROOM NUMBER]. At shower 89F 11:16AM 89F. At handsink 91F. 3rd floor mens shower room across room [ROOM NUMBER] 11:20AM at handsink 90F. At shower 80F. 2nd floor mens shower room [ROOM NUMBER]:29AM handsink 87F, at shower 86F. 2nd floor womens shower room [ROOM NUMBER]:35AM handsink 88F, at shower 88F. 1st floor womens restroom/shower room [ROOM NUMBER]A 11:45 AM at handsink 83F at shower 88F. 1st floor mens toilet room [ROOM NUMBER]C 11:50 AM handsink 70F. On 4/30/25 at 12PM the basement boiler room was observed in the following condition. The boiler room was entered with V5. The walkway was flooded and water was running along the floor towards the sump pit Water was observed flowing from the hot water mixing valve located next to the 2 hot water tanks. On 4/30/35 at 12:05 PM V5 was questioned as to what was wrong. V5 stated the mixing valve is no good and I have a new one. I have to replace the mixing valve when we are done here. V5 failed to mention this condition to the surveyor when the facility hot water temperatures were being taken during tour. On 5/1/25 at 12:20PM V6 (Corporate Project Manager) stated we have the wrong mixing valve and a new one is being found from supplier at this time. The impeller is the wrong size. We also are having an issue with the boiler since the pilot light went out and we cant get the boiler to restart. We will continue until the hot water issue is resolved. On 5/5/25 at 10:37AM V5 stated I was aware that the there was no hot water available to the residents on 4/29 late in the afternoon. The mixing valve for resident hot water started leaking and partially flooded the boiler room where the hot water tanks are located. I notified the administrator. V6 came to the facility and we discovered the hot water mixing valve was not functioning. The impeller inside the unit was corroded due to age of the mixing valve. At this time we ordered a new mixing valve. There was no hot water available for the residents. The hot water boiler pilot light also malfunctioned because the water from the leaking mixing valve put out the pilot light to the boiler. On 5/2/25 we replaced the mixing valve and restarted the boiler. Water temperatures returned to 108F at resident accessible hot water fixtures. On 5/5/25 at 10:45AM V1 (Administrator) stated when V5 notified me of the inadequate hot water I notified staff in the building not to give showers to the residents. I told nursing staff to give bed baths only to the residents and to use wipes for ADL (Activities of Daily Living) care. We do not have a preventative maintenance program that includes the facility plumbing system. Today we have hot water restored and nursing staff may give showers to the residents. Facility hot water monitoring logs V5 uses to record hot water temperatures were reviewed. Log shows that on 4/29/25 AM the resident hot water ranged from 102 to 104 F . (According to V5 the mixing valve failed on 4/29/25 after the facility hot water temperatures were taken for the day) . On 4/30/25 hot water temperatures ranged from 77 to 78F. On 5/1/25 74 to 76F and 5/3/24 84 to 89F. According to V5 the hot water was restored on 5/4/25. Facility policy titled Hot Water Policy states Facility will comply with CMS requirements. Water Temps must be within the 105-120F range not to exceed it. Illinois requires Water Temps to be within 105F-110F in residents rooms, bathrooms and shower rooms.

Based on interview and record review the facility failed to develop and implement appropriate measures to ensure adequate supervision for three of three residents (R1, R2, and R3) identified at high risk for falls reviewed for falls with injury in the sample. This failure affected R1, R2, and R3 who had multiple falls and unwitnessed falls with lacerations requiring adhesive strips, sutures, and staples to correct the lacerations at the local hospital. Findings include: 1. R1's medical record Admission Record showed that R1 was admitted to the facility 11/09/2023. R1 diagnosis list includes but not limited to Alcoholic cirrhosis of liver without ascites, altered mental status, hepatic encephalopathy, abnormal results of liver function studies, alcoholic polyneuropathy, unspecified injury of head, subsequent encounter, anemia, alcohol dependence, uncomplicated, hypertensive heart disease with heart failure, unspecified dementia, unspecified severity, with other behavioral disturbance, thrombocytopenia, unspecified. R1's fall risk review presented dated 11/09/2023 showed that R1 was determined to be high risk for falls. R1's medical record showed that R1 had three unwitnessed falls in the month of February dated 02/20/25, 02/16/25 and 02/27/25. R1' medical record documentation showed that R1 had a fall with no injury on 02/20/25. R1's hospital record dated 02/16/25 documentation showed reason for ER (emergency room ) visit as fall and head laceration with diagnosis listed as scalp laceration initial encounter and fall initial encounter. Laceration repaired with four (4) staples. R1's fall risk review presented dated 02/16/25 showed that R1 was determined to be high risk for falls. R1's hospital record dated 02/27/25 documentation showed reason for ER visit as fall with diagnosis listed as chin laceration, initial encounter, and fall initial encounter. Laceration to the chin repaired with eight (8) sutures. R1's fall risk review presented dated 02/27/2025 showed that R1 was determined to be high risk for falls. The facility investigation conclusion for the incident of 02/16/25 final report indicated that it was confirmed that R1 had fallen while visiting a friend who is another facility resident. The staff members were interviewed and reported that the resident (R1) was lying on the floor near the walker in another resident's room during rounds. Facility investigation witness statement V19 CNA (Certified Nurse's Aide) I did not witness the incident. I was assigned to resident (R1). According to the facility investigation staff interview/statement post incident/accident report dated 2/27/25, V21 RN (Registered Nurse) wrote that the CNA called my attention saying that the resident (R1) is on the floor in the hallway near the toilet doorway at around (15:30) 3:30pm. V21 wrote that (R1) did not use his walker and (R1) is unaware of safety precautions. On 03/24/25 at 2:45pm, V21 RN (Registered Nurse) stated none of the scheduled staff saw R1 before the fall. R1 was found after the fall. V21 stated that R1 should be under strict supervision since R1 is at high risk for falls because R1 is constantly falling. V21 stated that R1 had a laceration not a skin tear, V21 stated that laceration can be from a blunt trauma, forceful and the wound is a deeper than skin tear. On 03/25/25 at 1:25pm, V16 (Restorative Aide) stated that R1 is high risk for fall. We (facility) put residents in a fall prevention program after they have two to three fall incidents. Right now, starting today (03/25/25). R1 is using non-skid floor mat, chair/bed alarm and since Friday using wheelchair after therapy reevaluation. On 3/26/25 at 12:36pm, V19 CNA (Certified Nurse's Aide) stated that she was in the shower room when the incident occurred on 02/16/25 and that before leaving to assist the resident V20 RN (Registered Nurse) was made aware so that another staff can monitor V19's assigned residents in making sure their needs are met and fall is prevented. The surveyor asks V19 whether in her opinion as a CNA any resident using assistive ambulatory device like a walker should be monitored. V19 stated yes. At 12:43pm, V2 DON (Director of Nurses) who was present during the interview stated that V20 (RN) is no longer working at the facility. V2 stated that one of the other CNAs or V20 should have made the other staff on the floor aware so they can help to monitor. V2 stated that on every shift there should be a staff (CNA) monitoring the hallway. 2. R2's medical record Admission Record showed documentation that R2 was admitted to the facility on [DATE] with list of diagnosis that includes but not limited to chronic kidney disease, hydronephrosis with renal and ureteral calculous obstruction, anemia, laceration without foreign body of scalp, subsequent encounter, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R2's medical record showed two unwitnessed falls in the month of March dated 03/07/25 and 03/20/25 with injury. According to facility final investigative report form for 3/7/25 incident R2 had a fall and R2 was sent to the hospital. According to the facility investigation dated 03/07/25, V13 CNA witness statement form documentation, V13 wrote in part that R2's roommate came and got me (V13) to let me know that R2 fell when I (V13) got back from break, R2 was noted on the bed leaning forward and bleeding then V13 called the nurse (Referring to V11). R2's medical record Progress note dated 03/07/25 timed 01:55 (1:55am) V11 documented that (R2) was found in bed following an unwitnessed fall by CNA (referring to V13). Assessment revealed that (R2) hit the head. V11 noted a laceration on the left side of the forehead and blood on the floor. Physician and 911 (local emergency number) called and was sent to the hospital. On 03/07/25 at 10:29am, V23 ADON (Assistant Director of Nurses) documented that when she called the local hospital, she was informed that R2 is admitted to the ICU (Intensive Care Unit) with diagnosis of anemia and subdural hematoma with bleeding. R2's medical record showed that R2 was transferred back to the facility on [DATE] at 4:03pm via ambulance with 2 to 3 stitches. On 03/14/25 at 11:59am, V4 (Wound care Nurse) documented that she removed 3 sutures from the left side of R2's forehead. R2's medical record Progress Note showed documentation that on 03/20/25 R2 had another unwitnessed fall incident with laceration to parietal area with minimal bleeding. R2's hospital record dated 3/20/25 showed that R1 was at the hospital for fall and listed diagnosis includes fall initial encounter and laceration of scalp without foreign body. Laceration corrected with one staple on the scalp. On 03/25/25 at 12:51pm, V11 LPN (Licensed Practical Nurse) stated that she was the nurse in charge for care of R2 with two CNAs on the floor. I (V11) was doing my rounds when the CNA (V13) who was just coming back from break called me that R2's roommate called her that something is wrong with R2. When I (V11) got to the room R2 was on the floor in a pool of blood with laceration to the left side of the forehead. I took the vitals and called the doctor (physician) and R2 was sent to the hospital. V11 stated that the incident occurred around 1:55am, there were two CNAs on the floor and we should have at least three CNAs because we have lots of residents who are at risk for falls. The surveyor asked about how the staff supervise/monitor the residents if one of them goes on break. V11 stated that when one (CNA) goes on break the other ones takes over to monitor the floor that is why we ask them to sit in the hallway. V11 stated that on 03/07/25 I did not hear any, noise, no yelling or crying (from R2) until (V13) called me. 3. R3's medical record Admission Record showed that R3 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Hydrocephalus, unspecified, cerebral infarction, unspecified, sepsis unspecified organism, presence of cerebrospinal fluid drainage device, traumatic subdural hemorrhage without loss of consciousness subsequent encounter, altered mental status, unspecified, low vision right eye category 2, low density vision left eye category 2, and presence of urogenital implants. R3's medical record showed that R3 had an unwitnessed fall on 02/12/2025, R3 was found on the floor in the west dining room. R3 was sent to the local hospital for evaluation and treatment, R3's CT scan at the hospital showed acute subacute subdural hematoma. Facility investigation report concluded that R3 attempted to reposition self without asking for help and slid out of the wheelchair. R3's medical record showed that R3 had a fall on 03/15/25, according to facility investigation documentation, R3 was turned too far in bed while receiving perineal care (Incontinent care). R3 was sent to the hospital where adhesive strips were applied to correct laceration to the forehead. R3's MDS (Minimum Data Set) dated 1/31/25 scored BIMS as 12. On 03/24/25 at 4:10pm, V2 stated that all these falls happened in the room and there is no way the facility can put the staff in the room with the residents. On 03/26/25 at 10:58am to 11:15am, during interview with V25 (Physician), V25 stated that R1, R2, and R3 have comorbidities that put them at risk for falls. V25 stated that they can all benefit from close supervision to prevent falls and injury to the residents. When the surveyor asked whether these falls can be prevented, V25 stated these residents are being treated with medicine but close supervision by staff is the only way that is successful in preventing their falls (referring to R1, R2, and R3). Yes, they will all benefit from close supervision. Most of these falls happened on nights (Night shift). On 03/26/25 as at 4:25pm, V2 and the surveyor were unable to reach V10 (Nighttime LPN), V20 (Former RN), V23 (Former ADON), V24 (Former RN) via phone for interview. The facility policy presented dated 2/28/14 on Fall Prevention Program documented that it is the policy of this facility to have a fall prevention program to assure safety of all residents in the facility, when possible. the program will include measures which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Listed guidelines for safety precautions for resident at risk includes but not limited to the frequency of safety monitoring will be determined by the resident's risk factors and plan of care, any resident who falls at least twice within 30 days will be considered at risk. The facility policy on Supervision and Safety dated 3/15 documented that resident safety and supervision are facility-wide priority. Resident supervision is a core component of resident safety. Staff to make visual rounds on residents minimally every two hours and more often, if necessary, based on resident's assessment needs.

Based on interview and record review, the facility failed to ensure that a resident remained free from mental abuse for one (R5) of three residents reviewed for abuse. This failure resulted in V4 (Former Certified Nursing Assistant/CNA) taking inappropriate photos of R5 and sending them in a text to her peers. A reasonable person who had inappropriate photos taken of them and shared with others would have felt sad, humiliated, and angry. Findings include: Facility's final incident report of 1/3/2025, documents on 12/30/2024, it was reported that (V4 Former CNA) took some inappropriate photos of (R5) and sent them to a CNA group text. An investigation has been immediately initiated and completed. Upon investigation, it is noted that V4 took photos and posted in CNA group. Face sheet indicates R5 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including but not limited to: Cerebral Infarction (stroke), Occlusion and Stenosis of Right Carotid Artery, Coronary Angioplasty Status, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (paralysis and weakness on one side of body following stroke), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphagia (difficulty swallowing), and Sepsis (body's extreme reaction to infection). MDS (Minimum Data Set) assessment dated [DATE] indicates R5 has severely impaired cognition. 1/28/2025, at 3:05 PM, V2 (DON-Director of Nursing) said V4 (Former CNA) was terminated on 12/31/2024, for HIPPA (Health Insurance Portability and Accountability Act) and resident rights violations by posting photos of a resident (R5) to CNA chat group members. 1/28/2025, at 4:24 PM, V6 (Certified Nursing Administrator) said she received pictures of R5 via group text from V4 (Former CNA). 1/29/2025, at 11:06 AM, via telephone, V9 (Scheduler) said she received a text from V4 (former CNA) at approximately 10:30 PM on 12/30/2024. Included in the text were two pictures of R5 (V9's aunt). R5's face was visible, diaper open and soiled with feces, buttocks visible. V9 said she was upset V4 sent pictures of R5 to her in a CNA group. V9 said V4 responded, it's not right what's going on, everyone needs to know. V9 reported the incident to V2 (DON) and V11 (Human Resources Director). V2 followed up with all CNAs included in the group text to ensure that pictures were deleted from their phones and not forwarded. R5's family was informed of the incident. 1/31/2025, at 9:02 AM, via telephone, V4 (Former CNA) Spanish speaking states, that day I went to start my night shift, I got to the floor, there were no nurses or CNAs, nobody was on the floor. When I got there, I find R5, hanging from the side rail, full of stool/wet and R5 is a fall risk. V4 continues to state I got scared and how could they leave her like that. My first reaction was that it was not fair to leave a person like that. I took a picture of the status she was in, they always left her like that. V4 reports that they wouldn't keep her safe, they didn't have anyone watching her, on top of that they would close her door because she would yell out. V4 reports that she was added to the group chat via text that was made for support. V4 states that she took one picture of R5 and sent the same picture twice in the group text. V4 states that she doesnt know how many CNAs were in the group chat. V4 continued to state that she did not receive any abuse training in the facility. I'm told to sign things, I don't know what I'm signing. V4 states that she completed her CNA training outside of the facility and she did struggle during the CNA training due to her language barrier. V4 reports that she feels sorry about what she did, but she continues to state she (V4) didn't know she shouldn't send the picture. V4 reports that other CNAs had sent other residents' pictures of bruises in the group chat. 1/30/2025, at 7:49 PM, via telephone, V25 (R5's Daughter) said she was informed by V2 (DON) that a CNA (Certified Nursing Assistant) took pictures of R5 and posted them to other staff via a group chat. V25 said R5 is not in her right mind and could not have given consent for the pictures to be taken. The pictures showed R5's face, she was completely nude. I was very heated, my concern was if R5's picture was posted on social media. V25 said she did not tell R5 about the pictures. V25 added, R5 would have felt sad, humiliated, and angry because it was an invasion of R5's privacy. CNAs Group Text list documents there were 19 CNAs included in the text. Abuse Prevention Program Facility Policy and Procedure (reviewed 1/4/2018) page 6 Photographing and Recording Residents documents in part, staff photographing or recording residents or their private space for other than medical or facility purposes is strictly prohibited. Staff posting or sending a photo or recording on social media or otherwise keeping or sending a photo or record through multimedia messaging other than for facility purposes is also strictly prohibited. Staff taking or using a photograph or recording of a resident in a manner that demeans or humiliates a resident, regardless of the resident's cognitive status or whether the resident consented, is strictly prohibited and will be handled as an allegation of abuse. Photographing or recording includes taking photographs or recordings from any type of device, including smart phones. Screening Assessment to Determine the Presence of Trauma Factors Including Abuse and/or Neglect Policy Protocol (undated) documents Mental Abuse includes, but is not limited to humiliation, harassment, threats of punishment, deprivation, or offensive physical contact. This includes abuse that is facilitated or enabled through the use of technology.

Based on observation, interview and record review, the facility failed to manage R3's pain by failing to have R3's Norco pain medication in stock. This failure resulted in R3 going without his medication for more then 24-hours and experiencing excruciating leg, wound, and body pain rated as 8 out of 10 on a numerical rating pain scale. Findings include: R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: atherosclerosis of native arteries of other extremities with ulceration, cellulitis of right lower limb, peripheral vascular disease, pain in right leg, essential (primary) hypertension, low back pain, peripheral vascular angioplasty status with implants and grafts, muscle weakness (generalized). Minimum Data Set (MDS) section C (dated [DATE]) documents that R3 has a Brief Interview for Mental Status (BIMS) score of 14, indicating that R3's cognition is intact. Care plan (dated 10/16/2024) documents that R3 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to non pressure chronic ulcer of right leg. Care plan documents that R3 peripheral vascular disease and is at increased risk of skin integrity issues. Pain Management Policy (revised 08/2021) documents in part: It is the policy of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. Around the clock pain management should be considered when the resident has pain 12 out of 24 hours. Medications Ordering Policy (dated 02/2017) documents in part: Medications and related products are ordered from pharmacy on a timely basis. Refill requests should be sent in 72 hours prior to the last dose. On 01/02/2025, surveyor was conducting a complaint investigation related to residents not receiving their medications. During the complaint investigation, surveyor interviewed R3, to determine if the resident is receiving all of his medications, as per the physician order. At 9:38AM, R3 stated, I have not had any issues with my medications. My medications are always on time, and it is given to me daily. The only issue I have is with my pain medication, Norco. My Norco is not given to me as per the physician order. I can have a Norco every 6 hours, as needed, and they are not giving it to me because they continuously run out. It's always when I am low and close to running out of the Norco, the nurses wait to the last minute to re-order it. They keep running out of my pain medications and at times I have to wait for 3 days for the medication to get here. It depends on who the nurse is. Some nurses wait to the last minute to re-order the medication and I won't get my pain medications for 3 days. They do not take the Norco from the convenience box; they just give me Tylenol. The nurses won't even try to supplement my Norco by going to the convenience box, they will just give me Tylenol instead, and make me wait for my Norco for days. I am waiting for the Norco right now. I was supposed to have the Norco for pain. They have not given it to me since yesterday, around noon. Right now, they do not have my medication in stock. My pain level is 8 out of 10. My pain is in the right and left leg. The Norco brought down my pain from 10/10 to 4 out of 10. I also have arthritis in my knee, and I have a wound as well, so I need the Norco to alleviate the pain. I am experiencing pain that is not being controlled because they don't always have my medications in stock, and this keeps on happening over and over again. On 01/02/2025, at 10:18 AM, V4 (2nd floor licensed practical nurse) stated, He (R3) does not have any Norco currently. I have been giving him Tylenol for pain. I gave R3 Tylenol for pain because R3's Norco is not in stock. I have to get the script for R3's Norco from the doctor or the nurse practitioner. There is a convenient box on the 3rd floor. It looks like R3 ran out of Norco yesterday (01/01/2025). The last time that we gave R3 his Norco is on 01/01/2025 at 11:50 AM. R3's Norco is supposed to be given every 6 hours as needed for pain. The convenient box is there to replace the medication that we do not have. I never retrieved any medications from the (medication convenience box), so I am not sure if I will be able to log in. I did not try to retrieve the Norco for R3 from the (medication convenience box). This morning I gave R3 a Tylenol for pain, and I did not go to the convenient box to retrieve the Norco. On 01/02/2025, at 10:20 AM, surveyor inspected the medication cart on the second floor. Surveyor noted that the medication cart did not contain R3's Norco 10/325 MG (milligrams) medication. At 10:25 AM, surveyor accompanied V4 (2nd floor licensed practical nurse) to the medication convenience box located on the 3rd floor. Surveyor observed V4 attempting to log into the (medication convenience box). Surveyor observed that V4 did not successfully log in and open the (medication convenience box), as V4 did not have a correct password to retrieve medication. V4 requested the assistance of V14 (3rd floor licensed practical nurse) to retrieve a Norco 10/325 MG tablet for R3's pain management. Surveyor observed V14 successfully logging into the convenience box. When V14 selected R3's name in the (medication convenience box), the convenience box was noted to not have the Norco 10/325 MG tablets in stock, and V14 was not able to retrieve the Norco pain medication. On 01/02/2025, at 1:02 PM, V2 (director of nursing-DON) stated, I was working on the 2nd floor yesterday and I gave R3's last Norco tablet around 11:50 AM. There was only one Norco left in the bingo card, and I re-ordered it after I gave the last pill. The nurses should not wait to re-order the medication. The pain medication should be re-ordered when there are a few pills left in the bingo card, to avoid running out of the medications. I re-ordered it right away, but it has not been delivered yet. On 01/02/2025, at 1:23 PM, V7 (director of clinical services) stated, The pharmacy will automatically replenish medications that are not controlled every 3 days. The Norco for R3 has to be re-ordered because it is a as needed (PRN) medication. At this time, R3 is out of his Norco tablets. The policy is that the medications should be re-ordered before the last pill is used. The nurse is not supposed to wait till the last pill is given before they order the medication. The nurses on the floor are not supposed to wait to order the medications when the medications run out, the medications should be re-ordered prior to running out. The (medication convenience box) is like a convenience box for medications that run out of the resident's medication supply. When nurses run out of the resident's medications, the nurses can temporarily retrieve the medications from the (medication convenience box), while they wait for pharmacy to deliver the resident's medication supply. When the medications run out, the (medication convenience box) is another source of temporarily obtaining medication. R3 has an order for Norco 10/325 MG every 6 hours as needed. R3's Norco medication ran out yesterday (01/01/2025). R3's Norco was re-ordered by V2 (DON) on 01/01/2025, after the last Norco tablet was given around noon. R3 is currently out of the Norco medication. The (medication convenience box) is not currently stocked with the Norco 10/325 MG medication and that's why R3 did not receive the Norco for pain. The Norco is not currently available in the (medication convenience box) because the pharmacy did not stock the Norco 10/325 MG in the convenience box. I spoke to the pharmacy, and they said that R3's Norco supply is on the way to the facility, and it will be here during the evening shift, close to 3:00 PM. The pharmacy should have stocked the convenience box with the Norco 10 MG, however, they failed to do so and that is why R3 has not received the pain medication. On 01/02/2025, at 1:37 PM, V9 (medication convenience box manager/pharmacy) stated, There were 3 residents in the facility who had an order for Norco 10/325 MG tablets. At this time, R3 is the only resident who has an active prescription for this medication. R3 receives this medication as needed for pain every 6 hours. The (medication convenience box) is not currently stocked with this medication, that's why the nurse who tried to retrieve the Norco from the convenience box was not able to do so. Once we refill the (medication convenience box) with the Norco 10/325 MG tablets, the nurses will be able to get the medication in case the resident's medication runs out. I will send you a master list of the medications that are supposed to be filled in the (medication convenience box). I will also send you a new (medication convenience box) list once the Norco 10/325 MG tablet supply have seen refilled. I put the pain medication as a Stat (immediate) order and it should arrive at the facility today, around 3:00 PM. R3's Norco supply will also arrive at the facility today, around 3:00 PM. On 01/04/2025, surveyor received Inventory on Hand (dated 01/04/2025) document by email from V18 (National Director of Clinical Services/Pharmacy) containing. The (medication convenience box) inventory list documented that the facility has 3 tablets of Norco 10/325 MG in the convenience box. On 01/07/2025, at 10:0 1AM, V10 (nurse practitioner) stated, R3 takes Norco 10/325 MG for pain, scheduled for 8 hours. R3 has pain in bilateral legs. R3 has a vascular wound on the left leg, which also causes R3 to have increased pain. R3 needs the Norco for pain management. When R3 does not receive the Norco pain medication on time, R3 will request to have it. When R3 does not receive the Norco pain medication as scheduled or in a timely manner, the resident's pain will increase. R3 does have Tylenol in between. I order R3's Norco, and I make sure that R3's Norco is filled. I am always here, and the nurses must let me know ahead of time that a script needs to be written, in order for me to write the script. The nurses should let me know that the Norco medication needs to be filled, when there are 5 Norco pills left in the bingo card. R3's Progress Note (dated 01/01/2025) documents, Resident received last Norco at 11:50 AM. Provider notified and request new script. Resident has order for Tylenol to be administer PRN while waiting for script for Norco 10-325 MG. R3's Physician Orders (dated 01/02/2025) state: Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug*. Give 1 tablet by mouth three times a day for pain related to pain in right leg. Weekly Skin Alteration Review (Wound Nurse) (dated 01/02/2025) documents that R3 has a venous wound measuring 5.1 x 4.0 x 0.2.

