Every finding on record at Complete Care at Margate Park

Based on observation, interview and record review the facility failed to provide a clean, sanitary and homelike environment free from pests for three residents (R3, R4, R18) reviewed for physical environment. Findings include:On 08/11/26 at 11:27 AM, R3 stated she sees roaches in her room crawling on the walls and ceilings and the last time she saw roaches in her room was a week or so ago. R3 stated she sees black flies in her room all the time. R3 stated the black flies are very small, and they are like fruit flies or gnats. R3 stated she does not want any flies or bugs in her room and does not think they should be in there. R3 said, This is my home now and I don't want them around where I'm living.On 08/11/26 at 11:40 AM, observed R3's personal refrigerator in her room and non-refrigerated food stored on top of R3's dresser. Surveyor obtained R3's permission to look through her food and inside her refrigerator. Surveyor opened the door to R3's personal refrigerator and tiny black flies flew out of the refrigerator. Surveyor observed multiple unopened expired containers of 2% milk cartons stacked up on the inside of the refrigerator door and multiple bags and containers of food uncovered and not dated inside the refrigerator. R3 asked, What do you see in there? If it's gone bad throw it out! R3 stated she wants the staff to throw out her old food because she cannot see what is in there; she cannot walk.On 08/11/26 at 11:58 AM, surveyor picked up a clear plastic clam shell from the top of R3's dresser and a swarm of tiny black flies flew up into the air. Surveyor and V7 (Certified Nursing Assistant) could not identify what was inside the plastic container. There was a label on the outside of the plastic container which read German Chocolate Cake with a small white sticker on the container that read best by 4/24. R3 opened the plastic container, and more tiny black flies flew out. The product inside was completely covered in layers and layers of a light green/gray fuzzy material coating the food. Surveyor showed the product to R3 and R3 yelled, throw it out, throw it out!On 08/11/26 at 12:41 AM, V32 (Maintenance Director) stated the facility uses an outside contractor for pest control management, and the goal is to keep the facility pest free. V32 stated fruit flies and gnats are attracted to any kind of food and if residents leave out old food this will attract them. V32 stated fruit flies could be attracted to the food inside a refrigerator especially if the food is not covered or is old.On 08/11/26 at 1:10 PM, during the facility tour with V32 observed three live light brown bugs with flat, oval-shaped bodies with thin antennas running around on the floor in the 6th floor dining room near the baseboards. Observed pieces of French Fries and green peas on the floor. V32 looked at the bugs and said, those are roaches V32 stated he will notify pest control and tell the housekeeper to come clean the floor to remove the food from lunch because that is attracting the roaches.On 08/12/26 at 9:38 AM, observed tiny black flies flying around the 2nd floor dining room and a resident swatting them away from their face.On 08/12/26 at 9:45 AM, V42 (Housekeeping Floor Technician) stated there are roaches in the building and he sees fruit flies every day in the facility. V42 said, they are everywhere.On 08/12/26 at 9:53 PM, R4 stated he has little black gnats in his room and he has also seen roaches in his room. R4 stated he does not like having pests in his room and wishes they were not around. R4 stated he is the Resident Council President, and he hears other residents complaining about pests being in the facility. On 08/12/26 at10:11 AM, observed tiny black flies in the 2nd floor hallway outside the dining room flying around an open metal cart. On the opened cart there were two leftover breakfast trays with opened milk containers, tipped over empty plastic juice cups, half-eaten pancakes lying outside of the plate and an opened syrup container on its side.On 08/12/26 at 10:14 AM, R18 stated this place is full of pests and he sees roaches and flies in his room all the time. R18 stated there are fruit flies all over the place! R18 said, I cannot even eat my food without seeing one. They live here. They are everywhere. R18 stated he keeps his food covered to prevent them from coming into his room, but they are still around and he does not want them in his room. R18 said, I live here. I want my room to be clean. I don't want roaches and flies where I am living. R18 stated it is so bad that he does not want any of his family members to come into his room to see the conditions he is living in, he is embarrassed and does not want them to see the flies and pests.On 08/12/26 at between 10:20 -10:30 AM, observed