Based on observation, interview, and record review the facility failed to ensure that sufficient Wound Care Nurses are available to meet resident needs, failed to provide timely incontinence care, failed to administer prescribed treatments, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings and failed to ensure that the LALM was on the correct setting for three of three residents (R1, R2, R3) reviewed for pressure ulcers. These failures resulted in R1 sustaining a (facility acquired) sacrum pressure ulcer with tailbone exposure/fracture and radiographic suggestion of osteomyelitis, R2 sustained a stage 3 (facility acquired) pressure ulcer, and R3 sustained a stage 3 (facility acquired) pressure ulcer. Findings include: The (12/3/24) facility pressure ulcer log affirms R1, R2 and R3 sustained (facility acquired) sacrum pressure ulcers. 1) R1's diagnoses include dementia, multiple sclerosis, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, (Stage 4) pressure ulcer of sacral region, hemiplegia, and hemiparesis. R1's (11/21/24) functional assessment affirms resident requires substantial/maximal assistance with rolling left and right. R1's (11/21/24) risk assessment for potential skin integrity impairment determined a score of 13 (moderate risk). R1's (12/3/24) skin alteration assessment includes (facility acquired) sacrum (stage 2) pressure injury 1.3 x 1.3 x 0.3cm (centimeters). R1's (9/24/24) care plan states resident has an alteration in skin integrity and is at risk for additional and/or worsening skin integrity issues related to incontinence and impaired mobility. Intervention: Air loss mattress. R1's (1/8/24) POS (Physician Order Sheets) include pressure reduction mattress. R1's (12/5/24) weight was 133.6 pounds. On 12/9/24 at 2:03pm, R1 was in bed and the LALM was set on alternate #5. Surveyor inquired when R1 was placed in the wheelchair. V5 (CNA/Certified Nursing Assistant) stated A little bit after 10am (roughly 4 hours prior). V5 subsequently removed R1's incontinence brief (as requested) a large bowel movement was adhered to the skin between the buttocks and lower back. Surveyor inquired what was on R1's skin V4 (CNA) replied Poop. Bowel movement was also present on R1's sacrum dressing dated 12/7 (two days prior). R1's (November 2024) TAR (Treatment Administration Record) includes the following physician orders: apply to sacrum [NAME] Oil daily however 9 (see nurses note) is documented for 11/3, 11/9, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/26 and 11/27 entries. R1's (11/3, 11/9, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/26 and 11/27 2024) progress notes exclude wound care documentation. On 12/11/24 at 1:12pm, surveyor inquired what a #5 setting indicates on the LALM. V11 (Wound Care Nurse) stated I don't know, I don't know what weight that is. We got 2 of them (LALM) that don't got no weight on it and it may be the in between setting. I came back from maternity leave mid-November and I haven't checked them since I got back. Surveyor inquired about R1's sacrum wound and current treatments. V11 responded Currently she has collagen to the site. Her wound looks really good, its open in just a little area. It's healing very well. We have it (Collagen) scheduled every other day unless its PRN (as needed). R1's (12/13/24) CT (Computed Tomography) Pelvis (obtained 2 days later) states indication: worsening deep sacral wound. Check for soft tissue infection and underlying osteomyelitis. Findings: there is no skin or subcutaneous tissue over the distal vertebral column where the sacrum transitions to the coccyx. There is associated focal sacrococcygeal sclerosis and fracture of the distal bone concerning for osteomyelitis. Impression: penetrating 4.7 x 4.8cm skin and soft tissue defect (ulcer) exposes the tailbone beginning where the sacrum transitions to the coccyx, complicated by radiographic suggestion of osteomyelitis. On 12/16/24 at 2:18pm, surveyor inquired about potential harm to a resident if wound treatments are not administered as ordered. V18 (Medical Director) stated Its gonna get worse and worse. Surveyor inquired about potential harm to a resident with bone exposure. V18 responded osteomyelitis and sepsis. 2) R2's diagnoses include dementia, type 2 diabetes mellitus, and stage 3 chronic kidney disease. R2's (11/7/24) functional assessment affirms resident requires partial/moderate assistance with rolling left and right. R2's (11/7/24) risk assessment for potential skin integrity impairment determined a score of 16 (low risk). R2's (12/3/24) initial skin alteration assessment includes (facility acquired) sacrum (stage 3) pressure injury 3.2 x 5.8 x 0.2cm. What is the probable or known cause of the skin alteration? pressure and incontinence. R2's (5/11/24) care plan states resident is at increased risk for alteration in skin integrity related to peripheral vascular disease, diabetes mellitus and incontinence. Interventions: precautions for prevention of Pressure Ulcers will be completed: good peri care. R2's POS includes (2/5/24) pressure reduction mattress. On 12/9/24 at 2:18pm, R2 was lying atop of a LALM, and the setting was on 160 (pounds). Surveyor inquired about the settings on R2's LALM V4 (RN/Registered Nurse) stated I don't deal with this. I think who deals with this is restorative if I'm not mistaken. R2's incontinence brief had a blue line present (indicating the brief was wet). V6 (CNA) removed R2's brief (as requested) and it was soiled with urine. On 12/11/24 at 1:18pm, surveyor inquired if R2 weighs 160# (lbs). V11 (Wound Care Nurse) stated I don't think so then reviewed R2's electronic medical records and affirmed It's 123.4 (pounds) on 12/6/24. Surveyor inquired what R2's mattress is supposed to be set on. V11 responded I don't know. I'm not sure what the setting's supposed to be. Surveyor inquired about R2's current sacrum treatment. V11 replied He gets Medihoney to the sacrum. Surveyor inquired who's responsible for dressing changes. V11 stated I do them every time I'm here and sign them off. Today I'm working on the floor, so the Nurses are responsible for wound care and affirmed that she's the only Wound Care Nurse employed by the facility. R2's (December 2024) TAR includes the following physician orders: apply to sacrum Medihoney and cover with bordered foam daily however the treatment was not documented on 12/8 (the entry is blank). 3) R3's diagnoses include type 2 diabetes mellitus. R3's (9/1024) functional assessment affirms R3 requires substantial/maximal assistance for rolling left and right. R3's (9/10/24) risk assessment for potential skin integrity impairment determined a score of 14 (moderate risk). R3's (2/2/24) care plan states resident has potential/actual impairment to skin integrity. Intervention: Keep skin clean and dry. R3's (10/31/24) initial skin alteration assessment includes (facility acquired) sacrum (stage 3) pressure injury. 1.0 x 1.0 x 0.5cm. R3's (10/19/20) POS includes pressure reduction mattress. On 12/9/24 at 1:49pm, R3 was lying atop of a LALM. Surveyor inquired about the settings on R3's LALM V4 (RN) replied I am not too familiar with the air settings. V5 (CNA) affirmed that R3's LALM setting was on #8 (350 pounds) however R3 appeared to be less than half that weight. [R3's 12/6/24 weight was 138.0 pounds therefore the LALM was on the incorrect setting]. Surveyor inquired when R3's incontinence brief was last checked and/or changed V5 responded. Around lunch, she may be wet. V5 removed R3's brief (as requested) and affirmed it was soiled with urine. On 12/11/24 at 1:09pm, surveyor inquired who's responsible for the facility LALM settings. V11 (Wound Care Nurse) stated I set them, and I go around maybe once a month to check on them. Surveyor inquired why R3's LALM was set on #8 (on 12/9/24). V11 responded I can't answer that cause I'm not really sure why that was set on 8. It should not have been. Surveyor inquired if R3 weighs 350 pounds. V11 replied She does not, she's not big at all. Surveyor inquired about R3's current sacrum treatment. V11 stated She (R3) just has betadine to the site. R3's (December 2024) TAR (Treatment Administration Record) includes the following physician orders: apply Betadine to sacrum one time a day however on 12/8/24 the entry is blank. The (8/23) Low Air Loss Mattress policy states low air loss mattresses may be used for residents who are high risk for pressure ulcer/injury development. Operating instructions: turn the pressure adjust knob to set a comfortable pressure level from soft to firm. [required settings including numbers and/or weights are excluded from the policy].

Based on interviews and records reviewed, the facility failed to ensure staff report new behavior/s to appropriate supervisor and department head for one resident (R2) resulting with the resident to be observed on the floor and sustaining a laceration to the head, was sent out to the Hospital Emergency Department and treated with laceration repair (staples). This deficient practice affected one resident (R2) reviewed for quality of care in a total sample of 6 residents. Findings include: R2's Admission Record documented that R2's diagnoses (include but not limited to) epilepsy, laceration without foreign body of scalp (onset date: 05/11/2024) and restlessness and agitation, and failure to thrive. R2's (Date Of Occurrence: 05/12/2024) Smartsheet Email to V2 (Director of Nursing) documented, in part Sent: Monday, May 13, 2024 (at) 1:34pm. Subject: Confirmation -Facility Reported Incidents. Incident description: It was reported that resident had an unwitnessed fall. Body assessment completed and laceration observed to the right lateral side of forehead. Resident sent out 911. Resident returned from hospital with six staples to area. Definition: unusual occurrence is any unusual circumstances such as accidents incidents and accidents resulting in injury requiring the services of a physician, or other service provider on an emergency basis shall be reported to the Department of Public health within 24 hours of the incident or accident. Describe occurrence: it was reported that resident had an unwitnessed fall. Body assessment completed and laceration observed to the right lateral side of forehead. Resident sent out 911. Resident returned from hospital with 6 staples to area. Was hospital or ER treatment needed? yes. Evidence of new redness, bruises, abrasions, lacerations? Yes. Meets the State definition of serious incident? Yes. Initial report faxed. Date: May 13, 2024. License nurse signature: (V2- Director of Nursing). Date: May 13, 2024. Upon completion of the investigation, it was reported by nurses and CNA's that the resident usually positioned herself in the fetal position, and the resident always tried to reposition herself throughout the day and night, which may have caused the resident to fall. (V2). R2's (05/11/2024) Hospital Emergency Department notes (as translated by V1- Administrator) documented, in part Instructions: Laceration was stapled laceration should be monitored for signs of infection. Treated by: MD (medical doctor). Procedures and exams: laceration repair. Diagnosis: ground level fall, scalp laceration. Done today: laceration repair. R2's (05/17/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: no entry. C1000. Cognitive Skills for Daily Decision Making: 2. Moderately impaired. Section GG. Functional Abilities. GG0170. Mobility. A. Roll left to right: 1 - Dependent. B. Sit to lying: 88 - Not attempted due to medical condition of safety concerns. C. Lying to sitting on side of bed: 88 - not attempted due to medical condition of safety concerns. R2's (05/11/2024 15:17 (3:17pm)) nursing progress note documented, in part received report regarding resident on ground, upon assessment resident lying on ground next to the bed in designated room, active ROM with no deformities, however laceration to right side of head noted with moderate bleeding neurochecks initiated emergency response activated and taken to nearest hospital for unwitnessed fall and head contact with surface. Father, MD, Hospice, and management aware. 98.1, 74, 18, 119 / 70. Authored by: V9 (Registered Nurse). R2's (05/11/2024 15:18 (3:18pm)) progress note documented, in part en route to nearest hospital according to paramedics via stretcher in stable condition. Authored by: V9 (Registered Nurse). R2's (05/11/2024 23:43 (11:43pm)) progress note documented, in part arrived from hospital via stretcher accompanied by two ambulance paramedics. Head to toe assessment completed with six staples noted to right lateral head. management aware. Authored by: V9 (Registered Nurse). On 05/28/2024 at 11:45am, there was a blue star with a yellow arrow by R2's name identifier on the entry way. V3 (Assistant Administrator) stated that she (R2) is a falling star. The purpose of the star is to let the staff know that she (R2) is in the falling star program. Resident who has more than one fall in a month is placed on falling star program for precautions, so staff know to keep on eye on the resident. she has floor mats one on each side, bed on lowest positions and her mattress with foam on the sides. she is on hospice. She (R2) has history of falls. i cannot recall when. On 05/28/2024 at 11:54am, V5 (LPN) checked R2's head. There was a dry scab on the right side of R2's of head. V5 stated she(R2) had staples due to a fall. I (V5) was not here when it happened. On 05/28/2024 at 2:03pm, V7 (Restorative Nurse/LPN) stated she (R2) is on the falling star program. She (R2) is really weak, at times strong as a bull. I (V7) am not really sure how she(R2) has fallen with the wedges in place. It is impossible. For each fall, I (V7) or the MDS coordinator update her (R2) care plan. The (05/11/2024) Staffing documented that V5 (Licensed Practice Nurse), V15 (CNA), and V16 (CNA), worked the 6am - 2pm shift and were assigned to R2; and V8 (CNA) and V9 (Registered Nurse) worked the 2pm - 10pm shift and were assigned to R2. On 05/28/2024 at 2:10pm, V8 (CNA) stated when I (V8) got to her (R2) room, she (R2) was on the floor mat on the right side. The wedge was still on the bed but was moved a little to the side of the bed. There was blood coming from her (R2) head. On 05/29/2024 at 10:47am, V9 (Registered Nurse) stated she (R2) is bedbound and nonverbal. She (R2) made significant progress, (R2) no longer npo (nothing by mouth). The CNA (V8) informed me (V9). She (V8) said that during her (V8) rounds, (V8) noticed (R2) on the right side of bed, and (V8) immediately notified me (V9). When I (V9) came in, (R2) was on the right side of her (R2) bed. She (R2) was lying on the floor. Upon assessment, she (R2) has an injury on the right side of her (R2) head. I (V9) was not able to see much, but I (V9) did notice bleeding, minimal to moderate not profuse. I (V9) called 911. That is our policy for unwitnessed falls. On 05/29/2024 at 11:13am, V9 stated my shift starts at 2pm. I (V9) received report from the morning nurse (V5) about her (R2) meal consumption, that she is tolerating her meals well, that she (R2) is enjoying her food. On 05/29/2024 at 12:47pm, V5 (Licensed Practice Nurse) stated yes, I (V5) worked the morning of 5/11/24. She (R2) did have her (R2) days. I (V5) constantly go to her (R2) room because all of the sudden she (R2) would get up and move. I (V5) observed her (R2) putting both her (R2) hands to her (R2) back and extend her (R2) elbows on her (R2) back and moved her (R2) legs over the wedge and she (R2) was making cat noises as if she (R2) was possessed. Surveyor requested V5 to demonstrate what V5 observed R2 was doing. V5, still seated on a chair, arched her (V5) back on semi sitting position with elbows extended, and both hands on the edge of the seat. V5 made hissing sounds. V5 stated that is why I (V5) started putting her (R2) in front of the nurses station. But on that day, 05/11/2024, I (V5) observed her (R2) doing that again. But I (V5) did not put her (V5) in front of the Nurse's station because she (R2) scared me (V5) and I (V5) don't want her (R2) to scare other residents. That was the second time I (V5) saw her (R2) doing that. The first time I (V5) saw her (R2) doing that was a week before her (R2) last fall. I (V5) don't remember telling the restorative nurse (V7). I (V5) did not tell the DON (2). I (V5) don't really remember. On 05/31/2024 at 2:12pm, V15 (CNA) stated the nurse (V5) did not tell me anything. I (V15) have never observed her (R2) moving her (R2) legs over the wedge, I (V15) have never seen her (R2) on semi sitting position with her (R2) elbows extended on her (R2) back trying to get out of the bed. On 05/31/2024 at 3:24pm, V16 (CNA) stated she (R2) never attempted to get out of the bed on her (R2) own. I (V16) never witnessed her (R2) doing that. I (V16) was not informed by any staff, nurse or cna, that she (R2) is able to sit on semi sitting position and move her (R2) legs over the wedge. I (V16) definitely think it is important because if I (V16) was aware of that, I (V16) would have monitored her (R2) more frequently. If I (V16) do witness that, I (V16) will report it immediately to the nurse and Director of Nursing, in case, of future complications, like worst case scenario she (R2) would fall and have concussion. On 05/29/2024 at 1:21pm, V7 stated nobody informed me(V7) she (R2)can extend her (R2) elbow on her back. Nobody informed me that she can extend her elbows and put her legs over the wedge. I (V7) have never seen it. If I (V7) had known, I (V7)would have educated the CNA to keep an eye on her (R2) and get her (R2) up to reposition her (R2) more often. This information is important because it is probably what making her (R2) fall. The probability of her (R2) falling because of that is high. If there is a change of condition on a resident, everybody should be informed, like me, restorative nurse, other nurses and cna and the whole IDTeam. On 05/29/2024 at 1:44pm, V2 (Director of Nursing) stated upon admission, resident is assessed. If high risk for fall, resident is care planned. If we have a fall or a resident fell , I (V2) would do a fall investigation, try to figure out what happened, how a resident falls, and what causes the fall. Then we provide intervention. On 05/29/2024 at 1:47pm, V2 stated when I (V2) did my (V2) investigation, I (V2) concluded that she (R2) tried to reposition herself (R2) on the bed and ended up falling out of bed. I (V2) have never seen her (R2) extending her (R2) elbows and putting her (R2) legs over the wedges. Nobody informed me (V2) that she (R2) can extend her (R2) elbows and move her (R2) legs over the wedge. Those pieces of information are important because if she (R2) is able to extend her (R2) elbows and move her (R2) legs over the wedge it means she (R2) can push herself (R2) out of bed. The staff should have reported that to me (V2) so we (facility) could have placed interventions for those information you just gave me (V2). On 05/30/2024 at 10:13am, V2 (Director of Nursing) stated I (V2) did not speak with (V5) because her (R2) fall incident did not happen during her (V5) shift. She (V5) worked the morning shift at the time of the fall. R2's (5/13/2024) care plan documented, in part has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to: laceration to scalp - has 6 staples. Of note, R2's whole care plan was reviewed, the behavior or arching back and moving legs over the wedge was not care planned. R2's (5/14/2024) care plan documented, in part Focus: is at risk for falls R/T (related to) Dx (diagnoses): seizure disorder. Goals: will not sustain a fall related injury. Interventions: falling star 4/8/2024. Keep in common area (3/15/24). Gather information on past falls and attempt to determine the root cause of the fall. Anticipate and intervene to prevent recurrence. Of note, R2's whole care plan was reviewed with no notes of R2's ability to be on semi sitting position while on bed, extending both elbows, and both hands on R2's back and the ability to move both legs over the wedge. The (05/28/2024) Falling star program by unit documented that R2 was on the list. The (undated) LPN Job Description documented, in part Job Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility to ensure the highest degree of quality care. Essential duties and responsibilities: 1. Directs the day-to-day function of the nursing assistant. 3. Cooperate with other residents services when coordinating nursing services to ensure total care is maintained. 7. Makes written and oral reports concerning the day-to-day activities of your shift. 8. Meet with your assigned staff to plan the ship's services programs and activities. 12. Chart nursing progress notes in an informative and descriptive manner that reflects the care provided to the residents as well as the residents response. 25. Help and maintain a good working rapport with intradepartmental and interdepartmental personnel to meet the needs of the resident. 27. Meet with the unit staff regularly to assist in identifying and correcting problem areas.

Based on interview and record review the facility failed to provide emergency treatment and care for a resident (R3) with a low oxygen level, in accordance with professional standards of care, and failed to immediately contact 911 for an acute change in condition for R3 based on R3's code status of Do Not Resuscitate. This failure resulted in R3 not receiving timely care and treatment until 6 hours after the change in condition requiring hospitalization with admission diagnosis of Acute Respiratory Failure with Hypoxia (Deficiency In The Amount Of Oxygen Reaching The Tissues), Sepsis, Metabolic Encephalopathy, Severe Sepsis with Septic Shock, Urinary Tract Infection, Acidosis, and Coagulation Defect, and subsequently expiring at the hospital. This failure affected one (R3) of four residents reviewed for change in condition on the total sample list of 23. This was identified as an Immediate Jeopardy that began on [DATE]. R3's progress notes dated [DATE] at 6:20am by V5 (LPN) documents that at approximately 3:20 am V5 went to check on the R3 during rounds and R3's hands were cool to touch with a SPo2 of 84% (blood oxygen level of 84% measured with a pulse oximeter) and at 6 AM during rounds and med pass R3's SPo2 went to 82%. Progress notes reads: R3 DNR will continue to monitor. V5 does not document providing oxygen to R3 for oxygen saturation levels of 84% (3:20am) or 82% 6:00am). R3's POLST (Physician Orders for Life Sustaining Treatment) dated [DATE] documents A: Do Not Attempt Resuscitation/DNR, B: Selective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in Comfort-Focused Treatment (relieve pain and suffering through the use of medication by any route as needed; use oxygen), use medical treatment, IV (Intravenous) fluids and IV medications as medically appropriate and consistent with patient preference. V1 (Administrator), V2 (Assistant Administrator), V3 (Director of Nursing) and V4 (Regional Nurse Consultant) were notified of the immediate jeopardy on [DATE] at 10:12am. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: R3's Face sheet documents that R3 has a diagnosis of, but not limited to, Orthopedic Aftercare, Displaced Fracture of Medial Malleolus of Left Tibia, Subsequent Encounter for Closed Fracture With Routine Healing, Contusion of Unspecified Part of Head, Subsequent Encounter, Malaise, Osteoarthritis, Gastro-Esophageal Reflux Disease Without Esophagitis, Chronic Kidney Disease Stage 3 And Age-Related Osteoporosis Without Current Pathological Fracture. R3's Minimum Data Set (MDS) dated [DATE] documents, in part, a Brief Interview of Mental Status score of 08 that suggests moderate cognitive impairment. Progress note dated [DATE] at 6:08am by V24 reads, in part, R3 was noted pale. Surveyor reviewed progress notes for [DATE] and there were no progress notes from V25 (LPN) on the 1st shift (6:00am-2:30pm) and V15 (Registered Nurse-RN) on the 2nd shift (2:00pm-10:30pm) regarding R3's change in condition. 24-hour Shift Report dated [DATE] does not have any documentation about R3's change in condition on the 1st, 2nd or 3rd shift. Progress note dated [DATE] at 6:20am by V5 (Licensed Practical Nurse-LPN) reads at approximately 3:20 am V5 went to check on the R3 during rounds and R3's hands were cool to touch with a SPo2 of 84%. At 6 AM during rounds and med pass R3 SPo2 went to 82%. R3 DNR will continue to monitor. DON aware. V8 (Physician) notified. BP ,d+[DATE] T 96.7 SPo2 82% RA. On [DATE] at about 1:00pm surveyor reviewed the Nursing Daily Staffing Sheet that documents, in part, on [DATE] there was no Registered Nurse (RN) that was scheduled or worked the 10:00pm-6:30am shift. Surveyor reviewed progress notes for [DATE] and there were no progress notes for the 1st (6:00am-2:30pm) or 2nd shift (2:00pm-10:30pm) regarding R3's medical status. Surveyor also reviewed R3's progress notes for [DATE] and V5 (LPN) does not document giving R3 oxygen when R3's oxygenation levels were 84% (3:20am) and 82% (6:00am) on [DATE]. Progress note dated [DATE] at 6:57am by V6 (Registered Nurse-RN) reads received R3 in bed lethargic and SOB (shortness of breath) sating at 87% O2 at 4l/nc (nasal cannula) skin cool to touch R3 able to respond to tactile stimuli. HOB (head of the bed) elevated 45 degrees. b/p (blood pressure) ,d+[DATE]-,d+[DATE].5. R3 DNR will continue to monitor. DON (Director of Nursing) aware. Progress note dated [DATE] at 9:04am by V6 reads R3's vitals declining NP (Nurse Practitioner) notified with orders to send R3 to hospital. 911 called. Progress noted dated [DATE] at 9:11am V6 reads 911 Arrives R3 in route to nearest hospital. Local hospital record dated [DATE] reads, in part, R3's arrival time 9:28am with diagnosis of Sepsis, unspecified Organism and Acute Respiratory Failure with Hypoxia, Respiratory Insufficiency, Septic Shock. R3's hospital records also reads, in part, R3's discharge information that reads discharge date /time [DATE] at 11:30am and discharge disposition expired. Local hospital record dated [DATE] reads, R3 presents to Emergency Department (ED) for respiratory distress and hypotension and EMS (Emergency Medical Services) reports that nursing home states that approximately 3 AM they noticed her breathing was labored and her oxygen was low. On arrival of EMS patient was still hypoxic and was hypotensive. She (R3) was placed on a nonrebreather. Diagnoses this visit reads, in part, Respiratory Insufficiency (when the lungs cannot get enough oxygen into the blood). R3's hospital laboratory values at 9:51am reads [NAME] Blood Cells (WBC) 24.8 (H: higher than normal levels), Platelets 146 (L: lower than normal levels), RBC (Red Blood Cells) 3.20 (L), (Hemoglobin 10.6 (L) and Lactic Acid level of 4.9 (HH). Red blood cells measure the number of oxygen-carrying blood cells in your body. Article titled Hemoglobin Test on website mayclinic.org documents, in part, Hemoglobin measures the amount of a protein in red blood cells. Hemoglobin carries oxygen to the body's organs and tissues when you breath in and then it carries waste gas carbon dioxide back to the lungs to be breathed out. Article titled Lactic Acid Blood Test: What Your Levels mean from website www.webmd.com documents, in part, lactic acid is made in muscle cells and red blood cells. It forms when your body turns food into energy. (Your body relies on this energy when its oxygen levels are low). Local hospital record dated [DATE] also reads, in part, leukocytosis present, lactic acid is severely elevated, and R3 has severe metabolic acidosis (the chemical balance of acids and bases in your blood get thrown off. This can happen when your body: is making too much acid, isn't getting rid of enough acid and doesn't have enough base to offset a normal amount of acid.) On [DATE] at about 3:00pm surveyor reviewed R3's weights/vitals in Point Click Care software (PCC) and there were no vitals listed for [DATE]. Surveyor also reviewed progress notes for [DATE] and there were partial vitals listed at 6:20am (BP ,d+[DATE] T 96.7 SPo2 82% RA) and at 6:57am (at 87% O2 at 4l/nc {nasal canula}, ,d+[DATE]-,d+[DATE].5). On [DATE] at 12:10pm V5 (Licensed Practical Nurse-LPN) stated in interview if a person has a DNR there are no interventions that should be provided and with a DNR you should keep the R3 cleaned and comfortable. V5 stated R3's oxygenation level was 84% at about 3:20am on [DATE] and that she (V5) did not place oxygen on R3 until V6 came in, which was at about 5:55am, because she (V6) assisted her (V5) with placing oxygen on R3. V5 stated that she (V5) monitored R3 (kept clean and comfortable) frequently, every thirty minutes or so, but did not chart what interventions were done. On [DATE] at 2:06pm V8 (Medical Doctor-MD) stated if a patient is having shortness of breath and oxygenation is 92% or below you will place oxygen at 2 liters nasal cannula and call 911. V8 stated that care should be provided to a resident regardless of their code status (DNR or not) and timely care is necessary. V8 also stated that the nurse can use her nursing judgement to send a resident to the hospital if they are having issues with breathing and their oxygenation levels are below normal. On [DATE] at 2:31pm V3 (Director of Nursing-DON) stated if they (residents) are a DNR and they are declining, the nurses are still expected to provide care to the residents. DNR does not mean that a nurse does not provide care and care still needs to be provided. V3 also stated there is a standing order to give 2 Liter of oxygen via nasal canula and keep them (the resident) comfortable for someone who is having trouble breathing and I (V6) would expect for them (nurses)to use their nursing judgement and send the resident out via 911 and then the staff can call the MD, DON and the family. The nurse should be looking to see if they have labored breathing or panting, use of accessory muscles and use a pulse oximeter to determine the oxygenation level. If the oxygenation readings are in the 80's you would definitely start to give the resident oxygen 2liters via nasal cannula. It is expected for the nurse to call 911, raise head of bed, and use any measure to assist with opening the airway and not giving them water or fluids. Surveyor asked if they should wait to send resident out and V6 stated No, I would expect for them to place the resident on oxygen and immediately contact 911. The resident will continue to decline, and death could occur if oxygen is not given, and the resident is not sent to the hospital. On [DATE] at about 3:41pm surveyor reviewed hospital records from [DATE] that reads R3 was admitted with diagnosis of acute respiratory failure with hypoxia, sepsis, metabolic encephalopathy, severe sepsis with septic shock, urinary tract infection, acidosis, and coagulation defect. R3's hospital records reads: discharge disposition expired on [DATE] at 11:30am. On [DATE] at 12:34pm by V6 (Licensed Practical Nurse) stated that R3 did not have oxygen on when she arrived at 5:50am on [DATE] and her skin was cool to touch and R3 was responding to me by opening her eyes. V6 (LPN) stated that V5 (LPN) told her that she spoke with V3 (DON) who asked her about R3's code status, which was DNR, and V3 (DON) told V5 (LPN) to monitor R3. V6 (LPN) stated that V5 (LPN) did not know where the oxygen was and from the time, she (V6) placed the oxygen on R3 her oxygen levels began to fluctuate. V6 stated she (V6) placed an oxygen mask on R3 but R3 kept trying to pull it off, so I switched it over to a nasal canula and opened it all the way up (give 4 liters of oxygen). I had the CNA (Certified Nursing Assistant) to put R3 back in the bed and I checked her oxygen levels again, which were fluctuating, and decided it was time to send to the hospital because the levels were not approaching the normal limits. V6 stated that she thought she charted what R3's saturation levels were. Surveyor did not see a progress note from V6 indicating R3's saturation levels after V6 placed R3 on 4 liters of oxygen. On [DATE] at 3:36pm V15 (Registered Nurse-RN) stated R3 was pale and requested to be put in bed early on [DATE] during her (V15's) shift (2:00pm-10:30pm) and R3 was not really drinking the supplements and she only consumed 50% of the supplement and I (V15) offered it twice on my shift. V15 stated there was no issues with R3's blood pressure and R3 was ok at that time and her temperature was a bit cold, I took R3's temperature and it was on the lower end of normal, so I gave her a blanket. V15 said I did not check her oxygenation status because I did not have my pulse oximeter. On [DATE] at 9:27am V8 (MD) stated that he did review R3's chart briefly and that he had missed a call from the facility at around 3:30am on [DATE] but spoke with someone briefly early that morning around 7:00am. Stated that he spoke to the facility that morning, but he does not recall the details of the conversation, but I (V8) told them to apply oxygen and to monitor R3. Stated he did not hear back from the facility regarding R3. V8 stated he (V8) would expect for them (the nurses) to monitor R3 at least every 15 minutes to 30 minutes depending on how she (R3) is doing. V8 also stated that R3's DNR status and co morbidities does not change his answer that the nurse should apply oxygen (2Liters nasal cannula) and send R3 to the hospital via 911. V8 also stated that R3 had a change in condition quickly (oxygen saturation) and that it was not something he was treating her for. On [DATE] at 10:24am V3 (DON) stated after the orientation is done the new nurse shadows with an experienced nurse and are shown everything that needs to be done when they are working and some of other things that are explained are the med pass and the knowledge of the medicine that is given, the code status and the process if someone is found unresponsive and they are a DNR that you really don't do anything, but you notify the provider, DON and family. On [DATE] at 10:50am-V3 (DON) stated she (V3) believed did receive a call from V5 and it was at 3:23am, but it was a missed call. V3 stated I spoke with the nurse (V5) at 6:14am and the conversation was about the R3's oxygen saturation, she read the vitals to me, and I advised V5 to put the R3 on oxygen and call 911. V3 stated I do remember asking V5 if she put R3 on oxygen and was told No, and when I asked why I was told that she (R3) was a DNR. Nurse said that she did not put her oxygen because she did not have an order and she is a DNR. V3 continues, I expect them to follow the standing order and for oxygen it's 2liters via NC (nasal canula) and also call 911. R3's POLST (dated [DATE] reads, in part, A: Do Not Attempt Resuscitation/DNR, B: Selective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in Comfort-Focused Treatment (relieve pain and suffering through the use of medication by any route as needed; use oxygen), use medical treatment, IV (Intravenous) fluids and IV medications as medically appropriate and consistent with patient preference. Undated policy titled Do Not Resuscitate reads, in part, 4. When faced with a possible DNR order situation: If the order is valid and the physician does not order otherwise, follow the terms of the DNR Order, thoroughly document the circumstances following the use of the DNR Order. Policy titled Respiratory Distress: Emergency Procedure date ,d+[DATE] reads, in part, Residents exhibiting signs of respiratory distress will be assessed and treated immediately, 1. Elevate HOB, 2. Oxygen ,d+[DATE] L per nasal cannula, 3. Take and record vital signs, 8 Notify physician and 9. Call paramedic and transfer to hospital if indicated. Policy titled Physician Orders dated ,d+[DATE] reads, in part, these guidelines are to ensure that 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record and 2. Any orders given by Physician are carried out. Policy titled Change in Condition Physician Notification Overview Guidelines dated ,d+[DATE], documents, in part, 3. Medical care emergency problems are communicated to attending physician and family immediately (generally within two (2) hours or sooner), A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received and E. The nurse shall indicate in the nurses notes ongoing conversations with the physician regarding response to notification (phone calls) of changes in condition. Undated job description titled LPN Job Description reads, in part, the primary purpose of your job position is to provide direct nursing care to the residents, 2. Ensure that resident care procedures are followed in rendering nursing care, 4. Perform administrative duties as charting, 12. Chart nursing progress notes in an informative and descriptive manner that reflects the care provided to the residents as well as the resident's response, and 23. Make independent decisions concerning nursing care. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions remove the immediacy and correct the noncompliance: On [DATE], at 11:00am re-education began with Facility Nurses and CNAs with focus on: This will be ongoing until all Nurses and CNAs are re-educated by [DATE]. Facility roster of all Nurses and CNAs was printed and being used for Staff signage as they are educated on process to ensure all is educated. Facility will ensure new hires are educated during the first 3 days of orientation period for Understanding DNR and Understanding Change in Condition: o Understanding DNR Meaning no CPR or heroic measures in case of complete cardiac arrest Do not mean no treatment or hospitalization for acute symptoms o Understanding Change in Condition Vitals and thorough assessment must be done Must notify Physician/NP immediately or as soon as possible Must notify Family immediately or as soon as possible Must initiate nursing interventions based on assessment findings Closely monitor Resident until transported to ER Document, document, document May initiate oxygen as needed without Dr's order Call 911 and transfer to ER as warranted prior to Dr's order Solicit assistance from Co-Workers as needed If unable to contact Physician/NP, contact Medical Director Once Physician/NP is contacted, give thorough assessment findings and follow his/her instructions Nursing Management will evaluate the training by giving reminders and/or asking questions at Morning Standup Meetings with Nurses which is currently being held daily and by doing chart audits/reviews. Administrator will be responsible for overall compliance to plan of correction in conjunction with DON to ensure all Nursing Staff are re-educated on the process. The Quality Assurance Quality Improvement Team meets monthly. This event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. The facility presented a removal plan on [DATE] at 1:51pm and it was not approved. A revised abatement plan was submitted on [DATE] at 3:06pm and it was not approved. A revised abatement plan was submitted on [DATE] at 5:53pm it was not approved. A revised abatement plan was submitted on [DATE] at 12:18pm and it was not approved. A revised abatement plan was submitted on [DATE] at 1:22pm and it was approved at 1:28pm.

Based on interview and record review the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing services to ensure residents safety and to maintain the highest practicable physical, mental and psychosocial well-being for the residents. This failure resulted in a delay in care for R3 being sent out 911 and interventions not being implemented for respiratory distress and has the potential to affect all the residents residing in the facility. Findings include: R3 has a diagnosis of but not limited to Orthopedic Aftercare, Displaced Fracture of Medial Malleolus of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing, Contusion of Unspecified Part of Head, Subsequent Encounter, Malaise, Osteoarthritis, Gastro-Esophageal Reflux Disease Without Esophagitis, Chronic Kidney Disease Stage 3 And Age-Related Osteoporosis Without Current Pathological Fracture. R3's Minimum Data Set (MDS) dated [DATE] documents, in part, a Brief Interview of Mental Status score of 08 that suggests moderate cognitive impairment. Progress note dated [DATE] at 6:08am by V24 reads, in part, R3 was noted pale. Surveyor reviewed progress notes for [DATE] and there were no progress notes for the 1st (6:00am-2:30pm) or 2nd shift (2:00pm-10:30pm) regarding R3's medical status. Progress note dated [DATE] at 6:20am by V5 (Licensed Practical Nurse-LPN) reads: at approximately 3:20 am V5 (LPN) went to check on the R3 during rounds and R3's hands were cool to touch with a SPo2 (peripheral Capillary Oxygen Saturation) of 84%. At 6 AM during rounds and med pass R3 SPo2 went to 82%. R3 DNR (Do Not Resuscitate) will continue to monitor. DON (Director of Nursing) aware. V8 (Physician) notified. BP ,d+[DATE] T 96.7 SPo2 82% RA (room air). Progress note dated [DATE] at 6:57am by V6 (Registered Nurse-RN) reads: received R3 in bed lethargic and SOB (shortness of breath) sating at 87% O2 at 4l/nc (nasal cannula) skin cool to touch R3 able to respond to tactile stimuli. HOB (head of the bed) elevated 45 degrees. b/p (blood pressure) ,d+[DATE]-,d+[DATE].5. R3 DNR will continue to monitor. DON aware. Progress note dated [DATE] at 9:04am by V6 reads R3's vitals declining NP (Nurse Practitioner) notified with orders to send R3 to hospital. 911 called. Progress note dated [DATE] at 9:11am by V6 reads 911 Arrives R3 in route to nearest hospital. Local hospital record dated [DATE] reads, in part, R3's arrival time 9:28am with diagnosis of Sepsis, unspecified Organism and Acute Respiratory Failure with Hypoxia, Respiratory Insufficiency, Septic Shock. R3's hospital records also document, in part, R3's discharge information that reads discharge date /time [DATE] at 11:30am and discharge disposition expired. On [DATE] at about 1:00pm surveyor reviewed the Nursing Daily Staffing Sheet that documents, in part, on [DATE] there was no Registered Nurse (RN) that was scheduled or worked the 10:00pm-6:30am shift. Surveyor reviewed progress notes for [DATE] and there were no progress notes for the 1st (6:00am-2:30pm) or 2nd shift (2:00pm-10:30pm) regarding R3's medical status. On [DATE] at about 1:10pm surveyor reviewed R3's progress notes for [DATE] and V5 does not document giving R3 oxygen when R3's oxygenation levels were 84% (3:20am) and 82% (6:00am) on [DATE]. On [DATE] at 12:10pm V5 (LPN) stated that she (V5) only received 4 days of orientation and that was orienting to each floor plus an additional day of orientation. V5 stated she worked at the facility as Certified Nursing Assistant (CNA) initially, and then became an LPN and started working as a new nurse in December of 2023. On [DATE] at 2:31pm V3 (Director of Nursing-DON) stated if they (residents) are a DNR and they are declining, the nurses are still expected to provide care to the residents. DNR does not mean that a nurse does not provide care and care still needs to be provided. V3 also stated there is a standing order to give 2 Liter of oxygen via nasal canula and keep them (the resident) comfortable for someone who is having trouble breathing and I (V3) would expect for them (nurses) to use their nursing judgement and send the resident out via 911 and then the staff can call the MD, DON and the family. On [DATE] at 3:36pm V15 (Registered Nurse-RN) stated R3 was pale and requested to be put in bed early on [DATE] during her (V15's) shift (2:00pm-10:30pm) and R3 was not really drinking the supplements and she only consumed 50% of the supplement and I (V15) offered it twice on my shift. V15 stated there was no issues with R3's blood pressure and R3 was ok at that time and her temperature was a bit cold, I took R3's temperature and it was on the lower end of normal, so I gave her a blanket. V15 said I did not check her oxygenation status because I did not have my pulse oximeter. This change of condition was not documented on the 24-hour Shift Report and there was no progress note in regards to R3's change of condition by V15 (RN). On [DATE] at 12:06pm surveyor reviewed V5's employee file and V5 had an undated Nursing Skills Check List that confirms her orientation with V6 (LPN). Surveyor reviewed V5's General Orientation Checklist for All New Employees that is partially completed. Instructions state to initial beside each area when completed. Have manager to sign each. V5's did not initial any areas. V5 did not have a Self-Competency Packet in her (V5's) employee file. On [DATE] at 10:24am V3 (DON) stated she provides orientation to each nurse on each floor for a least 5 days on everything that falls under their job description and onboarding which is computer training, on abuse, nursing care and other topics. V3 stated that ideally the nurse will get a total of 5 days of orientation and more if needed. After this orientation is done the new nurse shadows with an experienced nurse and are shown everything that needs to be done when they are working and some of other things that are explained are the med pass and the knowledge of the medicine that is given, the code status and the process if someone is found unresponsive and they are a DNR that you really don't do anything, but you notify the provider, DON and family. V3 also stated that there is another Nursing Skills Orientation Checklist that is given to the new employee and that the checklist that I have (V5's checklist) is for (workforce education training) and that the employee must initial the boxes and have the supervisor signs off from each department and the form has to be completed before the floor orientation starts. V3 said, No, we don't have charge nurses for each shift and if it is after hours they can call me and they know to ask for help from other experienced nurses and the RN's who are always in the building on the third shift (10:00pm-6:30am). On [DATE] at 11:15am surveyor reviewed V22's (LPN) employee file and there were a Self-Competency Packet that was incomplete. Surveyor reviewed V23's (LPN) employee file and did not find a Self-Competency Packet or Nursing Skills Orientation Checklist. On [DATE] at about 12:15pm V3 stated that the facility did not have any other Self Competency Packets or Nursing Skills Orientation checklist for V5, V22 or V23 if it was not in their (V5, V22 and V23) employee file. On [DATE] at 12:44pm V23 (LPN) stated that she was hired about the end of [DATE] and had about 6 weeks of orientation. V23 stated I did have another nurse that was available for questions, but I had to pass meds by myself on one side of the hall and the nurse I was shadowing was passing meds on the other side of the hall. V23 stated on about the 3rd or 4th day of orientation I had to work by myself, while still in orientation, but she (V23) did not take the other side of residents. V23 stated she was questioned why, and she told administration that she (V23) did not feel comfortable taking care of 40 residents by herself. V23 stated that she had been scheduled to work by herself, while in orientation, on more than one occasion and that was the reason she (V23) left that job. V23 stated that she did not have to complete a Nursing Skills Orientation checklist or anything like that and she did not have to submit anything to the Director of Nursing. On [DATE] at 1:40pm V6 (LPN) said I was V5's preceptor when she first started and I only precepted her one shift on the first floor sometime in December of 2023 and I did complete R5's orientation checklist for the one time I precepted R5. On [DATE] at 6:31pm via email V1 (Administrator) stated No, we do not have a policy on training/orientation of nurses. On [DATE] at 11:55am by V3 (DON) via email that reads a new nurse with previous nursing experience gets a minimal 2 days classroom orientation doing paper work, being in-serviced on various topics and watching educational videos and then a minimal 3 days orientation shadowing with another facility Nurse and a new grad nurse will typically get a minimal of 2 weeks of shadowing another Nurse and same 2 days of classroom orientation. V3 also stated no new Nurse is to be scheduled solo (to work alone) to work a floor and be responsible for a group of residents during the above listed orientation period. Undated job description titled LPN Job Description reads, in part, the primary purpose of your job position is to provide direct nursing care to the residents, 2. Ensure that resident care procedures are followed in rendering nursing care, 4. Perform administrative duties as charting, 12. Chart nursing progress notes in an informative and descriptive manner that reflects the care provided to the residents as well as the resident's response, and 23. Make independent decisions concerning nursing care. Policy titled Physician Orders dated ,d+[DATE] reads, in part, these guidelines are to ensure that 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record and 2. Any orders given by Physician are carried out. Policy titled Change in Condition Physician Notification Overview Guidelines dated ,d+[DATE], documents, in part, 3. Medical care emergency problems are communicated to attending physician and family immediately (generally within two (2) hours or sooner), A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received and E. The nurse shall indicate in the nurses notes ongoing conversations with the physician regarding response to notification (phone calls) of changes in condition.

Based on interview and record review the facility failed to ensure the nurses provided care, in accordance with professional standards of care for one (R3) of four residents who was experiencing a reduction in oxygenation and a delay in receiving emergency medical attention reviewed for change in condition on the total sample of 23. Findings include: R3 has a diagnosis of but not limited to Orthopedic Aftercare, Displaced Fracture of Medial Malleolus of Left Tibia, Subsequent Encounter for Closed Fracture With Routine Healing, Contusion of Unspecified Part of Head, Subsequent Encounter, Malaise, Osteoarthritis, Gastro-Esophageal Reflux Disease Without Esophagitis, Chronic Kidney Disease Stage 3 And Age-Related Osteoporosis Without Current Pathological Fracture. R3's Minimum Data Set (MDS) dated [DATE] documents, in part, a Brief Interview of Mental Status score of 08 that suggests moderate cognitive impairment. Local hospital record dated [DATE] reads, in part, R3's arrival time 9:28am with diagnosis of Sepsis, unspecified Organism and Acute Respiratory Failure with Hypoxia, Respiratory Insufficiency, Septic Shock. R3's hospital records also reads, in part, R3's discharge information that reads discharge date /time [DATE] at 11:30am and discharge disposition expired. Progress note dated [DATE] at 6:08am by V24 reads, in part, R3 was noted pale. Progress note dated [DATE] at 6:20am by V5 (Licensed Practical Nurse-LPN) reads: at approximately 3:20 am V5 (LPN) went to check on the R3 during rounds and R3's hands were cool to touch with a SPo2 (peripheral Capillary Oxygen Saturation) of 84%. At 6 AM during rounds and med pass R3 SPo2 went to 82%. R3 DNR (Do Not Resuscitate) will continue to monitor. DON (Director of Nursing) aware. V8 (Medical Doctor) notified. BP ,d+[DATE] T 96.7 SPo2 82% RA (room air). Progress note dated [DATE] at 6:57am by V6 (LPN) reads: received R3 in bed lethargic and SOB (shortness of breath) sating at 87% O2 at 4l/nc (nasal cannula) skin cool to touch R3 able to respond to tactile stimuli. HOB (head of the bed) elevated 45 degrees. b/p (blood pressure) ,d+[DATE]-,d+[DATE].5. R3 DNR will continue to monitor. DON aware. On [DATE] at about 1:00pm Surveyor reviewed progress notes for [DATE] and there were no progress notes for the 1st (6:00am-2:30pm) or 2nd shift (2:00pm-10:30pm) regarding R3's medical status. Surveyor also reviewed R3's progress notes for [DATE] and V5 (LPN) does not document giving R3 oxygen when R3's oxygenation levels were 84% (3:20am) and 82% (6:00am) on [DATE]. On [DATE] at about 3:00pm surveyor reviewed R3's weights/vitals in Point Click Care software (PCC) and there were no vitals listed for [DATE]. Surveyor also reviewed progress notes for [DATE] and there were partial vitals listed at 6:20am (BP ,d+[DATE] T 96.7 SPo2 82% RA) by V5 and at 6:57am (at 87% O2 at 4l/nc {nasal cannula}, ,d+[DATE]-,d+[DATE].5) by V6. On [DATE] at 12:10pm V5 (LPN) stated R3's oxygenation level was 84% at about 3:20am on [DATE] and that she (V5) did not place oxygen on R3 until V6 (LPN) came in, which was at about 5:55am, because she (V6) assisted her (V5) with placing oxygen on R3. V5 (LPN) stated in interview if a person has a DNR there are no interventions that should be provided. R3 had a code status of DNR (DO NOT RESUSCTATE) and I (V5) kept R3 cleaned and comfortable. V5 stated that she (V5) monitored R3 (kept clean and comfortable) frequently, every thirty minutes or so, but did not chart what interventions were done. V5 stated that she attempted to contact the doctor, nurse practitioner and the Director of Nursing and no one answered the phone. On [DATE] at 2:06pm V8 (Medical Doctor-MD) stated if a resident is having shortness of breath and oxygenation is 92% or below you will place oxygen at 2 liters nasal cannula and call 911. V8 also stated that the nurse can use her nursing judgement to send a resident to the hospital if they are having issues with breathing and their oxygenation levels are below normal. On [DATE] at 12:34pm by V6 (Licensed Practical Nurse) stated that R3 did not have oxygen on when she arrived at 5:50am on [DATE] and her skin was cool to touch and R3 was responding to me by opening her eyes. V6 said V5 told her (V6) that R3 was not doing good and that R3 was not breathing well and I (V6) asked V5 did she (V5) give R3 oxygen and V5 said no because V5 could not find it. V6 said she placed an oxygen mask on R3 but R3 kept trying to pull it off so I switched it over to a nasal cannula and opened it all the way up. I put her on 4 liters of oxygen and R3 oxygen was at 87%. V6 (LPN) stated that V5 (LPN) told her that she spoke with V3 (DON) who asked her about R3's code status, which was DNR, and V3 (DON) told V5 (LPN) to monitor R3. V6 (LPN) stated from the time, she (V6) placed the oxygen on R3 her oxygen levels began to fluctuate. V6 (LPN) stated R3 was responding to the oxygen therapy and the treatment nurse was doing her treatment and that is the reason why she was still in the building. The CNA (certified nursing assistant) got R3 out of the bed to eat and I told her that R3 can't eat and to put R3 back in the bed. On [DATE] at 9:27am V8 (MD) stated that he did review R3's chart briefly and that he had missed a call from the facility at around 3:30am on [DATE] but spoke with someone briefly early that morning around 7:00am and told them (V6) to apply oxygen and to monitor R3. V8 stated he (V8) would expect for them (the nurses) to monitor R3 at least every 15 minutes to 30 minutes depending on how she (R3) is doing. V8 also stated that R3's DNR status and co morbidities does not change his answer that the nurse should have applied oxygen (2-Liters nasal cannula) and send R3 to the hospital via 911. R3's POLST (dated [DATE] reads, in part, A: Do Not Attempt Resuscitation/DNR, B: Selective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in Comfort-Focused Treatment (relieve pain and suffering through the use of medication by any route as needed; use oxygen), use medical treatment, IV (Intravenous) fluids and IV medications as medically appropriate and consistent with patient preference. Undated job description titled LPN Job Description reads, in part, the primary purpose of your job position is to provide direct nursing care to the residents, 2. Ensure that resident care procedures are followed in rendering nursing care, 4. Perform administrative duties as charting, 12. Chart nursing progress notes in an informative and descriptive manner that reflects the care provided to the residents as well as the resident's response, and 23. Make independent decisions concerning nursing care. Policy titled Physician Orders dated ,d+[DATE] reads, in part, these guidelines are to ensure that 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record and 2. Any orders given by Physician are carried out. Policy titled Change in Condition Physician Notification Overview Guidelines dated ,d+[DATE], documents, in part, 3. Medical care emergency problems are communicated to attending physician and family immediately (generally within two (2) hours or sooner), A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received and E. The nurse shall indicate in the nurses notes ongoing conversations with the physician regarding response to notification (phone calls) of changes in condition.

Based on observation, interview and review of records, the facility failed as follows: Failed to supervise and monitor an elopement risk resident with behavioral needs. Failed to maintain the right of a resident to be safe related to accessing facility area (stairwell). Failed to complete a comprehensive assessment for a newly admitted resident. Failed to follow individualized care plan policy in addressing hip precaution or safety measures on the plan of care for a resident that had undergone hip surgery. Failed to investigate an incident for a hip prosthesis dislocation. These failures affected 2 (R1, R2) out of 3 residents reviewed for safety, hazards, and incidents on a total sample of 5 residents. This failure resulted in (R2) sustaining a left hip fracture after a fall. Findings include: 1. R2 was [AGE] years old, initially admitted on [DATE] with diagnosis of dementia, psychotic disturbance, mood disturbance, and anxiety. Progress notes of R2 dated 9/11/2023 by V3 (Licensed Practical Nurse) documents that R2 was sitting in an upright position on the stairs. R2 was sent to the hospital. Notes of V2 (Former Director of Nursing) documents that hospital diagnosis was left hip fracture. On 10/24/2023 at 1:35 PM, V1 (Administrator) stated during the incident that happened night of 9/11/2023. She (V1) was the staff that first saw R2 on the stairwell. Per V1, R2 used the elevator to go from first floor to ground floor. R2 then went to the door and pushed the button to get into the stairwell. R2 was found on the stairwell east side. V1 stated when R2 was asked, R2 stated, I (R2) rode the elevator down to go to work. I go (sic) back up and lost my balance and fell . V1 presented a written statement that reads as follows: R2 was noted sitting on the ground floor stairwell on the east side, on 9/11/2023. When I (V1) asked R2 what happened. R2 stated that he rode the elevator down to go to work. And I go (sic) back up and lost my balance and fell . On 10/24/23 at 1:57 PM, V16 (Restorative Nurse / Licensed Practical Nurse) stated that R2 was an elopement risk and needs monitoring and supervision. R2 sometimes goes down to the ground floor from first floor. V16 stated that residents are not allowed to go to the stairwell. On 10/24/23 at 2:42 PM, V2 (Former Director of Nursing) stated that he received a call regarding fall incident of R2. V2 stated that R2 needs to be monitored and preventative measures because R2 was an elopement risk. V2 said that residents are not allowed in the stairwell. And that alarm will go off upon entering the stairwell. On an earlier note, by V17 (Registered Nurse) dated 9/11/2023, before R2 fell on the stairwell it was documented. R2 had two episodes of agitation and confusion at about 1:30 AM and 3:00 AM, insisting he has to go to work. R2 has multiple attempts to leave the facility. R2 needs frequent monitoring and one on one supervision. On 10/24/23 at 3:23 PM, with V12 (Maintenance Director) checked both doors going into the stairwells located at the ground floor. Both doors when entering going to the stairwells does have a doorbell-like button. Once pressed and upon opening the door, the alarm does not sound. Inside the stairwells there was the pad where the code needs to be entered before going out of the stairwells. V12 stated that once the doorbell-like button is pressed it disables the alarm for 5 seconds. Once the door is open it disables the alarm for 10 more seconds. The person then is able to enter the stairwell without the alarm sounding. If R2 was able to enter without sounding the alarm, I think it would be a good idea to place the code pad outside the stairwell. Because every time someone goes inside the stairwell, they need to put the code first. Earlier at 10:39 AM, upper floors (first, second, and third) were seen with keypads that a code was needed before entering the stairwell. Unlike on the ground floor where keypad was located inside the stairwell for code to be used when exiting the stairwell. Care plan of R2 documents that R2 is a fall and elopement risk. Under elopement intervention: R2 needs preventative intervention strategies that includes make rounds and room checks per facility protocol to minimize chance of unauthorized leave. Unusual Occurrence Report Form dated 9/12/2023 initial report documents, that R2 was sent to ER (emergency room ) in the hospital. X-ray was done, there is evidence of injury bruising to left eye and with left lower extremity pain. Report obtained from (local hospital), resident admitted with diagnosis of left hip fracture. On 10/26/2023 at 11:45 AM. V3 (Licensed Practical Nurse) upon hearing the name of R2 stated, I am a nurse not a babysitter. V3 stated that R2 has dementia and was wandering a lot that day. Proximity of time the incident happened was about 8:00 PM. R2 was trying to escape all day. V3 said, I do med pass, watch residents, and do patient care. I cannot do all those things. Elopement Risk Assessment policy dated 5/14, reads: the purpose is to identify residents who may be potentially at risk for elopement and at risk for harm. To use a baseline to maintain a secure resident environment. The Social Service Department will notify facility staff and initiate interventions necessary to protect the resident. Intervention include one-on-one observation. 2. R1 was [AGE] years old, initially admitted in the facility on 8/23/2023 and was discharged on [DATE]. R1 was admitted in the facility for orthopedic aftercare due to left artificial hip joint. R1's progress notes dated 8/25/2023 by V2 (Former Director of Nursing) documents erythema to left hip was observed and an order for total left hip x-ray. X-ray result dated 8/25/2023 documents R1 has dislocated hip prosthesis. Progress notes dated 8/26/2023 by V14 (Licensed Practical Nurse) documents that R1 was sent to hospital. On 10/24/2023 at 1:34 PM, V15 (Minimum Data Set / Licensed Practical Nurse) stated that she works on the floor, so she knows what nurses use as an assessment tool. V15 stated that the assessment form that needs to be filled up on every admission is called Admission/Readmission Screener. This assessment has everything in itself to familiarize with the resident. It covers head-to-toe assessment, vital signs, skin assessment, ADLs (Activity of Daily Living) or how much assistance the resident needs. R1's Admission/Readmission Screener dated 8/23/2023 was not completed, almost all sections were not filled up except for allergies and vital signs. R1 does not have any full assessment during admission on record. V15 stated I noticed that it was not done. R1's care plan also does not address hip precautions. V15 stated, I cannot find anything that addresses proper transfer (technique) for R1's hip replacement. V15 was asked to present an incident report related to R1's dislocated hip. V15 stated that V1 (Administrator) informed her that a report was not done. At 2:20 PM, there was no incident report that was done when R1's X-ray was taken and R1 was sent to the hospital. On 10/24/2023 at 2:42 PM, V2 (Former Director of Nursing) stated that R1 needs hip precaution. And stated that he (V2) was the first person to notice irregularities of R1's left hip. None of the staff informed him. V2 said that incident report and investigation is needed when there is a change of condition. But he (V2) cannot remember if he made an incident report. What he can remember was that he spoke to V13 (Certified Nursing Assistant) about the incident. V2 said he cannot remember the nurse. On 10/26/2023 at 10:15 AM, V14 (Licensed Practical Nurse) stated that she cannot remember R1 because a lot of residents needed attention. After informing V14 that R1's family member spoke to her multiple times about R1 hip after therapy during transfer from wheelchair to bed. V14 stated, Now I remember. V14 stated that either R1's son or daughter told her that a staff moved or transferred R1 and caused hip redness and pain. V14 said, R1's family was here almost every day. V14 stated that she explained to either the son or daughter that when R1 was moved or transferred it happened on a previous shift. V14 stated, I do remember a staff transferred R1, but I forgot the name of the staff. When asked to elaborate V14 also said that she forgot how the transfer happened. Then V14 said, V2 was covering the floor before she (V14) arrived. And that she (V14) only covered the floor due to original nurse that was scheduled did not arrive. V14 stated that x-ray was followed up the next day and the result was dislocation of hip. On 10/26/2023 at 11:39 AM, V18 (Physical Therapy Director) stated that he (V18) did the exercise with R1 on 8/25/2023 and it was in the morning time. But V18 cannot remember the exact time. V18 stated that after therapy, R1 was endorsed to a CNA (Certified Nursing Assistant) but he cannot remember who, or if it was a male or female CNA. V18 said that there was no problem with the wheelchair R1 used. Nursing staff that was working in the morning shift on 8/25/2023 were interviewed (V22/Licensed Practical Nurse, V13/Certified Nursing Assistant) both denied transferring R1 the whole shift. On 10/26/23 at 1:20 PM, V20 (Restorative Aide) stated that R1 was using the wheelchair of her roommate who was in the hospital during that time. The wheelchair was a little big for R1's size. And that therapy was on the process of getting R1 her wheelchair. Admission of Resident Policy dated 4/14, reads: The purpose is to facilitate smooth transition into a health care environment. To gather comprehensive information as a basis for planning individualized therapeutic care. To ensure adherence to facility policies. Equipment during admission of residents includes assessment tool. Conduct head-to-toe nursing assessment of body system, parts, and surfaces identifying functional status abilities, needs, or problem. Complete other admission forms within 72 hours and begin resident care plan. Under care plan policy with the same date, reads: All residents will have comprehensive assessments and individualized plan of care developed to assist them in achieving and maintaining their optimal status.

Based on interview and record review, the facility failed to maintain a safe resident environment and protect residents (R8 & R3) from physical abuse by (R9) for three of three residents reviewed for abuse in the sample of nine. This failure resulted in R9, a resident with known aggressive behavior, striking R8 in the face. As a result of the abuse, R8 was sent to the local hospital and diagnosed with subtle depressed fracture at the left nasal bone (broken nose). Findings include: 1) R8's medical record (Face Sheet, MDS-Minimum Data Set of 6/7/23) documents R8 is a severely cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Hyperlipidemia, Chronic Kidney Disease, and Hypertension. R8's Nursing Progress Note dated 9/4/2023 at 4:24 PM documents in part, resident was noted during normal treatment to be bleeding from the facial area and forehead and with scratches. Resident pointed to the roommate (R9) who attacked him in the bed. 911 was called, resident was taken to (local hospital) for evaluation. R8's Emergency Department Progress Note, dated 9/4/2023 documents in part, patient states today his roommate punched him 6 times in the head. States he was in bed when this happened. R8's CT Scan results, dated 9/4/2023 documents: Facial Bones Impression: 1. Subtle depressed fracture at the left nasal bone at level of the nasomaxillary suture. 2. Corresponding left-sided nasal mild soft tissue swelling to the left malar soft tissue. On 9/5/2023 at 3:55 PM, R8 stated, his roommate hit him. On 9/6/2923 at 3:45 PM via telephone, V15 (LPN-Licensed Practical Nurse) stated, I went to (R8's) room to do blood glucose test. (R8's) face was bloody (forehead and bridge of nose). (R8) pointed to roommate (R9) who was up walking, (R8) was in bed. V24 (CNA-Certified Nursing Assistant) came to translate. (R8) said (R9) attacked him, (R9) denied the allegation to (V15) but told (V24) that (R9) scratched (R8). The irony of the fact is that (R9) attacked someone else (R3). (R8) was sent out hospital for medical evaluation, I think he had a closed fracture of his nasal bones. R9s' Nursing Progress Note documents on 9/4/2023 at 4:30 PM in part, resident punched and scratched roommate (R8) in the facial area and forehead with some bleeding noted. When asked what happened, resident said, he attacked me. Actually roommate (R8) was lying in the bed. (Physician) was called with orders given to transfer to (local hospital) for psych evaluation. On 9/4/2023 at 6:49 PM, Nursing Progress Note documents in part, transferred to (local hospital). R9's Nursing Progress Note dated, 9/5/2023 at 1:25 AM documents in part, (Hospital RN) admitting diagnosis is aggressive behavior. 2) R3's medical record (Face Sheet, MDS-Minimum Data Set of 7.26.2023) documents R3 is a severely cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease, Heart Failure, Hypertension, and Chronic Obstructive Pulmonary Disease. On 9/8/2023 at 3:45 PM, R3 was unable to tell surveyor what happened. R3's Social Service Note dated, 8/25/2023 at 2:59 PM, documents in part, (R3) was observed by a staff member to have been stuck in the face just above the bridge of the nose. He did not report being in distress but also could not verbalize a reason for being struck. He states the peer (R9) walked over and struck him. Staff eventually learned this was over to some disagreement between the two (R3 & R9) on the air conditioning unit being on. R3's Nursing Progress Note dated 8/25/2023 at 3:08 PM documents in part, resident observed with abrasion above the bridge of his nose. MD notified with orders to continue to monitor resident's neurological status for next 72 hours. On 9/7/2023 1:39 PM, V2 (DON-Director of Nursing) said, on the 8/25/2023 I was called up to the floor. R9 struck R3 because of a dispute over air-conditioning. When R9 returned to the facility after hitting R3, we separated the residents (R3 and R9). R9 should have been put in a private room. R9's medical record (Face Sheet, MDS-Minimum Data Set of 8/21/23) documents R9 is a severely cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Extrapyramidal and Movement Disorder, Bipolar Disorder, Major Depressive Disorder, Psychotic Disorder with Delusions, and Anxiety Disorder. R9's Nursing Progress Note dated 8/25/2023 at 2:39 PM documents in part, resident (R9) was observed sitting in front of nurses' station after allegedly struck his roommate (R3) just above the bridge of his (R3) nose. While (R9) did not originally indicate a specific. Staff eventually learned his roommate (R3) were arguing over the air conditioning unit being on. (Physician) notified with orders to petition resident for involuntary admission to (local hospital). Facility's Abuse Prevention Policy (effective November 22, 2017) documents in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on interview and record review, the facility failed to provide adequate supervision to R1. This failure resulted in R1 sustaining four falls requiring emergency room evaluations and R1 sustaining a right arm humerus fracture, scalp hematoma in the left parieto-occipital region with soft tissue swelling and a head laceration with one staple to R1's head. This failure affects one of four residents reviewed for falls on the sample list of five. Findings include: R1's diagnosis include but are not limited to encounter for other orthopedic aftercare, unspecified fracture of upper end of left humerus subsequent encounter for fracture with routine healing, unspecified fall subsequent encounter, laceration without foreign body of scalp subsequent encounter, and history of falling. R1's Brief Interview of Mental Status (BIMS) dated 04/11/23 documents that R1 has a BIMS of 07 which indicates some cognitive impairments. On 07/25/23 at 11:28 am, V6, Licensed Practical Nurse (LPN) stated, R1 was ambulatory and recalls R1 falling at the facility twice within one month. V6 stated R1 went out to the local hospital on 04/15/23 and 05/25/23 after a falling and sustaining injuries. V6 stated that when R1 fell on [DATE], V6 was told by an unknown CNA staff that R1 fell in the sunroom. V6 stated the unknown CNA's back was turned to R1 when R1 fell on [DATE]. After R1's fall on 05/25/23, R1 complained of right arm pain and sent R1 to the local hospital for evaluation. V6 was informed the next day that R1's right arm was placed in a sling due to R1 having a right arm fracture. On 07/25/23 at 1:59 pm, V11 (R1's Physician) stated that V11 was informed of R1 having multiple falls with injuries at the facility. V11 stated every time V11 was informed that R1 had a fall, R1 was sent to the local hospital for an evaluation of R1's injuries. V11 explained that R1 was a confused resident with dementia and high risk for falls due to R1's condition. V11 also stated that staff should monitor residents who are high risk for falls and have a history of multiple falls with injuries more closely. When V11 was asked what could happen if a resident who is high risk for falls is not closely monitored and sustains a fall, hitting their head or falls on their arm and V11 stated that the resident would have to go to the emergency room to rule out brain bleeds, fractures, and treatment of any injuries. V11 also stated, R1 should have been supervised closely every shift by staff due to R1's dementia. On 07/26/23 at 1:02 pm, V2 (Director of Nursing, DON) stated that R1 was high risk for falls and had multiple falls with injuries at the facility from April 2023 through May 2023. When V2 was asked regarding R1's how often was R1 being monitored, V2 stated that staff cannot watch all the residents all the time. When V2 was asked if R1 was ever placed on a one-to-one monitoring due to R1 having multiple falls in one-month V2 stated, No. When V2 was asked in V2 professional opinion was R1 closely supervised V2 stated, No. It is impossible for the facility to prevent every fall. There is always room to improve supervision. When V2 was asked what could happen if a resident who is high risk for falls and sustains a fall is not supervised, V2 stated that the probability of the resident falling increases and the resident could get injured from the fall. On 07/27/23 at 11:11 am, V10 RN (R1 nurse on 04/18/23) observed (R1) on the floor after falling on 04/18/23. V10 could not recall when the last time V10 was seen prior to R1's fall on 04/18/23. V10 stated R1 was trying to go to the bathroom and fell . R1 had a large hematoma on the back of R1's head that R1 had from a previous fall a few days prior to 04/18/23. R1 was sent to the hospital to evaluate R1's hematoma. V10 recalls R1 having at least three falls while at the facility. The facility's Reportable Incident to local State Agency dated 04/15/23 at 8:53 am, documents R1 fell on the floor with blood next to R1's head. R1 was sent to local hospital. R1 returned with one staple to the back of R1's head. The facility's Reportable Incident to local State Agency dated 05/26/2 at 4:52 pm, documents R1 was observed in a supine position, with arms by R1's side and legs extended. R1 with minor superficial abrasion to right elbow. R1 complained of pain six out of ten to right arm with limited range of motion. R1 was sent to the local hospital for treatment and evaluation. R1 returned to facility with right arm sling related to hairline humorous fracture. R1's local hospital records dated 04/15/23 documents R1 was sent to the local hospital for scalp laceration, staple care, and skin avulsion. R1's CT (Computed Axal Tomography) shows no evidence of acute intracranial hemorrhage, mass effect or shift. There is extensive scalp hematoma in the left parieto-occipital region. There is extensive soft tissue swelling and hematoma measured approximately 4.4 by 1.2 cm (centimeter). R1's local hospital records dated 04/18/23 documents R1 was sent to the local hospital for laceration of scalp. R1 with a 3 (cm) laceration to the left parieto-occipital area. 1 staple in place inferior aspect of the laceration. R1's local hospital records dated 04/19/23 documents R1 was sent to the local hospital for fall with posterior head laceration. CT of head without intravenous contrast findings: soft tissues: Left occipital scalp soft tissue swelling and small soft tissue gas are seen. No intracranial bleed is identified. R1 had a fall on 04/16/23 resulting in hematoma in the occiput, dried blood with one staple in place. On 07/24/23 surveyor requested and was unable to obtain R1's hospital records dated 05/25/23. R1's progress noted dated 04/15/23 at 8:50 am, by V6 (Licensed Practical Nurse, LPN) documents V6 was made aware that R1 was on the floor with blood next to R1's head. R1 stated that R1 was walking out of R1's room got dizzy and fell backwards and hit R1's head. V6 assess R1 and called 911. R1's progress noted dated 04/15/23 at 7:50 pm, by V8 LPN documents R1 returned to the facility from the local hospital with 1 staple and prescription for Bacitracin ointment twice a day for seven days. R1's progress not dated 05/22/23 at 11:50 pm, by V9 (Registered Nurse, RN) documents V9 rushed to the second floor and noted R1 lying on R1's back with R1's upper body on the floor and R1's lower body on the safety mat. V9 documents that R1 reached for R1's bedside commode but loss balance and fell on the floor. R1's progress noted dated 05/25/23 at 4:52 pm, by V6 LPN documents R1 was seen lying face down on the floor in the sunroom by activity aide. V6 observed R1 lying on R1's back. R1 complained of pain to R1's right arm/elbow. R1's practitioner was called and R1 was sent to the local hospital. R1's progress noted dated 05/26/23 at 3:21 pm, by V13 LPN documents R1 returned to the facility from the local hospital with a proximal humerus fracture (break in the top of R1's upper arm bone). R1's care plan dated 02/08/21 documents R1 has is at risk for falls related to (R/T) history of falls, DJD (Degenerative Joint Disease), side effects of medication, limitations in ROM (Range of Motion) to BUE (bilateral upper extremity) and has flaccid RUE (right upper extremity) Focus . Anticipate and meet individual needs of the resident. R1's fall risk review dated 05/25/23 documents R1 has had three or more falls within the last six months and that R1 is high risk for falls. The facility's document/policy dated 06/14 and titled Falls documents, in part: Falling Star Program: Resident is at risk for falls based on Fall Risk assessment. Resident has had a least two (2) falls within a thirty (30) day period. The facility's document dated 03/15 and titled Supervision and Safety documents, in part: Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are the facility-wide priorities. 1. Our facility-oriented approach to safety addresses risk for groups of residents such as wanderers, behaviors, aggressiveness, confusion, etc. 4. Resident supervision is a core component to resident safety . 10. Staff to make visual rounds on residents minimally every two hours and more often, if necessary, based on residents assessment needs.

Based on interview and record review, the facility failed to ensure that residents remain free from abuse for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in R2, a resident with known aggressive behavior, pushing R1 and causing R1 to strike their head before falling on the floor. R1 was sent to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's medical record (Face Sheet, Minimum Data Set) notes R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 8//10/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record (Face Sheet, Minimum Data Set) notes R2 is a severely cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility's final incident report (9/24/2022) notes in part, R1 allegedly had a physical encounter with co-peer R2, which caused alleged victim, R1, to lose balance and fall. R1 alleged that esa vieja me empujo, (that old lady pushed me). R1 was sent out to the hospital for medical evaluation and R2 was sent out to hospital for psych evaluation. R1's Progress Notes, on 9/16/2022 at 10:45 AM, notes in part, @Approximately 10:45am Resident Allegedly receive Physical Contact from Peer. Immediately Complete Body assessment done Lump observed to Left side back of the Head. R2's Progress Notes, on 9/16/2022 at 7:00 AM, note in part, At approximately 6:50 am resident allegedly had physical contact with peer. Resident was immediately Separate and place on 1:1 monitoring. Resident refused body assessment and vital signs to be taken. Spoke to NP give orders for Resident be sent out to (local hospital) for Psych elevation. At 5:59 PM, writer contacted sister and POA(Power of Attorney) of (R2) and informed her that an Involuntary Discharge Notice has been issued to (R2). (Sister) verbalized understanding and thanked me and facility for taking care of (R2) all these years. She voiced that she knows that it's difficult to take care of (R2) when (R2) doesn't want to take (R2's) medication. R2's Low Frustration Tolerance care plan, initiated 7/30/2018, revised 11/20/2018, notes in part, R1 may become physical with others. There are no additional interventions to address R2's aggressive behavior of 9/6/2022. V1 (Administrator) on 9/24/2022 at 12:50 PM said, V3 (Assistant Administrator) reported they heard a yell, ran, and saw R1 on the floor. V1 said they reviewed video of incident. R2 was in their room, R1 was walking down the hallway. R2 is seen coming out of their room, R2 can be seen pushing R1. R1 is seen falling backwards on the floor, apparently hitting their back on handrail before landing on floor. V1 said R2 has a history of prior unwitnessed physical altercations in the past with other residents where R2 was the aggressor. There was a previous incident with R1 and R2 this month, it was reported to IDPH (Illinois Department of Public Health). Surveyor asked V1 what interventions were in place to address R2's aggressive behavior, V1 responded, re-direction, if that didn't work, call PCP, look at medications, refer to psych. V3 (Assistant Administrator) on 9/24/2022 at 1:29 PM said, R1 allegedly had an incident with R2 but we didn't know what it was, it was just hearsay. R1 reported, earlier this month, that R2 smacked R1. There were no witnesses, we did investigate, but were unable prove anything. R1, on 9/24/2022 at 2:12 PM said, R2 pushed me. I didn't say anything to R2 (before R2 pushed R1). R1 said R2 could hurt me. I hit my head before I fell on the floor. R2 was not available for interview. V5, (Certified Nursing Assistant) on9/24/2022 at 2:32 PM said, I heard someone scream. I ran around the corner, that's when R2 came past me, and I saw R1 on the floor. R2 didn't say anything to me, they just walked by real fast. R1 said R2 pushed me. V5 said, R2 paced around and talked to herself, I'm not aware of any incidents of physical abuse (where R2 was the aggressor). Facility's Abuse Prevention Policy (effective November 22, 2017) notes in part, Residents have the right to be free from abuse .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means .Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Deficiencies at this level require more than 1 Deficient Practice Statement (DPS): A. Based on observation, interview, and record review, the facility failed to ensure two residents (R1 and R9) at risk for falls were monitored to prevent falls and injuries in a sample of 8 residents reviewed for falls. This failure resulted in R1 falling sustaining acute rib fractures and requiring hospitalization , and R9 falling and sustaining a fracture of the right femur requiring surgical repair. B. Based on observation, interview, and record review the facility failed to implement fall interventions for six residents (R2, R3, R4, R5, R6, and R7), in a sample of eight residents reviewed for falls. Findings include: A.1. R1 is [AGE] years old with diagnosis including, but not limited to, [CONDITION(S)], Hypertension, Diabetes, Asthma, [CONDITION(S)], Dementia, Anxiety, and Urinary Incontinence. R1's cognitive assessment, dated 6/8/21, notes R1 is cognitively impaired with a score of 3. R1's Fall Risk Review, dated 6/04/21, notes R1 is determined to be high risk for falls. Review of R1's care plan, date initiated 3/05/21, notes at risk for falls related to cognitive impairments. R1's cognitive care plan, date initiated 3/12/21, notes R1 is disoriented to time and place. Review of R1's Monthly Summary, dated 7/02/21, notes R1 is at risk for falls. Review of R1's CT of the chest, abdomen, and pelvis, approval date 7/25/21, notes in an Addendum: fractures of the right sixth through eleventh ribs. Fractures of the tenth and eleventh ribs may be chronic, but the remainder appear acute. Review of R1's 7/25/21 hospital admission record notes Chief Complaint: fall with rib fractures on right side. The facility's initial investigation report for R1, dated 7/26/21, notes R1 has rib fractures of ribs 6-11. The facility final investigation report, dated 7/30/21, notes R1 received report from hospital of rib fracture. On 8/17/21 at 12:21PM, V9, CNA, said she assisted R1 with her cares and toileting. V9 said for night shift, R1 was incontinent of urine, but on day shift she would toilet R1 every 2 hours. V9 said if she did not assist R1, R1 would try to get up and go to the bathroom, unassisted. V9 said she knew R1 had fallen in the past. During a phone interview on 8/17/21 at 1:04PM, V4, Registered Nurse (RN), said she was on duty the evening of 7/24/21 on the evening shift, prior to R1's fall. V4 said R1 was always a fall risk. On 8/17/21 at 1:26PM, V3, RN, said R1 was confused and forgetful at baseline. V3 said, I saw (R1) about 11:00PM and 1:00AM. (R1) was in the second bed in the room and had one other roommate located in the bed near the door. On the night of 7/24/21, when (V3) checked her at 11:00PM, (R1) was drifting to sleep, and at 1:00AM (R1) was sleeping. V3 said, (R3) is incontinent of urine and we just change her, we don't get her up to use the bathroom. While in another room (V3) heard a noise boom, it sounded like something fell . V3 said, When I approached (R1's) room I saw the call light was on. I opened the door to the room, and saw (R1) laying on the floor behind the door. V3 said all R1 said was she was going to her casa (home). V3 said when she was turning R1 on her left side, R1 said leg pain. V3 said R1 was wearing a brief and a gown and the floor was wet from R1 being incontinent of urine. V3 said R1 was a known fall risk. V3 said before the fall R1's door was closed because R1's roommate wants it closed. V3 said 911 was called, and R1 was taken to the hospital and did not return on her shift. On 8/17/21 at 2:00PM, V2, Director of Nursing (DON), said he investigated R1's fall. V2 said R1 woke up during the night, was confused, and verbalized she wanted to go home. V2 said he was told V3 and V5, Certified Nursing Assistants (CNAs), said they heard a sound and went to R1's room and saw her on the floor. V2 said he was told R1 was observed sleeping 30 minutes before the fall. V2 said he was not told when R1's incontinent brief was last changed. V2 said before the fall, R1 was not able to safely stand, transfer, or walk independently. V2 said R1 was at risk for falls. V2 said the door to R1's room should not be closed when staff is not in the room. On 8/17/21 at 2:25PM, during a phone interview, V7, R1's family, said at 2:30AM (07/25/21), V26, R1's son, received a call R1 had fallen and was sent to the hospital. V7 said V26 told V7 that R1 had 6 broken ribs. On 8/17/21 at 3:43PM, V21, CNA, said R1 would try to get up unassisted. V21 said the door to R1's room was kept closed because R8 wanted it closed. On 8/18/21 at 10:37AM, V2 said he did not collect a written statement from V5, CNA, working when R1 fell . V2 said, I don't recall speaking to him (V5) about R1's fall. On 8/18/21 at 10:41AM, V12, CNA, said on 7/24/21 she changed R1 into a nightgown and assisted her with toileting around 8:00 PM. V12 said she placed a new brief on R1, transferred R1 into bed, and covered her with blankets. V12 said R1 was drifting to sleep when V12 left the room. V12 said she closed the door to R1's room when she left the room. V12 said R1 had a history of trying to get up unassisted and R1 was not safe to get up unassisted. V12 said R1 did not know how to use the call light to call for assistance. V12 said she last checked R1 about 9:30PM before she ended her shift. V12 said R1 was sleeping and clean, and V12 did not wake R1 up. V12 said after checking R1, she closed the door to R1's room and left the room. On 8/18/21 at 12:00PM, V17 (Physician) said after her fall, R1 was taken to the trauma hospital on 7/25/21. V17 said R1 had a history of Cervical #7 and #8 fractures from multiple falls in the community. V17 said before her fall, R1 was stable and at baseline on 7/25/21, alert and oriented times one, and was confused. V17 said R1's diagnoses included Dementia, [CONDITION(S)], and Incontinence. V17 said R1 had cognitive impairments and walked unsteady. V17 said he expected R1's room door to be open to see if she has any changes because her mentation is disorganized. V17 said if R1 got up unassisted in her room she would not be able to navigate her surroundings. A.2. R9 is a [AGE] year old with diagnoses including but not limited to: Diabetes, Repeated Falls, Dementia, and Weakness Review of R9's care plan, revised on 3/24/21, notes R9 has weakness and will have active range of motion exercises to left and right upper extremities and right and left lower extremities for strengthening. Fall Risk Assessments, dated 6/20/21 and 6/32/21, notes R9 is determined to be high risk for falls. On 7/11/21, R9 suffered a fall at the nursing home requiring hospitalization due to right leg pain. X-Ray of the right hip, performed on 7/11/21, notes a comminuted intertrochanteric fracture involving the right femur. Review of R9's hospital records include an X-Ray of the right hip, performed on 7/11/21, note Comminuted intertrochanteric fracture involving the right femur. Review of R9's Functional Status assessment, dated 7/7/21, notes R9 required extensive assistance of two persons to provide weight bearing support to transfer between surfaces. R9 required extensive assistance from one staff person to provide weight bearing support with toilet use. Mobility devices used indicate only a wheelchair. The bowel and urinary continence assessment, dated 7/7/21, for R9 notes he was frequently incontinent of bowel and bladder. Review of R9's care plan, revised on 7/8/21, notes R9 has self care deficit and requires assistance due to Dementia and weakness and requires limited to extensive assistance with most activities of daily living. Intervention, dated 6/24/21, notes wheelchair for weakness. Review of R9's Progress Notes, dated 7/16/21, note right hip surgery site is covered with gauze. On 8/20/21 at 10:35AM, R9 was observed sitting up in wheelchair in the dining room being supervised by activity staff. R9 did not give details when surveyor asked him why he is in wheelchair. On 8/24/21 at 12:58PM, V21, CNA, said R9 had a walker in the bathroom, but R9 should not be walking alone into the bathroom. V21 said R9 is known to get up unassisted, because he does not like staff needs to help him. V21 said R9 was in his bed in his room about 30 minutes before she saw him in the bathroom. V21 said R9 would have walked out of his room and past two doors to get into the bathroom. V21 said R9 was in an area not visible from the nurses' station. On 8/24/21 at 2:11PM, V19, Restorative Nurse, said R9 began to use a wheelchair on 6/24/21. V19 said R9 was unable to walk when she assessed R9 on 6/24/21. V19 said on 7/11/21, R9 still required the use of a wheelchair because he was unsteady, unsafe, had weakness, and was not able to ambulate. V19 said R9 was unable to use a walker safely at this time. On 8/24/21 at 2:47PM, V4, Registered Nurse (RN), she said she was working when R9 fell while using a walker and trying to get to the bathroom. V4 said when she entered the bathroom to assess R9 she saw he had been incontinent of urine and loose bowel movement, and bowel movement was on R9 and on the floor. V4 said on 7/11/21, R9 was not able to safely ambulate in the hallway using a walker independently. V4 said she saw R9's right leg was shorter than the left, and it appeared like a fracture. V4 said the ambulance was called to send R9 for evaluation at the hospital. On 8/25/21 at 9:44AM, V2, Director of Nursing, said R9 fell on [DATE]. V2 said R9 got up from his bed unassisted and fell in his room. V2 said R9 was sent to the hospital following the fall, and when he was readmitted to the facility R9 was in a wheelchair and no longer able to ambulate independently. V2 said R9 got up unassisted on 7/11/21, and was walking using a walker into the bathroom. V2 said R9 was not supposed to have been walking using a walker independently. V2 said R9 did not have a bathroom in his room and had to walk into the hallway to use the bathroom. V2 said the expectation for staff is that they meet the resident needs during rounds. V2 said R9 had been incontinent when he was observed on the floor in the bathroom on 7/11/21. V2 said he was notified verbally by the hospital that R9 suffered a fracture following the fall on 7/11/21. B.1. R2 is [AGE] years old with diagnoses including, but not limited to [CONDITION(S)], [CONDITION(S)] and Collapse, [CONDITION(S)], Dementia, Alzheimer's Disease, Delusional Disorder, and History of Falling. R2's Fall Risk Review, dated 8/17/21, notes R2 has been determined to be high risk for falls. Review of the facility Floor Safety Rounds includes following residents and interventions: R2: Call light, floor mat, and bed/wheelchair alarm On 8/17/21 at 11:41AM, surveyor toured with V15, Licensed Practical Nurse (LPN), into R2's room where R2 was sitting in his wheelchair. Surveyor asked V15 if R2 has a chair alarm. V15 checked the alarm attached to R2's wheelchair. Surveyor observed with V15 that the clip was not attached to R2 or his clothing, and when she tested the alarm it did not make a sound. B.2. R3 is [AGE] years old with diagnoses including, but not limited to Adult Failure to Thrive, Repeated Falls, Unsteady on Feet, and Dementia. R3's care plan, date initiated 3/04/20, notes R3 is at risk for falls related to history of falls, cognitive impairments, and unsteadiness on feet. Interventions include floor mat. Review of the facility Floor Safety Rounds includes following residents and interventions: R3: Floor mat, call light On 8/17/21 at 11:32AM, surveyor observed R3 in his bed and no floor mat observed. On 8/17/21 at 11:41AM, surveyor observed R3 in his bed and no floor mat observed. On 8/17/21 at 12:00PM, surveyor was in R3's room with V16, and asked about floor mats. V16 said R3 should have a floor mat. Surveyor observed a floor mat against the wall in the room. B.3. R4 is [AGE] years old with diagnoses including, but not limited to of [CONDITION(S)], [CONDITION(S)], Hypertension, Diabetes, Weakness, and Dementia. R4's care plan, revision dated on 10/04/19, indicates R4 is at risk for falls related to cognitive impairments, side effects of medication, unsteadiness on feet. R4's Fall Risk Review notes R4 is at high risk for falls. Review of the facility Floor Safety Rounds includes following residents and interventions R4: Call light On 8/17/21 at 12:01PM, surveyor observed R4's room door closed. Surveyor knocked on door and entered. R4 was sitting in a wheelchair with nothing on her feet, near the window and air conditioning unit. The call light was not visible on the bed. R4 had no call light in reach. R4 was not wearing shoes, slippers, or any foot covering. V16 delivered R4's meal tray and was asked where her (R4's) shoes were. R4 did not answer, and then V16 left the room. V16 did not put any shoes on R4. On 8/18/21 at 2:30PM, V19, Restorative Nurse, said she expects staff to follow the fall prevention interventions. V19 said the floor safety rounds sheet is used so staff can identify who is at risk for falls and what interventions need to be in place to keep them safe. V19 said R4 is at risk for falls and in the falling star program. While reviewing R4's medical record with the surveyor, V19 said R4 had a fall on 5/06/21 and 6/11/21. V19 said R4 should have her call light in reach when she is in her room. V19 said R4 should have shoes on her feet when she is in her wheelchair and she would not be safe to stand without shoes. V19 said R4's room door should not be closed so she can be visualized often by staff in the hall. B.4. R5 is [AGE] years old with diagnoses including, but not limited to Chronic Obstructive Pulmonary Disease, Diabetes, [CONDITION(S)], [CONDITION(S)], Weakness, and History of Falling. R5's care plan, revised on 8/19/19, notes R5 is at risk for falls related to history of falls, weakness, and subsequent fall. R5's Fall Risk Review, dated 7/19/21, notes R5 is at high risk for falls. Review of the facility Floor Safety Rounds includes following residents and interventions R5: Floor mat (X2), call light On 8/17/21 at 11:42AM, surveyor toured with V15 to R5's rooms. R5 in her bed with floor mat under her bed and R5's call light was not in reach. V15 said the mats are not protecting R5 from injury under the bed while V15 placed R5's call light in her reach. On 8/18/21 at 9:55AM, surveyor observed R5 in a wheelchair with the call light not in reach. B.5. R6 is [AGE] years old with diagnoses including, but not limited to [CONDITION(S)], [CONDITION(S)], Hypertension, Weakness, Dementia, and Alzheimer's Disease. R6's care plan, revised on 12/29/20, notes R6 is at risk for falls related to cognitive impairments. R6's Fall Risk review, dated 6/30/21 notes, R6 is at high risk for falls. Review of the facility Floor Safety Rounds includes following residents and interventions R6: Floor mat, call light, bed/wheelchair alarm On 8/17/21 at 11:49AM, V16, Certified Nursing Assistant, (CNA), toured R6's room with surveyor. R6 was in her bed. V16 said, I don't know where (R6's) floor mat is. V16 said, (R6) has no alarm or call light in reach. (R6) is at risk for falls and tries to get up unassisted. V16 called out in hallway that R6 needs a floor mat. V16 then began passing meal trays in the hallway. On 8/18/21 at 9:52AM, surveyor observed R6 in her bed without an alarm and the call light located on the night stand, out of R6's reach. B.6. R7 is [AGE] years old and with diagnoses including, but not limited to [CONDITION(S)] of knee, Unsteady on Feet, and Weakness. R7's Fall Risk Review, dated 5/21/21, notes R7 is at high risk for falls. R7's care plan notes she has cognitive impairments, and care plan, revised on 7/13/21, notes R7 is at risk for falls related to history of falls On 8/17/21 at 12:17PM, surveyor observed the shared door to R7's and R8's room closed. R8 was R1's roommate on 7/25/21. On 8/18/21 at 1:10PM, surveyor observed R8's (and R7's) room door closed. Surveyor knocked on the door and entered. R8 acknowledged surveyor and pointed to her ears and gestured for surveyor to go. R8 was R1's roommate and surveyor was attempting to interview R8 regarding R1's fall on 7/25/21. R7 is now R8's roommate, and R7 said R8 wants the door to be kept closed. R7 said if the door is not closed then R8 begins to yell door, door until someone closes the door. On 8-18-21 at 2:30 PM, V19 said R8 likes to have her room door closed. V19 said R8 was R1's roommate and is now R7's roommate. V19 said R7 is at risk for falls. The facility's undated Fall Prevention Program notes: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. 16. All nursing personnel will be informed of residents who are at risk of falling. 17. Residents at risk of falling will be assisted with toileting needs. 19. Footwear will be monitored to ensure the resident has proper fitting shoes or footwear is non skid.

Based on observation, interview, and record review, the facility failed to accurately evaluate and analyze the gait of a resident at risk for falls on admission, and failed to implement fall prevention interventions to reduce the risk of injury to the resident. These failures affected one resident (R1), of three residents, reviewed for fall risk and fall prevention interventions. As a result of these failures, R1 sustained a [MEDICAL CONDITION] from an unwitnessed fall, was hospitalized , and needed surgery to repair the arm. Findings include: R1's face sheet shows that R1 was originally admitted to the facility on [DATE]. R1's admitting [DIAGNOSES REDACTED]. On 12/24/20 at 10:56am, during observation of residents on the second floor of the facility, R1 was observed in bed. R1's call light was hanging on the wall behind the head of the bed and not within the reach of the resident. In addition, R1 did not have a safety mat on the floor, as indicated on R1's care plan. At this time, V4 (Certified Nurse Assistant, CNA) and V3 (Licensed Practical Nurse, LPN) were asked if the resident was able to use her call light button. Both V3 and V4 stated the resident was able to use the call light. V4 took the call light button, gave it to R1, and asked R1 to use the call button. R1 responded by pushing the call light button and the call light came on. R1's physician progress notes [REDACTED]. R1's Restorative progress notes, dated 6/19/20 at 8:32am, written by V12 (LPN, Licensed Practical Nurse), states R1 has weakness and pain but can walk short distances, and will be using a wheelchair for now. R1's MDS (Minimal Data Set), dated 10/1/20, shows that R1 needs extensive assistance for transfer and bed mobility. R1's care plan, dated 11/4/20, says R1 should have a safety mat and that call light should be within reach and resident should be encouraged to use the call light for assistance as needed. There is no record to show that R1 had a safety mat at the time of the fall. R1's progress notes show that R1 recently had an unwitnessed fall that resulted in a right arm fracture for which R1 was hosptalized on [DATE] and re-hosptalized on [DATE]. On 12/28/20 at 1:28pm, V1 (Administrator) presented the facility's initial and final incident reports that were sent to the State Agency. This report states that on 11/4/20 at 2:58am, R1 was found on the floor at her bedside with injury to the right arm and was sent to the hospital. On 12/29/20 at 10:12am, V1 presented R1's Initial Fall Risk Review, dated 6/18/20, that was incomplete because the Gait Analysis part of the assessment was not done. Since the Gait Analysis part was left blank, R1 was wrongly assessed as a resident who was not at high risk for falls. On 12/29/20 at 12:25pm, V13, Nurse Practitioner, was interviewed regarding R1's initial risk assessment for falls based on the R1's diagnoses, nurses' documentation and her (V13)'s documentation of 6/24/20 as stated above. V13 stated the resident should have been assessed as a high risk for falls and the expectation is that staff will do frequent rounds on the resident, and that the resident should have fall prevention interventions in place. Facility's Fall Prevention Program, dated 2/28/14, states in part: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. #1 states: 1. A Fall Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. #3 states: Safety Interventions will be implemented for each resident identified at risk using a standard protocol. #2 states in part: The nurse call device will be placed within the resident's reach at all times. The location of the placement will be verbalized for those residents with visual deficits

Based on interview and record review, the facility failed to transfer a resident with the required number of staff members and to use the required mechanical lift. This applied to 1 of 4 residents (R25) reviewed for falls/accidents in the sample of 29. This failure resulted in R25 being sent to local ER (emergency room ) for evaluation of pain and swelling to the left ankle, with a resulting fracture to the left ankle. Findings include: R25 has [DIAGNOSES REDACTED]. R25's MDS (Minimum Data Set) dated 7-25-18 indicates R25 requires the extensive assistance of two or more staff members to transfer. This MDS also indicates R25's BIMS (Brief Interview for Mental Status) score was 9, indicating moderate cognitive impairment. V10's (Nurse) note 8-3-18 at 2:30 pm documents, Writer observed left ankle noted slightly swollen, complaining of pain to the touch and with movement. Unable to give a description of what happened. Left leg elevated with a pillow and immobilized. V11 (Physician) was called and made aware. V11 ordered to get X-Ray and arterial Doppler with ABI (Ankle Brachial Index). V10's note 8-6-18 at 3:20 pm documents, Received X-ray results, V11 made aware, order to send out to hospital ER (emergency room ) for left ankle fracture distal tibia and distal fibula. R25's 8-3-18 X-ray noted Oblique [MEDICAL CONDITION] tibia and an incomplete oblique [MEDICAL CONDITION] fibula. V2 stated 10-17-18 at 11:32 am the initial report of R25's injury was sent to IDPH (Illinois Department of Public Health) on 8-6-18, which was the day the facility received the X-Ray results. The facility fax machine was not working, and numerous faxes, including R25's X-ray result, came out of this machine once fixed on 8-6-18. V2 investigated this fracture, and it was found that on 8-2-18, V12 (CNA - Certified Nursing Assistant) stated that at approximately 6:30 pm that evening, R25 twisted her left ankle as V12 was attempting to transfer R25 from a shower chair into bed. V12 acted alone in transferring R25 and did not report to anyone that R25 twisted her left ankle during this transfer. V12 only reported to V10 that R25 was complaining of left ankle pain and did not tell V10 the reason. V2 stated it was known that R25 was a mechanical lift transfer, and needed two staff members to assist in transfers. R25 received a splint and soft cast in the hospital, and returned to the facility 8-8-18. V12 was disciplined for improper transfer of resident resulting in an injury. V2 provided a copy of this Employee Report warning. V2 also provided copies of the written statements of V12 and V10. The final investigation report was faxed to IDPH 8-13-18, and indicates, in part Upon investigation it was determined that mechanical lift was not used for the transfer by the CNA. CNA was in-serviced on transfer procedures and process of resident refusal and disciplined appropriately. V9 (Restorative Nurse) stated 10-17-18 at 12:35 pm, R25 has been using a mechanical lift and two staff members to transfer for more than three years. V9 does quarterly, annual, and significant change restorative assessments on all residents. R25's most recent Transfer and Bed Mobility/Limited Lift Review was completed 7-25-18 and indicated M = Mechanical Lift (Requires 2 Caregivers). V9 stated the symbol (the facility uses H to designate mechanical lift) is posted on a communication board behind the head of the bed of each resident, to inform staff of how the resident transfers. All CNA's are to use two staff members to assist in transferring residents via mechanical lift. For showers, residents requiring a mechanical lift should be placed in a shower sling, laid on top of his/her bed, then raised up via the mechanical lift and placed in his/her wheelchair. The resident should then be taken to the shower room, and raised up and placed in the shower chair utilizing the mechanical lift and shower sling. Once done showering the resident, the CNA's should place the resident back in his/her wheelchair, using the shower sling and mechanical lift. The resident is then taken back to his/her room, and placed in bed, again using the mechanical lift and two assists. The shower sling is then sent to the laundry. Residents should not be transported to their rooms using the shower chair, and residents requiring mechanical lifts should not be transferred by only one staff member under any circumstance. R25's care plan includes the intervention: Resident will be transferred with a 2 person transfer when using a mechanical lift, or per our policy and procedure and manufacturer's guidelines. Facility policy (undated) titled, Limited Lifting Resident Handling Policy documents: Mechanical lifting devices shall be used for any resident requiring a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H = Mechanical Lift with 2 caregivers. Facility policy titled, Fall Prevention Program (undated), documents: Transfer conveyances shall be used in accordance with the plan of care.

Based on observation, interview and record review the facility failed to implement effective fall prevention measures for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 incurring a fracture of the arm and a laceration requiring sutures. Findings Include: The Admission Face Sheet, 12/10/13, documents R1 with [DIAGNOSES REDACTED]. R1's Care Plan for falls, initiated 1/31/14, documents R1 as requiring use of a non-skid floor mat, keep personal items in reach, anticipate needs, use of a personal alarm, monitor closely and a room close to the nurses station. The Fall Risk Review, 1/11/14, documents R1 at a high risk for falls. On 1/11/14 at 7:25am, the facility incident report documents R1 was found by E3 (Nurse) on the floor in a sitting position in front of the closet door. The report does not document the personal alarm being in place. No injuries were noted. The Nursing Management Investigation Report, 1/11/14, documents R1 stated he was walking towards the closet and lost balance and fell . On 3/14/14 at 9:30am, E3 showed the surveyor the location R1 was found on the floor and E3's location at the nurses station at the time of the fall. E3 stated R1 was found on the floor by the closet. R1's room was directly visible from the nurses station where E3 stated she was sitting (10 feet between the nurses station and R1's room). R1's bed was the first bed inside the room, directly left of the bedroom entrance, which was pushed up against the wall on one side. The closet in that room was across the room near the windows in the room (approximately feet from the foot of R1's bed). E3 stated R1 was found on the floor when she looked over from the nurses station. E3 was unable to indicate if R1's personal alarm was sounding and stated she was aware of the fall when she observed R1 on the floor by the closet. On 2/20/14 at 1:30pm, the facility incident report, completed by E3, documents R1 was found on the lying on the floor with a laceration to the right eyebrow and complaints of right shoulder pain. The hospital record, 2/20/14, documents R 1 was diagnosed with [REDACTED]. On 3/13/14 at 12:46pm, E4 (Nursing Assistant) stated she responded to a personal alarm in R1's room on 2/20/14 and found R1 on the floor. R1 was face down on the mat with part of R1's upper body off of the mat on the floor. On 3/14/14 at 12:52pm, E5 (Nursing Assistant) stated on 2/20/14 she entered the room to find R1 on the floor laying on his stomach. R1 was half on the mat with the upper half of his body laying on the floor. E5 was asked to demonstrate the placement of the mat and placed the mat so approximately half of the mat was underneath the bed. E5 stated R1 can remove the personal alarm and move the floor mats. E5 stated R1 uses a personal alarm at all times in the bed and wheelchair. On 3/14/14 at 10:25am, E2 (Director of Nursing), stated R1 incurred a laceration requiring 7 sutures and a fracture requiring use of a sling on 2/20/14 after R1 fell . When asked if proper mat placement could have prevented R1 from incurring injuries E2 stated, "Yes, it may have." On 2/23/14 at 11:34pm, the facility incident report documents E7 (Nurse) heard a loud noise. R1 was found sitting on the floor with juice all over R1's gown and the bedside table on the floor. R1 stated, "I wanted to drink juice." On 3/14/14 at 10:12am, E7 stated a noise was heard and R1 wasn't in bed. R1 was found on the floor at the foot of the bed. The bedside table fell also and was lying next to R1. Mats were down. R1 stated he wanted a drink and juice was all over R1's gown. The alarm was not sounding. E7 stated R1 can remove the alarm. On 3/14/14 at 10:25am, E2 stated R1's bedside table should have been within reach. R1 also uses mats and a personal alarm at all times. E2 stated she was unaware R1 would remove the personal alarm. On 3/14/14 at 11:40am, Z1 stated all falls cannot be prevented. The expectation is to do a fall risk evaluation and implement protocols. Implementation of intervention reduces falls and injuries from falls. The facility policy, Fall Risk and Post Fall Assessment, undated, documents the purpose of fall risk assessment is to detect reversible causes of falls and identify supportive aids to prevent falls. Residents are to be monitored regularly for changes which might increase the potential for future falls.

Based on interview and record review the facility, failed to protect 3 of 3 female residents(R1, R4 and R5) from potential sexual abuse from R3 a male resident. On 8/12/2013, as a result of escalating inappropriate behavior, R3 removed sheets from R5 , touched R4 and was found on top of R1 a cognitively impaired female resident. This failure had the potential to affect 17 other female residents( R2, R6-R21) residing on the 3rd floor. Immediate Jeopardy was called on 8/16/2013 at 2PM with E1(Administrator), E2(Director of Nursing), E12(Assistant Director of Nursing) and Z4(Director of Operations). The Immediacy was determined to have begun on 8/12/2013 at 7:00AM with R3's wandering behavior. The Abatement Plan was accepted on 8/16/2013. The Immediacy was removed on 8/16/2013 at 6PM. The facility remains at a severity level two for this deficient practice until in-service, training and policy revisions are complete. Findings Include: Face Sheet documents that R3 was admitted on [DATE] with the following pertinent diagnosis, senile dementia/delusional and depressive features, muscle weakness and altered mental status. Abuse Investigation dated 5/22/2013 states that R3 was found laying on the floor clothed with a female resident next to him, the female resident had no underpants on. R3 was sent and admitted to the hospital. Hospital Record dated 5/29/2013 states R3's chief complaint was inappropriate sexual behavior, aggressive and disorganized. Discharge Note from the hospital states, " Direction given by staff received [MEDICATION NAME] 50 milligram via injection today and will be given every 4 weeks with due date on 7/1/2013. Depo-[MEDICATION NAME] 150 milligram injection received today and will be given every 4 weeks due date on 7/1/2013. Clinical Assessment Report dated 6/4/2013 states that family declined De-[MEDICATION NAME] injections ' and [MEDICATION NAME] injections ' . It also states that R3 is ambulatory, independent for bed mobility, transfers, dressing, eating and toilet use. Care Plan dated 6/14/2013 and revised on 7/15/2013 states " Monitor hourly times 72 hours and make every attempt to keep in highly supervised areas during the day. " Social Service Note dated 7/18/2013 states, " Per administration and nursing staff he is now being discharged from our resident monitoring list. Writer will visit as needed to check on well being. " Care Plan for [MEDICAL CONDITION] Medications dated 7/26/2013 states, R3 should receive [MEDICATION NAME] as needed. Monitor for target behaviors like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others. " Nurses Note dated 8/12/2013 at 7:00AM states, " resident ambulating the hallways. Noted wandering in and out of other residents room. Reoriented by staff. Resident verbalized understanding. Escorted to day room to be with other staff. 8:30AM, resident in room [ROOM NUMBER]-2 reports unwilling to leave room for breakfast reports male resident was in room last night wandering in and out twice last night. Resident placed on every 15 minute monitoring by staff. 8:35AM informed doctor of behavior, new order to send resident out to Psych facility to evaluate .... Family member made aware. 8:45AM, resident noted eating in dining room area still on 1:1 observation. Paramedic transport stated it will take 45 minutes for arrival to pick up R3. 1:20PM, R3 was noted in room [ROOM NUMBER] in bed with female resident(R1). Nurse entered room resident was facing window fixing pants. Nurse escorted R3 out of room. Nurse assessed R1. While nurse was on the phone with administration R3 was noted wandering in and out of rooms. R3 was found in room [ROOM NUMBER]-2. Paramedics arrived and escorted R3 out to the hospital. " On 8/13/2013 at 12:12PM, E6(Certified Nursing Assistant) stated, " at about 1:20PM I was going into the room to provide care I noted the door closed, I opened and saw R3 on top of R1. I talked to him and said what are you doing? He got off of her and I stayed in the room and called the nurse(E5) to come in and assess both residents. Both residents went to the hospital. " On 8/13/2013 at 1:57PM E4(Social Service Director) stated, " I was just hired 2 weeks ago the previous social service worker assigned for R3 is no longer here, I am R3's current social worker. R3 is alert and oriented of self. R3 needs direction from staff, R3 likes to walk around. For inappropriate sexual behavior I believe R3 was monitored every 15 minutes, R3 is confused, I am not sure about procedures for supervision you will have to ask the E2(DON). " On 8/13/2013 at 3:17PM, E5(Nurse) stated " I was alerted by E6(CNA) screaming. When I arrived I saw R3 standing at the window by R3's bed fixing his pant zipper. I was trying to get R3 out for psychological evaluation. I called the administrator after R3 was found on top of R1 and R3 disappeared while I was on the telephone. We had to search for him again. With redirection R3 is compliant. R1 was assessed she had an incontinent brief on during the incident, When I assessed her one side of the incontinent brief was opened. R1 was on every 15 minute monitoring starting at about 8:30AM. At 1:15PM, R3 was in the day room with both activity aides, the activity aids saw R3 last before the incident happened. Everybody is responsible to monitor R3, no one person is assigned. If I knew of R3's sexual history I would have kept R3 in close proximity of the nursing station all the time. I do not know how R3 got away from the activity aides that were in the dining room. When they saw him leave they should have told me. R3 should have been monitored more. " On 8/14/2013 at 12:00Noon via telephone, Z1(Psychiatrist) stated, I saw R3 while in the hospital and when R3 returned to the nursing home. I ordered Depo-[MEDICATION NAME] for R3 while in the hospital and the injections were to continue monthly to decrease sexual aggression that R3 has. When R3 returned from the hospital I continued the order for monthly Depo-[MEDICATION NAME] injections. R3 was on [MEDICATION NAME] and R3 would wander. This resident needed to be supervised, structured supervision. If R3 ' s sexually inappropriate behaviors continued, he needed to be hospitalized . Family refused for R3 to receive Depo-[MEDICATION NAME] injections and hospitalization . R3 is a high risk individual, R3 absolutely needed to have a separate setting, a separate floor and keep him separate from other residents. That is hard to do in an opened population. R3 clearly needed an intervention. I wanted R3 to go to a specific hospital, family declined. I told them I could not be his doctor because this is a dangerous situation. I am no longer his Psychiatrist because of these reasons. R3 needs to be in a separate facility that can handle high risk patients. " On 8/14/2013 at 1:05PM, E8(Acitvity Aide) stated, " I was not there when it happened. I went to lunch at 12Noon and I have an hour for lunch, Talk to E9(Activity Aide) she covered for me. " On 8/14/2013 at 1:10PM, E2(DON) stated, " If necessary we do 1:1. It is stress on the staff. If we feel that R3 was a true danger to himself or others we provide 1:1. They found R3 on top of R1, but R3 did not penetrate. " On 8/14/2013 at 1:33PM, E9(Activity Aide) stated, " I start at 8:30AM and work until 4:30PM. I went to lunch at 12 noon and have an hour for lunch. The certified nursing assistants were in the dining room. I can not remember the names. R3 was with me in the morning doing activity. When I went to lunch I do not know what happened. No body from activity was on the 3 rd floor at 1PM. " On 8/14/2013 at 12:43PM, E5(Nurse) stated, " I was the receiving nurse on 6/1/2013 and I educated the family on Depo-[MEDICATION NAME] to decrease sexual aggression. I was aware that something happened, I just was not thinking on 8/12/2013. Family did not want any medication. " Nurses Noted dated 6/1/2013 documents that E5(Nurse) readmitted R3 and informed the family of Depo-[MEDICATION NAME] injection for decrease of sexual aggression. Family wanted R3 observed closely because R3 received the injections in the hospital. On 8/14/2013 at 3:06PM, via telephone and E13(Staff interpreter), Z2 stated, " I was not aware that the hormone shot needed to be given every 4 weeks. R3 received it in the hospital, I had to sign consent in the hospital and I did. When R3 got here I did not want R3 on those 2 injections. " On 8/14/2013 at 2:11PM, E5(Nurse) " I was supposed to start duty at 6AM, I punched in at 6:30AM. On 8/12/2013 R3 was having problems from the night shift. No one reported it. A resident (R4) told me that R3 was in and out of her room pulling the sheets off of her and that she was afraid to come out of the room. That is when I put R3 on every 15 minute monitoring. I did not give any medication. The 1:1 documentation is an error that I wrote. Looking back on things giving R3's history of sexual aggression and I was the readmitting nurse on 6-1-2013 who talked to the family about the Depo-[MEDICATION NAME] injections to decrease sexual aggression. I should have kept R3 with me at the nursing station until I got him out. R3 should have been put on 1:1 observation, I feel so bad, the incident with R1 should not have happened, I should have called 911 and kept R3 with me until 911 arrived. There are so many things I should have done differently. " Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. It was not given on 8/12/2013. On 8/14/2013 at 3:40PM, Z3(Medical Doctor) stated, " I am the attending physician for R1 and R3. R3 is always wandering. The administrator wanted to dump him to another facility when the last incident happened. I pleaded with the administrator to keep him here. I do not know what to do with a resident that needs help like this. I am familiar with the last sexual incident. R3 did it again, R3's mind is not right. R3 did not penetrate R1, I don ' t even believe that R3 can get an erection. I do not know what happened, R3 did it again. In terms of supervision speak with the director of nursing. I understand all residents need to be safe, but what are we going to do with this resident. The family told me about the residents drooling so I tapered the [MEDICATION NAME]. R3 was overmedicated. The family wants me to discontinue needed medications. If we dumped this resident to another facility that facility will get the problems. " On 8/12/2013 at 11:48AM with tour guide E3(Restorative Nurse), R1 and R2 were in assisted chairs in the dining room being assisted to eat lunch. E3 stated that neither resident was cognitively independent. According to the Physician order [REDACTED]. The Minimum (MDS) data set [DATE] states that R1 was asked cognitive questions and did not answer any question. According to the Abuse Investigation Report dated 8/12/2013 ; On 8/12/2013 at 1:25PM, E6(Certified Nursing Assistant) found R1 female resident( laying in R1 ' s assigned bed and room) with R3 a male resident on top of her. E6 alerted E5 while in the room. E5(Nurse) entered the room and found R1 by the window fixing pants and zipper. The Chicago Police were called and arrived at 1:35PM. R1 was sent to the hospital for evaluation and treatment. R3 was sent to the hospital for a psychological evaluation. Hospital Record dated 8/12/2013 was reviewed for R1. [DIAGNOSES REDACTED]. R1 is alert and oriented to person only. " Family at bedside do not want a rape kit done at this time as they feel it will be more traumatic to the patient because of the dementia. Family wants resident transferred back to nursing home and will look for different placement in the next couple of days. Pelvic exam revealed no bleeding or signs of trauma. R1 was discharged back to the Nursing home in stable condition on 8/12/2013. " On 8-16-2013 at 9:30AM, R4, Spanish speaking only, ambulatory with a walker cane, alert and oriented to person, place and thing stated via E11(Social Service Aide) " I reported a man was in my room on 8/12/2013. A man came into the room and took off the sheet of my roommate R5 and threw it to the floor. I heard the sheet drop. The man walked over to me and touched me like he was waking me up. I cursed him out. I thought he was family of my roommate(R5). When he came and touched me I knew he was not family of R5. I told him what are you doing here, shame on you, you already dropped R5's cover. Get out of here. As I said that to him he went away. When I went to eat I saw him, I told the staff what he did. I was not sure of what time it happened because I was nervous. The staff were offering him food. I became upset when I saw him drop my roommate, R5's sheet. I felt safe until he touched me. Then I felt unsafe, he was not my roommates family. Why was he in here. They should have taken him and put him in jail. I would be upset if that were to happen again. Staff re-assured me that he is no longer in the facility. If I were wearing a shoe I would have hit him with it. " R5's Face Sheet was reviewed, it documents that R4 is [AGE] years old and list the following diagnosis; Alzheimers, fracture of pelvis and [MEDICAL CONDITION]. The Facility's Abuse Prevention Program Facility Procedures dated 2012 states, " Resident Assessment: as part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict. Through the Care Planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse which would reduce the chances of abuse, neglect or mistreatment for [REDACTED]. Protection of Residents, Residents who allegedly mistreated another resident will be removed from contact with other residents during the course of the investigation. The accused residents condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety as well as safety of other residents and employees of the facility. Quality Management Review: Any investigation that concluded that abuse occurred shall be reviewed by the facility quality management committee for possible changes in facility practices to ensure that similar events do not occur again. " On 8/16/2013 at 10:46AM, E1(Administrator) stated, " We were investigated for a previous sexual incident that R3 had in May of 2013. We put R3 on hourly monitoring. I got a call about his behavior on 8/12/2013. They were sending R3 out. Family took R3 out the day before maybe they did not give him his medication. He returned confused. Then I got another call about him on top of R1. I told the staff to follow the abuse protocol. I understand that all residents had a right to be fee from sexual incident, R3 was re-direct able R3 should have been provided a 1:1 earlier to prevent R1 from having that incident. R1 will not be returning to the facility we will be issuing a 30 day notice because we cannot take care of his needs. " The facility took the following steps to remove the Immediate Jeopardy: The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance which will be achieved by the stated date of completion. The Facility respects and protects residents' rights to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. I. Corrective action for residents identified in the deficiency. R- 3 has been sent to the hospital, Emergency Discharge Notice given and resident will not be returning to the facility. II. Identifying other residents with potential for being affected and corrective action. The Administrator and/or Director of Nursing will review and revise, as needed, with input from the QA Committee, its policies and procedures on the Prevention of Abuse and Neglect and Safety and Supervision, to assure they are compliant with the rules and regulations. The Facility will not knowingly admit any resident who poses a threat to himself or herself or any other resident, visitor or staff. In order to protect vulnerable residents, any resident who is subsequently identified as posing a threat to himself or herself or any other resident, visitor or staff, that resident will be assessed, staff assigned to monitor one on one, physician and family notified and resident will be sent to the hospital. The Facility will identify, assess and monitor all residents who exhibit wandering, pacing, aggressive and/or unusual behaviors. Care Plans will updated as soon as such behaviors are identified and assessed. Physicians will be notified immediately, as necessary, and residents sent out in accordance with the Facility ' s revised Safety and Supervision Policy. One on one monitoring will be initiated with assigned staff immediately in accordance with the Facility ' s revised Safety and Supervision Policy. No " every 15-minute " monitoring will be used. Residents will be given Discharge Notices if their welfare and needs cannot be met in the Facility, as documented in their clinical record by the attending physician or if the safety of individuals in the Facility is endangered. All residents who have been identified as wanderers or with aggressive behaviors will be reassessed and Care Plans updated, this process has been initiated 08/16/13 and will completed by 08/19/13. Social Service Department will evaluate all new and readmissions for screening for wandering, aggressive and/or harmful behaviors within 72 hours of admission. Staff will be notified, as soon as the need is identified, to provide increased monitoring for these residents in accordance with the Facility ' s Revised (8/16/13) Safety and Supervision Policy. Staff will be inserviced on the provisions of the Revised (8/16/13) Safety and Supervision Policy. All incidents of suspected abuse will be thoroughly investigated, appropriate action taken to minimize re-occurrence, physicians (including psychiatrists, when appropriate) and families notified, police called, if appropriate, and report sent to IDPH, within time frames set forth in the Minimum Standards and Regulations. Investigation process will begin upon learning of the incident and will be concluded upon the filing of reports and completion of any corrective actions within 5 working days. All residents who are involved in a suspected abuse will be reassessed using the Risk Assessment tool for Abuse and Neglect when the incident occurs and upon admission and readmission and Care Plan updated within 24 hours. Residents will be reassessed in one month. III. Systemic changes to reasonably assure deficiency does not recur. Beginning 08/12/13 (to be completed by 08/19/13) inservices have been held with all Facility staff. The inservices were conducted by the Administrator and/or Director of Nursing and included: 1) a review that all residents are to be free from abuse, neglect and misappropriation of property; 2) a review of the alleged deficiency; 3) a review of how to identify, assess and monitor residents with wandering, pacing, aggressive and/or unusual behaviors; 4) a review of how to handle these specific behaviors, how and when to increase supervision and monitoring, when to call the physician and/or send the resident out, when to initiate one on one monitoring; 5) a review of the Facility's policies and procedures on the prevention, investigation and reporting of abuse; and 6) a review of the use of the Risk Assessment tool for Abuse and Neglect. Inservices will be part of the new employee orientation training. Inservices will be conducted for all employees quarterly. IV. How corrective actions will be monitored. Quality Assurance Committee has met to assure that systems are in place and are effective in preventing abuse and that each resident receives the level of supervision that he or she needs. The Director of Nursing will review all reports of unusual occurrences, reports of abuse, neglect, assessments of new admissions and readmissions to assure that all assessments are accurate, interventions are appropriate and are carried out. Administrator will monitor for overall compliance. V. Completion Date: 08/16/13

Based on interview and record review the facility, failed to provide effective supervision for 1(R3) of 3 residents reviewed for wandering/inappropriate behaviors. As a result of ineffective supervision R3's inappropriate behavior escalated from dropping sheets of R4 and touching R5 to being found on top of R1 a cognitively impaired female resident on 8/12/2013 .The facility failed to provide effective supervision interventions to keep 20 of 20 (R1, R2, R4-R21) female residents on the floor safe. Immediate Jeopardy was called on 8/16/2013 at 2PM with E1(Administrator), E2(Director of Nursing), E12(Assistant Director of Nursing) and Z4(Director of Operations). The Immediacy was determined to have begun on 8/12/2013 at 7:00AM with R3 found wandering in and out of rooms. The Abatement Plan was accepted on 8/16/2013. The Immediacy was removed on 8/16/2013 at 6PM. The facility remains at a severity level two for this deficient practice, until in-service, training and revision of policies are complete. Finding Include: According to the Abuse Investigation Report dated 8/12/2013; on 8/12/2013 at 1:25PM, E6(Certified Nursing Assistant) found R1 female resident ( laying in R1's assigned bed and room) with R3 a male resident on top of her. E6 alerted E5 while in the room. E5(Nurse) entered the room and found R1 by the window fixing pants and zipper. The Chicago Police were called and arrived at 1:35PM. R1 was sent to the hospital for evaluation and treatment. R3 was sent to the hospital for a psychological evaluation. Hospital Record dated 8/12/2013 was reviewed for R1. [DIAGNOSES REDACTED]. R1 is alert and oriented to person only. " Family at bedside do not want a rape kit done at this time as they feel it will be more traumatic to the patient because of the dementia. Family wants resident transferred back to nursing home and will look for different placement in the next couple of days. Pelvic exam revealed no bleeding or signs of trauma. R1 was discharged back to the Nursing home in stable condition on 8/12/2013. Face Sheet documents that R3 was admitted on [DATE] with the following diagnosis, senile dementia/delusional and depressive features, muscle weakness and altered mental status. Abuse Investigation dated 5/22/2013 states that R3 was found laying on the floor clothed with a female resident next to him, the female resident had no underpants on. R3 was sent and admitted to the hospital. Hospital Record dated 5/29/2013 states R3 chief complaint was inappropriate sexual behavior, aggressive and disorganized. Discharge Note from the hospital states, " Direction given by staff received Haldol decanoate 50 milligram via injection today and will be given every 4 weeks with due date on 7/1/2013. Depo-Provera 150 milligram injection received today and will be given every 4 weeks due date on 7/1/2013. Clinical Assessment Report dated 6/4/2013 states that family declined deprovera injection and Haldol injection. It also states that R3 is ambulatory, independent for bed mobility, transfers, dressing, eating and toilet use. Care Plan dated 6/14/2013 and revised on 7/15/2013 states " Monitor hourly times 72 hours and make every attempt to keep in highly supervised areas during the day. " Social Service Note dated 7/18/2013 states, " Per administration and nursing staff he is now being discharged from our resident monitoring list. Writer will visit as needed to check on well being. " Care Plan for Psychotropic Medications dated 7/26/2013 states, R3 should receive Ativan as needed. Monitor for target behaviors like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others. " Nurses Note dated 8/12/2013 at 7:00AM states, " resident ambulating the hallways. Noted wandering in and out of other residents room. Reoriented by staff. Resident verbalized understanding. Escorted to day room to be with other staff. 8:30AM, resident in room 320-2 reports unwilling to leave room for breakfast reports male resident was in room last night wandering in and out twice last night. Resident placed on every 15 minute monitoring. By staff. 8:35AM informed doctor of behavior, new order to send resident out to Psych facility to evaluate .... Family member made aware. 8:45AM, resident noted eating in dining room area still on 1:1 observation. Paramedic transport stated it will take 45 minutes for arrival to pick up R3. 1:20PM, R3 was noted in room 308 in bed with female resident. Nurse entered room resident was facing window fixing pants. Nurse escorted R3 out of room. Nurse assessed R1. While nurse was on the phone with administration R3 was noted wandering in and out of rooms. R3 was found in room 323-2. Paramedics arrived and escorted R3 out to the hospital. On 8/13/2013 at 12:12PM, E6(Certified Nursing Assistant) stated, " at about 1:20PM I was going into the room to provide care I noted the door closed, I opened and saw R3 on top of R1. I talked to him and said what are you doing? He got off of her and I stayed in the room and called the nurse(E5) to come in and assessed both residents. Both residents went to the hospital. " On 8/13/2013 at 1:57PM E4(Social Service Director) stated, " I was just hired 2 weeks ago, I am R3 ' s current social worker. For inappropriate sexual behavior I believe R3 was monitored every 15 minutes. I am not sure about how supervision works, you will have to ask the E2(Director of Nursing). On 8/13/2013 at 3:17PM, E5(Nurse) stated " I was alerted by E6(CNA) screaming. When I arrived I saw R3 standing at the window by R3 ' s bed fixing his pant zipper. I was trying to get R3 out for psychological evaluation. I called the administrator and R3 disappeared while I was on the telephone. We had to search for him. R1 was assessed she had an incontinent brief on during the incident, When I saw her one side of the incontinent brief was opened. R1 was on every 15 minute monitoring. At 1:15PM, R3 was in the day room with both activity aides, the activity aids saw R3 last before the incident happened. R1 was sent out in what she had on. ... " On 8/14/2013 at 12:00Noon via telephone, Z1(Psychiatrist) stated, I saw R3 while in the hospital and when R3 returned to the nursing home. I ordered Depo-Provera for R3 while in the hospital and the injections were to continue monthly to decrease sexual aggression that R3 has. When R3 returned from the hospital I continued the order for monthly Depo-Provera injections. R3 was on Aricept and R3 would wander. R3 definitely needed a Care Plan for wandering. This resident needed to be supervised, structured supervision. If R3 sexually inappropriate behaviors continued, he needed to be hospitalized . R3 is a high risk individual, R3 absolutely needed to have a separate setting, a separate floor and keep him separate from other residents. That is hard to do in an opened population. R3 clearly needed an intervention. I wanted R3 to go to a specific hospital, family declined. I told them I could not be his doctor because this is a dangerous situation. I am no longer his Psychiatrist because of these reasons. R3 needs to be in a separate facility that can handle him. It is not fair to other patients. The family refused medication and hospital visits that he required. The family has their right and responsibilities. R3 definitely needed structured supervision and Depo-Provera injections, that was very necessary to keep everyone safe " The family refused it, R3 did not get it. On 8/14/2013 at 1:05PM E8(Activity Aide) stated, " I was at lunch when R3 incident happened. I was not there. E9 was present. " On 8/14/2013 at 1:05PM, E2(DON) stated, " If necessary we do 1:1 for resident if we feel that they are a danger to themselves or others. That provides stress on the staff. " On 8/14/2013 at 1:33PM, E9(Activity Aide) stated, R3 was with me in the morning doing activity. I went to lunch at 12 noon and I have an hour lunch. After lunch I had a memorial service on another floor. I do not know what happened to R3, I was not there. Sometimes residents are in the day room and no one is in there to supervise. There was nobody from activity on the floor on 8/12/2013 at 1PM. I heard a page that something was happening on the third floor. I had R3 in the morning only. I was not there; I do not know what happened. " On 8/14/2013 at 2:40PM, E10(Care Plan Coordinator) stated, " Family stated on 6/4/2013 they did not want injections for resident. " On 8/14/2013 at 3:06PM, via telephone and E13(Staff, interpreter) , Z2 stated, " I was not aware that the hormone shot needed to be given every 4 weeks. R3 received it in the hospital, I had to sign consent in the hospital and I did. When R3 got here I did not want R3 on those 2 injections. On 8/14/2013 at 2:11PM, E6(Nurse) stated, " On 8/12/2013 R3 was having problems from the night shift. No one reported it. A resident told me that R3 was in and out of her room pulling the sheets off of her and that she was afraid to come out of the room. That is when I put R3 on every 15 minute monitoring. The 1:1 documentation is an error that I wrote. Looking back on things giving R3 ' s history of sexual aggression and I was the readmitting nurse on 6-1-2013 who talked to the family about the De-Provera injections to decrease sexual aggression. I should have kept R3 with me at the nursing station until I got him out. R3 should have been put on 1:1 observation, I feel so bad, the incident with R3 should not have happened, I should have called 911 and kept R1 with me until 911 arrived. There are so many things I should have done differently. " On 8/14/2013 at 3:40PM, Z3(Medical Doctor) stated, " I am the attending physician for R1 and R3. R3 is always wandering. The administrator wanted to dump him to another facility when the last incident happened. I pleaded with the administrator to keep him here. I do not know what to do with a resident that needs help like this. I am familiar with the last sexual incident. R3 did it again, R3's mind is not right. R3 did not penetrate R1, I don ' t even believe that R3 can get an erection. I do not know what happened, R3 did it again. In terms of supervision speak with the director of nursing. I understand all residents need to be safe, but what are we going to do with this resident. The family told me about the residents drooling so I tapered the Haldol. R3 was overmedicated. The family wants me to discontinue needed medications. If we dumped this resident to another facility that facility will get the problems. " On 8-16-2013 at 9:30AM, R4, Spanish speaking only, ambulatory with a walker cane, alert and oriented to person, place and thing stated via E11(Social Service Aide) " I reported a man was in my room on 8/12/2013. A man came into the room and took off the sheet of my roommate(R5) and threw it to the floor. I heard the sheet drop. The man walked over to me and touched me like he was waking me up. I cursed him out. I thought he was family of my R5. When he came and touched me I knew he was not family of my roommate. I told him what are you doing here, shame on you, you already dropped R5's cover. Get out of here. As I said that to him he went away. When I went to eat I saw him, I told the staff what he did. I was not sure of what time it happened because I was nervous. The staff were offering him food. I became upset when I saw him drop R5's sheet. I felt safe until he touched me. Then I felt unsafe, he was not my roommates family. Why was he in here. They should have taken him and put him in jail. I would be upset if that were to happen again. Staff re-assured me that he is no longer in the facility. If I were wearing a shoe I would have hit him with it. " R5's Face Sheet was reviewed, it documents that R4 is [AGE] years old and list the following diagnosis; Alzheimers, fracture of pelvis and cerebral degenerations. The Facility's Abuse Prevention Program Facility Procedures dated 2012 states, " Resident Assessment: as part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict. Through the Care Planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse, neglect or mistreatment for [REDACTED]. Protection of Residents, Residents who allegedly mistreated another resident will be removed from contact with other residents during the course of the investigation. The accused residents condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety as well as safety of other residents and employees of the facility. Quality Management Review: Any investigation that concluded that abuse occurred shall be reviewed by the facility quality management committee for possible changes in facility practices to ensure that similar events do not occur again. " On 8/16/2013 at 10:46AM, E1(Administrator) stated, " We were investigated for a previous sexual incident that R3 had in May of 2013. We put R3 on hourly monitoring. I got a call about his behavior on 8/12/2013. They were sending R3 out. Family took R3 out the day before maybe they did not give him his medication. He returned confused. Then I go another call about him on top of R1. I told the staff to follow the abuse protocol. I understand that all residents had a right to be fee from sexual incident, R3 was re-direct able R3 should have been provided a 1:1 earlier to prevent R1 from having that incident. R1 will not be returning to the facility we will be issuing a 30 day notice because we cannot take care of his needs. " Behavior Monitoring Documentation was reviewed from July- August of 2013. On August 12, 2012 the day of the incident Every 15 minutes R3 was monitored. On 8/12/2013 at 1:15PM, a yes is recorded for behaviors. On 8/16/2013 at 11:39AM, E6(Certified Nursing Assistant) stated, " I was assigned to R3 on 8/12/2013 as R3 ' s aide. We usually fill out a sheet for monitoring. It's just a check list to say he had behaviors or not. I know that I documented that I saw R3 last at 1PM on 8/12/2013, that is when I left the dining room. I started to take residents to their rooms. At 1:15PM I was showering residents and I opened the closed door of R1's room and saw R3 on top of her in bed. I know I signed at 1:15PM that R3 was having behavior but I did not see R3 until 1:20 or 1:25PM and when I saw R3 he was on top of R1. At 1:15PM we do not know where R3 was. " Safety and Supervision of Residents Policy dated 2001 states, " Implementing interventions to Reduce Accident Risks and Hazards shall include the following, a). Communicating specific interventions to all relevant staff, b). Assigning responsibility for carrying out interventions, c). Providing training as necessary, d). Ensuring that interventions are implemented and e). Documenting interventions. The facility -oriented and resident oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors and then adjust interventions accordingly. Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The facility took the following plan to remove the Immediate Jeopardy: The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance which will be achieved by the stated date of completion. The Facility reasonably assures that the resident environment remains as accident free as possible. I. Corrective action for residents identified in the deficiency. R- 3 has been sent to the hospital, Emergency Discharge Notice given and resident will not be returning to the facility. II. Identifying other residents with potential for being affected and corrective action. The Administrator and/or Director of Nursing will review and revise, as needed, with input from the QA Committee, its policies and procedures on the Prevention of Abuse and Neglect and Safety and Supervision, to assure they are compliant with the rules and regulations. The Facility will not knowingly admit any resident who poses a threat to himself or herself or any other resident, visitor or staff. In order to protect vulnerable residents, any resident who is subsequently identified as posing a threat to himself or herself or any other resident, visitor or staff, that resident will be assessed, staff assigned to monitor one on one, physician and family notified and resident will be sent to the hospital. The Facility will identify, assess and monitor all residents who exhibit wandering, pacing, aggressive and/or unusual behaviors. Care Plans will updated as soon as such behaviors are identified and assessed. Physicians will be notified immediately, as necessary, and residents sent out in accordance with the Facility ' s revised Safety and Supervision Policy. One on one monitoring will be initiated with assigned staff immediately in accordance with the Facility ' s revised Safety and Supervision Policy. No " every 15-minute " monitoring will be used. Residents will be given Discharge Notices if their welfare and needs cannot be met in the Facility, as documented in their clinical record by the attending physician or if the safety of individuals in the Facility is endangered. All residents who have been identified as wanderers or with aggressive behaviors will be reassessed and Care Plans updated, this process has been initiated 08/16/13 and will completed by 08/19/13. Social Service Department will evaluate all new and readmissions for screening for wandering, aggressive and/or harmful behaviors within 72 hours of admission. Staff will be notified, as soon as the need is identified, to provide increased monitoring for these residents in accordance with the Facility ' s Revised (8/16/13) Safety and Supervision Policy. Staff will be inserviced on the provisions of the Revised (8/16/13) Safety and Supervision Policy. All incidents of suspected abuse will be thoroughly investigated, appropriate action taken to minimize re-occurrence, physicians (including psychiatrists, when appropriate) and families notified, police called, if appropriate, and report sent to IDPH, within time frames set forth in the Minimum Standards and Regulations. Investigation process will begin upon learning of the incident and will be concluded upon the filing of reports and completion of any corrective actions within 5 working days. All residents who are involved in a suspected abuse will be reassessed using the Risk Assessment tool for Abuse and Neglect when the incident occurs and upon admission and readmission and Care Plan updated within 24 hours. Residents will be reassessed in one month. III. Systemic changes to reasonably assure deficiency does not recur. Beginning 08/12/13 (to be completed by 08/19/13), inservices have been held with all Facility staff. The inservices were conducted by the Administrator and/or Director of Nursing and included: 1) a review of the requirement that the Facility reasonably assures that residents' environment remain as accident free as possible; 2) a review of the alleged deficiency; 3) a review of how to identify, assess and monitor residents with wandering, pacing, aggressive and/or unusual behaviors; 4) a review of how to handle these specific behaviors, how and when to increase supervision and monitoring, when to call the physician and/or send the resident out, when to initiate one on one monitoring; 5) a review of the Facility's policies and procedures on the prevention, investigation and reporting of abuse; and 6) a review of the use of the Risk Assessment tool for Abuse and Neglect. Inservices will be part of the new employee orientation training. Inservices will be conducted for all employees quarterly. IV. How corrective actions will be monitored. Quality Assurance Committee has met to assure that systems are in place and are effective in preventing abuse and that each resident receives the level of supervision that he or she needs. The Director of Nursing will review all reports of unusual occurrences, reports of abuse, neglect, assessments of new admissions and readmissions to assure that all assessments are accurate, interventions are appropriate and are carried out. Administrator will monitor for overall compliance. V. Completion Date: 08/16/13

Based on observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring of meals for two resident ' s (R1 and R3) of 4 reviewed in the feeding program out of 8 in the sample. This failure resulted in the death of one resident (R1). R1 choked on a sausage. Because the facility staff failed to properly supervise R1 during meal time and failed to ensure appropriate diet which resulted in R1's death, an Immediate Jeopardy was called on [DATE] at approximately 1:05PM to E2 RN,MDS Coordinator (Registered Nurse, Minimum Data Set Coordinator) E3 Restorative Nurse and to E1 Administrator at 1:45PM. The Immediate Jeopardy began on [DATE] when R1 choked on a sausage and died . While the Immediate Jeopardy was abated on [DATE] at 4:30 PM, the facility remains out of compliance at severity level 2 because the facility has yet to inservice all current staff on all shifts, has yet to assess all possible affected residents and the facilty needs time to determine the effectiveness of QA tools implemented. Findings include: According to Physician order [REDACTED]. According to MDS(Minimum Data Set Assessment) dated [DATE], R1 required extensive assistance with one person physical assistance for ADL ' s (Activities for Daily Living). Per MDS, R1 is coded for a Mechanical altered diet and staff support provided. According to facility incident report dated [DATE] indicates that R1 was transferred to emergency room via ambulance after choking on a piece of sausage. The emergency room record dated [DATE] indicates " R1 was brought to the ED(Emergency Department) in full cardiac arrest. The ER report indicates EMS (Emergency Management Service) was called because patient was choking on his food and orally intubated in field. The report further describes patient on arrival as having no pulses, he was intubated, Epinephrine was given and brought to ED after 25 minutes of resuscitation; pupils dilated and fixed, breath sounds decreased, no heart beat. After a brief CPR(Cardio-Pulmonary Resuscitation), manual ventilation, ashen in color, resident was pronounced dead. " Nurse ' s notes dated [DATE] indicate R1 was in room during dinner time while CNA placed resident ' s tray on tray table as R1 was being set up for feeding, resident choking on food, Heimlich and CPR performed. Physician, DON, 911 and family were notified. Interviewed Z1 (daughter of R1) by phone on [DATE] at approximately 10:55AM. Z1 indicated she was notified by a staff member that R1 was taken to emergency room after choking on a sausage. Z1 commented that her father had swallowing difficulties, father was weak and had [DIAGNOSES REDACTED]. Z1 stated that they are understaffed at the facility, they should have the cooks cut up resident ' s food. Z1 stated that her mother (R2), whom is also a resident at facility, does not know that her husband( R1) is dead. Interviewed Z5 (Primary Physician) by phone on [DATE] at approximately 9:50AM, stated that the nurse called and informed her that resident(R1) was rushed to hospital because he had choked on some food. Z5 stated that resident was weak and had many medical problems. Z5 said, "R1 needed supervision all of the time. Unfortunately, they (CNA ' s) have too many patients (10 to 15). On [DATE] at 2:20 PM E5(CNA) indicated he set R1 ' s tray on tray table in front of him, proceeded to cut up sausage but stopped momentarily to go to sink, a short distance away from resident, to add water to resident ' s hot coffee. E5 stated he should not have to do that(cut up the food) because resident should have received a Mechanical soft diet. E5 stated that as he turned back around towards R1, he noticed resident had fork in his hand. E5 stated R1 looked to be in distress, not talking, lips turning blue so, he assumed resident ate some food(sausage and spaghetti) off of his plate. E5 stated that he proceeded to perform Heimlich Maneuver on resident but was unsuccessful. E5 then put on call light but, no one responded so, he ran to hallway and yelled for help at which time staff called code blue, E10(Nurse/LPN) and E2(DON/Director of Nursing) arrived with crash cart to perform emergency treatment on R1. 911 was called. E5 stated that paramedics arrived, were able to remove sausage with forceps but resident was still not breathing. Resident was then intubated by paramedics and taken to emergency room . On [DATE] at 1:20pm E9 (Speech Therapist) stated that R1 had choked before in the Spring of this year. While in dining room eating he choked on food. 911 was called, he was stabilized and sent to hospital. R1 returned to facility with choking instructions. E9 stated R1 received a swallow evaluation, resident was on swallowing precautions; aspirations and mechanical soft diet with thickened liquids. On [DATE] at 1:00 PM E2(DON) stated R1 was in their feeding program. In an interview on [DATE] at 3:30PM with E1, Administrator shared the same events of incident that were in incident/accident report dated [DATE]. E1 stated that the Incident was investigated and reported to state agency. E1 stated that after the incident all staff were in-serviced on ensuring proper diets for all residents and proper feeding procedures for residents in feeding program. On [DATE] at lunch time, R3, a [AGE] year old female, with history of dementia, Dysphagia, Renal Failure and Pressure Sores observed sitting in bed with tray on tray table in front of her. R3 identified on list for Feeding Program. Although resident was asleep at the time, she was unsupervised and had shredded chicken on tray as opposed to mechanically altered chicken (chopped or ground). Review of R3 ' s speech therapy evaluation [DATE] indicates R3 to have Mechanical soft consistency with thin liquids and is on aspiration precautions. On [DATE] at 12:55PM, E3(LPN) stated that resident ate some of her food. She especially likes desert, the tray is still on the cart, this is the tray ticket, she eats a mechanical soft diet. On [DATE] at 12:15 PM Z6 (daughter of R8) stated she has to come to facility at lunch and dinner time everyday to make sure her mother is fed because they miss sometimes, mother has problems with swallowing, she coughs and chokes sometimes when eating, I want her to have a swallow evaluation, they don ' t give good care here. E9 (Speech Therapist) stated that R8 was discussed this morning in care conference with doctor. Review of Diet Standardization policy and procedure dated 2010 indicates a Mechanical Soft Diet is; texture and consistency of the general or therapeutic diet is modified. Foods may be served in the form of ground, chopped, or whole foods of a soft consistency. Review of Assistance with Meals policy dated 2009 specifies that residents requiring full assistance will be fed by nursing staff and/or Feeding Assistant will feed those residents needing full assistance within certain time frame/minutes of the delivery of trays. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. On [DATE] at 3:00PM, E9(CNA) stated that R1's sausage was not chopped up but in carrot slices, little larger than a quarter and had the thickness of a gait belt. On [DATE] at 3:20PM, E10(LPN) stated, R1 had received spaghetti and sausage-it was not properly chopped up, it didn't have any skin on it but most sausage you don't peel off the skin. The CNA was trying to chop it up before the resident took a bite. Interviews with E12CNA and E13CNA indicate that sometimes residents on special diets, like(altered textured diets) would not get the right diet but nothing happened recently. On [DATE] at 11:35AM, E11(LPN) stated she always tells her CNA's to check the diets to make sure diet is right if resident diet is changed. In the past CNA's would tell me resident received wrong diet but nothing recent. Sometimes the kitchen, I know, will send up thin liquids but resident should receive thickened liquids(nectar). Interviewed E1 regarding quality assurance (QA) of nursing care. E1 stated that monthly QA meetings are held, meetings are record, indicate the various disciplines whom attend and how resident care issues are addressed, interventions and approaches implemented. E1 stated that consultant dietician has not come in a while but will have dietician come more regularly. E1 provided three months of billed hours for dietician except for November, 2012. The surveyor confirmed through observation, interviews and record review that the facility took the following actions to remove the Immediate Jeopardy. I. Corrective action for residents identified in the deficiency. R-1 is no longer in the facility. II. Identifying other residents with potential for being affected and corrective action. There are _31_ residents on mechanical soft and _27_ residents on pureed diets. All meals will be served as ordered by residents ' physicians. All dietary cards were reviewed for accuracy. Facility policies and procedures on food preparation and service will be reviewed and revised, as necessary. III. Systemic changes to reasonably assure deficiency does not recur. On or before [DATE], in-services were held with appropriate Facility staff which includes all Dietary Department staff and all staff involved in the service of meals. Food Service Supervisor and Dietary Consultant and designees will conduct in-services. In-services included: 1) a review of the requirement that the resident environment remains as accident free as possible; 2) review of the requirement that the residents receive food prepared in a form designed to meet individual needs; 3) a review of the alleged deficiencies; 4) a review of the differences among the various therapeutic diets, including consistencies; 5) a review of the requirement to check diet card with meal before service; 6) a review of the proper method for feeding residents who need assistance; and 7) a review of emergency procedures. Staff will be inserviced prior to the start of their shift. All new employees will be oriented to these policies and procedures before they begin working on the floor. Education will be ongoing. IV. How corrective actions will be monitored. Food Service Supervisor and/or another Department Head or House Supervisor (when Food Service Supervisor is unavailable) will perform dietary spot checks to determine level of staff compliance and evaluate need for additional in-service training. This will be done daily for two weeks, the twice a week for three months, need for frequency will be reevaluated after that. All findings will be reviewed by the QA committee and will review systems and procedures. Administrator will monitor overall compliance through her own rounds, general supervision, and reports of Food Service Supervisor. V. Completion Date: [DATE]

Based on observation, interviews and record reviews, the facility failed to provide mechanically altered /therapeutic diet for one of 4 (R1) reviewed for Feeding Programs in a sample of 8. This failure resulted in R1's death after choking on meat. Because the facility staff failed to properly supervise R1 during meal time and failed to ensure appropriate diet which resulted in R1's death, an Immediate Jeopardy was called on [DATE] at approximately 1:05PM to E2 RN, MDS Coordinator (Registered Nurse, Minimum Data Set Coordinator) E3 Restorative Nurse and to E1 Administrator at 1:45PM. The Immediate Jeopardy began on [DATE] when R1 choked on a sausage and died . While the Immediate Jeopardy was removed on [DATE] at 4:30 PM, the facility remains out of compliance at severity level 2 because the facility has yet to in-service all current staff on all shifts, has yet to assess all possible affected residents and the facility needs time to determine the effectiveness of QA tools implemented. Findings include: Incident/accident report dated [DATE] indicates that R1 was a [AGE] year male whom choked on uncut/ground sausage during dinner meal while being supervised by E5 CNA (Certified Nurse Aide). Nurses notes by E10 LPN (Licensed Practical Nurse) dated [DATE] remarks E5 noted R1 with difficulty breathing and unable to cough. Notes indicate E5 assessed resident airway and saw evidence of obstruction and proceed to perform [MEDICATION NAME] maneuver. R1 was able to cough out small amount of food particles but continued to have difficulty breathing, [MEDICATION NAME] continued, pulse palpable but weak. Emergency procedures were implemented. Eight minutes later resident became unresponsive, placed on floor by E10, E2 DON (Director of Nursing) and E5 while CPR initiated. Paramedics arrived and provide advanced emergency treatment. Notes indicate that paramedics were able to remove food particles from resident's throat. Resident was intubated and placed on monitor. Resident was transported to hospital. emergency room report dated [DATE] documents that resident (R1) brought in to emergency room in full [MEDICAL CONDITION]. Notes section remarks that " EMS (Emergency Medical Service) was called because patient was choking on his food. On arrival there were no pulses, intubation, [MEDICATION NAME] given and brought to ED (Emergency Department) after 25 minutes of resuscitation. In the ED patient still had no pulse, pupils dilated and fixed. No heart beat. After a brief CPR (Cardio-Pulmonary Resuscitation), manual ventilation we pronounced patient dead. " MDS (Minimum Data Set) dated [DATE] indicates R1 required extensive assistance with all ADL's (Activities of daily Living), indicated for Cognitive loss/Dementia, Visual Impairment-right eye [MEDICAL CONDITION] due to [MEDICAL CONDITION], Impaired Nutrition Status, Mechanical Altered Diet and Pressure Ulcers. physician's orders [REDACTED]. Aspiration Care plan dated [DATE] indicates R1 demonstrates risk to potentially choke or aspirate food or liquids related to [DIAGNOSES REDACTED]. Speech therapy evaluation notes dated [DATE] remarks that R1 is to receive skilled speech therapy 5 times per week for two weeks to address dysphasia, resident on swallowing precautions; aspiration precautions; resident readmitted from hospital on mechanical soft diet with nectar thick liquids. Care Plan Conference dated [DATE] Dietary remarks that resident on a mechanical soft/Non-concentrated sweet/ No Salt diet and Resident on Feeding Program. Nursing Monthly Summary dated [DATE] indicates R1 requires extensive assist with all ADL ' s. Restorative Nursing assessment dated [DATE] indicates R1 requires extensive assistance/dependent in eating setup, feeding. On [DATE] at 3:00PM, E9 (CNA) stated that R1's sausage was not chopped up but in carrot slices, little larger than a quarter and had the thickness of a gait belt. On [DATE] at 3:20PM, E10(LPN) stated, R1 had received spaghetti and sausage-it was not properly chopped up, it didn't have any skin on it but most sausage you don't peel off the skin. The CNA was trying to chop it up before the resident took a bite. E9 (Speech Therapist) stated on [DATE] at 1:20PM that she differs with Z4 (Consultant Dietician) on how mechanically altered meat, chopped versus ground, should be prepared at this facility. E9 stated that residents on mechanically altered diet should receive meats that are ground not chopped up. E9 then stated that R1 had choked on food before in the spring of this year, 911 code and resuscitated resident and taken to hospital. E9 also stated that R1 needed to have ground food. On [DATE] at 11:30 am Z4 (Consultant Dietician) stated that she only sees residents that are considered high risk for weight loss, on hospice, [MEDICAL TREATMENT], has wounds [MEDICAL CONDITION]. The speech therapist evaluates residents with swallowing difficulties and makes recommendations that are conveyed to her, and the doctor. Z4 states that she does not recall resident (R1). On [DATE] at 11:30am E4 (Dietary Aide) stated that she had just started working in the kitchen. On [DATE], the day of the incident, E4 stated that she cooked sausage and spaghetti, prepared meat the way the supervisor told her. According to E4, she was directed to bake the sausage whole and then slice them thin for all trays. E4 defined mechanical soft diet meats as chopped. E4 stated that she has not attended the dietary class but will be attending dietary class in the future. On [DATE] at approximately 1:15PM, E8 (Dietary Manager) stated she started working on [DATE] and the other dietary manager resigned [DATE]. E8 stated that mechanical soft meats are cooked and then chopped up, ground it in food processor. On [DATE] at 1:30PM, E1 provided copy of Menu spread sheet from [DATE](date of incident) and copy of Vendors Information of product (Italian Sausage) served at evening meal. Item description sheet from vendor indicates Real Italian sausage was ordered and delivered on [DATE]. Italian sausage described as a .35 cube, fully cooked, best heated over a char grill to dark brown color and can be grilled from frozen. The product is also described as skinless. Review of Diet Standardization policy and procedure indicates a Mechanical Soft Diet is; texture and consistency of the general or therapeutic diet is modified. Foods may be served in the form of ground, chopped, or whole foods of a soft consistency. The kitchen failed to serve R1 the diet as prescribed by the physician and deemed to be safe by E9 when the sausage served to R1 was not ground. Interviews with E5 (nurse aid) on [DATE] and E10 (Nurse) on [DATE], they state that they have to chop up residents food; hot dogs, chicken when the dietary is responsible for doing this. E5 and E10 stated that the mechanically altered diets are not really mechanically soft because the meat is not always cut up so they take it upon themselves to do it so that the residents can eat. When E5 and E10 saw that R1 or other residents did not receive proper diet, they did not report it to supervisor or dietary services. Interviews with E12 (CNA) and E13 (CNA) indicate that sometimes residents on special diets, like (altered textured diets) would not get the right diet but nothing happened recently. On [DATE] at 11:35AM, E11(LPN) stated she always tells her CNA's to check the diets to make sure diet is right if resident diet is changed. In the past CNA's would tell me resident received wrong diet but nothing recent. Sometimes the kitchen, I know, will send up thin liquids but resident should receive thickened liquids (nectar). Interviewed E1 (Administrator) regarding quality assurance (QA) of nursing care. E1 stated that monthly QA meetings are held meetings are record; indicate the various disciplines that attend and how resident care issues are addressed, interventions and approaches implemented. E1 stated that consultant dietician has not come in a while but will have dietician come more regularly. E1 provided three months of billed hours for dietician except for November, 2012. The facility in-services and training to ensure appropriate diets, meal supervision for residents in the feeding program and emergency training was reviewed from [DATE] to [DATE]. In addition, the facility policies and procedures on tray identification and monitoring, emergency management procedures, special diets and safety and supervision of residents were also reviewed. On [DATE] at 3:30pm E1 (Administrator) stated that all staff were in-serviced on diet cards and ensuring all residents receive prescribed diets. On [DATE] during the afternoon, Consultant dietician was in the facility conducting in-services for dietary services on mechanically altered diets: mechanically soft and pureed diets. On [DATE], restorative nurse, facilitated training with CNA's and nurses on ensuring residents receive proper diets, ensuring close supervision for residents in feeding program and ensuring residents a safe. The surveyor confirmed through observation, interviews and record review that the facility took the following actions to remove the Immediate Jeopardy. I. Corrective action for residents identified in the deficiency. R-1 is no longer in the facility. II. Identifying other residents with potential for being affected and corrective action. There are 31 residents on mechanical soft and 27residents on pureed diets. All meals will be served as ordered by residents ' physicians. All dietary cards were reviewed for accuracy. Facility policies and procedures on food preparation and service will be reviewed and revised, as necessary. III. Systemic changes to reasonably assure deficiency does not recur. On or before [DATE], in-services were held with appropriate Facility staff which includes all Dietary Department staff and all staff involved in the service of meals. Food Service Supervisor and Dietary Consultant and designees will conduct in-services. In-services included: 1) a review of the requirement that the resident environment remains as accident free as possible; 2) review of the requirement that the residents receive food prepared in a form designed to meet individual needs; 3) a review of the alleged deficiencies; 4) a review of the differences among the various therapeutic diets, including consistencies; 5) a review of the requirement to check diet card with meal before service; 6) a review of the proper method for feeding residents who need assistance; and 7) a review of emergency procedures. Staff will be in-serviced prior to the start of their shift. All new employees will be oriented to these policies and procedures before they begin working on the floor. Education will be ongoing. IV. How corrective actions will be monitored. Food Service Supervisor and/or another Department Head or House Supervisor (when Food Service Supervisor is unavailable) will perform dietary spot checks to determine level of staff compliance and evaluate need for additional in-service training. This will be done daily for two weeks, the twice a week for three months, need for frequency will be reevaluated after that. All findings will be reviewed by the QA committee and will review systems and procedures. Administrator will monitor overall compliance through her own rounds, general supervision, and reports of Food Service Supervisor. V. Completion Date: [DATE]

Based on observation, interview and record review the facility failed to provide assistance and/or supervision while providing hot coffee for 1 of 3 residents R1, all reviewed for feeding assistance in a sample of 3 residents. This failure resulted in R1 sustaining a second degree burn to his right thigh. Findings include: According to the facility's unusual occurrence report report dated 8/4/2012 at 5:00pm R1 was taken to the wash room by E4 (certified nurse aide), at 8:30pm. E4 noted that R1's thigh was reddened and blisters were present. E4 noted that R1 was asked what happened, and R1 indicated that he spilled coffee on himself. The report denotes that the event was unwitnessed. According to the R1's clinical record physician order [REDACTED]. According to the MDS section G functional status R1 requires extensive assistance with 1 person physical assist with eating and drinking. On 8/10/2012 at 9:35 a.m. R1 was observed sitting in a wheel chair waiting for assistance to be placed in bed for an assessment of his right thigh. R1 was observed with sporadic muscle twitching and shaking of the bilateral upper extremities. E6 (Nurse) was present and said that R1 has Parkinson disease and a history of intermitted tremors. R1's right hand was also observed to be partially contracted. Once in the bed R1's right thigh was observed to have a large bruised area, with a red open area which as measured by E5 (wound nurse) to be 3cm by 2.5cm. During this observation E5 said that she was a certified wound nurse, and that R1 had sustained a second degree burn. On 8/10/2012 at 9:40 a.m. R1 said that on 8/4/2012 he was given a cup coffee, and he was in the hallway. R1 said that he attempted to place the cup of coffee on the handrail and the coffee spilled onto his leg. R1 was observed to primarily speak Spanish, E1(Administrator) provided interpretation during this interview. On 8/16/2012 at 3:30 p.m. via telephone E4 said that she didn't witness R1 spilling coffee on himself, however while assisting R1 to the washroom at approximately 8:00 p.m. on 8/4/2012, she observed bruising and blisters to R1's right thigh. However E4 said that she has taken care of R1 in the past and that R1 didn't require assistance with eating and drinking. On 8/16/2012 at 3:45 p.m. via telephone E3 (Certified nurse aide) said that on 8/4/2012 around 7:00 p.m. she was passing coffee out to resident in the activity room. E3 said that coffee was being passed out in Styrofoam cups with no lids/cover. E3 said that she was aware that R1 arms shake a little so indicated that she poured R1 a half cup of coffee. E3 indicated that the coffee was hot enough to see steam after it was poured. E3 said that she was unaware of R1's [DIAGNOSES REDACTED]. However E3 said that she did inform R1 that the coffee was "caliente" (hot). E3 denies the ability to speak Spanish. E3 said after giving R1 coffee she left the activity room to continue to pass coffee out at the bedside. E3 denied being aware that R1 required physical assistance with eating and drinking. On 8/10/2012 at 12:45 p.m. Z1 (physician), said that she was aware that R1 spilled hot coffee on his right thigh and sustained a burn. Z1 said that she had not seen the burn, however said that she would be in tomorrow to assess R1 status/condition. Z1 said that R1 has very bad tremors, that are difficult to manage. Z1 said that R1 requires some assistance with drinking beverages, Z1 also said that based on R1's frail condition and age that an extreme hot beverage would cause R1 to have a very bad outcome. Z1 said that the facility staff should not have left R1 alone with a hot beverage without providing some assistance with drinking it. Z1 was notified of the serving temperature measured at 10:25 a.m. to be 160 degree Fahrenheit, and Z1 said that 160 degrees is extremely too hot to serve coffee to R1. According to the progress note dated 8/13/2012 written by Z1 denotes R1 to have a second degree burn to the right thigh. According to R1's current plan of care there were no plans noted that are developed to assist R1 with eating and/or drinking. There was no plan noting R1's [DIAGNOSES REDACTED]. On 8/10/2012 at 9:50 a.m. in the kitchen E7 (lead cook), prepared coffee from the automatic coffee dispenser, the temperature was measured at 172 degrees Fahrenheit. E7 said that the brewing temperature was preset by the manufacture. E7 also said that he calibrated the thermometer earlier that morning. E7 was observed to prepare coffee and transport the coffee to the third floor where R1 resided. The coffee was dispensed and the temperature taken and measured to be 160 degrees Fahrenheit at 10:25 a.m. On 8/10/2012 at 10:00am Z2 (Dietary consultant), said that and adequate serving temperature should be 120 to 140 degrees Fahrenheit. E1 did not provide the survey team with any policies with guidance for the serving temperature of hot coffee.