tiny black flies flying around in R18's room, and found expired food items on top of R18's dresser and food items inside R18's refrigerator that were not labeled or dated.On 08/12/26 at 12:15 PM, V15 (Social Worker) stated the residents' food should be labeled with a date so the staff knows how long the food has been in there and when it will spoil so they will know when to throw out the food. V15 stated the facility should provide a safe, clean and homelike environment for the residents.On 08/12/26 at 2:20 PM, V1 (Administrator) stated the facility does not have a separate policy for pest control and instead the facility uses the policy on homelike environment. V1 stated the facility should be providing an environment where someone would like to live and it should feel homelike, so the residents feel at home. V1 stated if there are pests in the facility it does not contribute to a homelike environment with the understanding that if someone is living at their home, they would not want pests in their home. V1 stated the environment should be clean and safe for the residents. R3's diagnosis which includes but not limited to Quadriplegia, Type 2 Diabetes Mellitus Without Complications, Anxiety Disorder, Neuromuscular Dysfunction of Bladder, Chronic Obstructive Pulmonary Disease, Contracture of Muscle, Left Shoulder, Contracture of Muscle, Unspecified Forearm, Heart Failure, Pressure Ulcer of Sacral Region, Stage 4, Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed, Carrier of Carbapenem-Resistant Acinetobacter Baumannii. R3's MDS (Minimum Data Set) dated 05/28/26 BIMS (Brief Interview for Mental Status) indicates intact cognition.R4's diagnosis which includes but not limited to Cerebral Palsy, Morbid (Severe) Obesity, Heart Failure, Localized Edema, Primary Osteoarthritis. R4's MDS dated [DATE] BIMS indicates intact cognition.R18's diagnosis which includes but not limited to Heart Failure, Quadriplegia, Acquired Absence of Other Right Toe(s), Acquired Absence of Other Left Toe(S), Primary Open-Angle Glaucoma, Bilateral, Chronic Obstructive Pulmonary Disease, Spinal Stenosis, Pulmonary Fibrosis, Carrier of Carbapenem-Resistant Acinetobacter Baumannii, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Type 2 Diabetes Mellitus. R81's MDS dated [DATE] BIMS indicates intact cognition.Facility provided document titled, Resident Rights dated 2026 which documents in part, the resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Facility provided document titled, Safe and Homelike Environment dated 09/01/2024 which documents in part, in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review the facility failed to a.) label and date food items in resident personal refrigerator, b.) discard unlabeled/undated spoiled food for three residents (R3, R4, R18) reviewed for personal food storage. Findings include:On 08/11/26 at 11:40 AM, observed R3's personal refrigerator in her room and non-refrigerated food being stored on top of R3's dresser. Surveyor obtained R3's permission to look through her food and inside her refrigerator. Surveyor opened the door to R3's personal refrigerator and tiny black flies flew out of the refrigerator. Surveyor observed multiple unopened expired containers of 2% milk cartons stacked up on the inside of the refrigerator door and multiple bags and containers of food uncovered and not dated inside the refrigerator. R3 asked, what do you see in there? If it's gone bad throw it out! R3 stated she wants the staff to throw out her old food because she cannot see what is in there; she cannot walk.On 08/11/26 at 11:50 AM, V7 (Certified Nursing Assistant/CNA) stated she is the CNA taking care of R3 today and R3 goes out with her family and returns with food which is then put in R3's refrigerator for storage. V7 stated the food put into R3's personal refrigerators is not labeled with a date, only if the food is put into the facility refrigerator down the hall are the items labeled and dated.On 08/11/26 at 11:58 AM, surveyor picked up a clear plastic clam shell from the top of R3's dresser and a swarm of black gnats flew up into the air. Surveyor and V7 could not identify what was inside the plastic container. There was a label on the outside of the plastic container which read German Chocolate Cake with a small white sticker on the container that read best by 4/24. R3 opened the plastic container, and more tiny black flies flew out. The product inside was completely covered in layers and layers of a light green/gray fuzzy material coating the food. Surveyor showed the product to R3 and R3 yelled, throw it out, throw it out!On 08/11/26 at 12:00 PM, V7 removed items one by one from inside R3's refrigerator which included:Five unopened 8-ounce cartons of 2% milk labeled May 17, June 11, June 24, July 1, and July 18.Yellow dry bread (appeared to be cornbread) in an open plastic bag with multiple small circular green spots covering it. The bag was not labeled or dated.Small piece of sausage in bun in an opened plastic bag covered with light white/green/gray fuzzy material. The bag was not labeled or dated.Tuna fish mixed with mayo and hard-boiled eggs in a covered plastic container. The container was not labeled or dated.Opened Styrofoam take out container with shredded beef and French Fries. The container was not labeled or dated.Piece of pound cake covered in ice in a bowl covered with plastic wrap. It was not labeled or dated.Dried out slices of meat covered in a brown paper towel. It was not labeled or dated.Covered container of shrimp mixed with walnuts. The container was not labeled or dated.Opened 14-ounce package of mini smoked sausages covered in ice crystals. On the package it was printed discard within 7 days of opening.Large, opened container from McDonalds which contained numerous bacon slices which were overflowing over of the sides of the container, 2-3 pancakes, and a dried-out biscuit. It was not labeled or dated.Plastic container uncovered with two cooked chicken wings inside. It was not labeled or dated.On 08/11/26 at 12:17 PM, V28 (Infection Preventionist Nurse/2nd Floor Unit Manager) stated when the staff place resident's food items into their refrigerator they should be labeled with the date. V28 stated she is not sure how long items are allowed to stay inside the refrigerator before they should be thrown out. V28 stated the purpose of dating the food items is so staff can keep up with how long the items are in there because the facility does not want the residents to be eating old food because that can cause other issues like nausea, vomiting, diarrhea, salmonella, food poising. V28 stated R3 is non-ambulatory, she is a quadriplegic and cannot walk so anything put into her refrigerator was put there by the staff or R3's family members, not R3. V28 stated housekeeping is responsible for going through residents' refrigerators and throwing out old food, not the nursing staff. V28 stated if old food is left in R3's room that could attract flies and pests.On 08/11/26 at 12:27 PM, V31 (Housekeeper) stated if the resident has a personal refrigerator in their room, then she wipes down the outside of the refrigerator. V31 stated she does not look to see if items are labeled with a date or throw out old food inside the refrigerator. V31 stated she has nothing to do with the resident's refrigerators other than wiping down the outside of them. V31 stated it is the Certified Nursing Assistants responsibility to label date, clean and discard old food.On 08/11/26 at 12:36 PM, V28 viewed inside R3's refrigerator and saw the containers of tuna fish and shrimp with walnuts. V28 stated those are not labeled with a date because that is something her family brought in for her or that she ordered herself. V28 stated if the family or the resident does not tell one of the staff that they are putting something in the refrigerator than the staff would not know about it so it would not get dated.On 08/12/26 at10:05 AM, R4 gave surveyor permission to look inside R4's personal refrigerator. When surveyor opened R4's refrigerator the flat surfaces inside were covered in a brown sticky substance. Observed an opened 1 pound, 8-ounce plastic container labeled as Beef Chili with Beans dated with a use by date of 08/06/26. Observed a mini cherry pie covered in plastic wrap not dated. On 08/12/26 at 10:20 AM, observed on top of R18's dresser next to R18's personal refrigerator six-4 ounce fruit pies marked with a label which read Reduced 0.44. Observed two lemon pies, one peach pie, one blueberry pie and two cherry pies all unopened and dated 7/13. Observed an opened loaf of bread with a label which read reduced 0.70 and best by 07/31 printed on the outside of the plastic bread bag. Observed tiny black flies in R18's room.On 08/12/26 at 10:27 AM, R18 gave surveyor permission to look in his personal refrigerator. Observed the following items inside R18's refrigerator:Opened package labeled Hot Head Cheese packed on 08/04/26, sell by 08/10/26. R18 said, I don't know how long it has been in there, but I probably have another day and then I have to toss it.Opened plastic bag with sliced yellow sliced cheese inside. The plastic bag was not labeled or dated.Piece of orange pie in a plastic bag. The plastic bag was not labeled or dated.On 08/12/26 at 10:31 AM, R18 stated the staff never asks him when he brings in food to date the items and they never look inside his refrigerator or throws out old food. R18 said, the food could be in there two years and they wouldn't know it.On 08/11/26 at 1:40 PM, V30 (Director of Environmental Services) stated he manages the housekeeping and laundry departments. V30 stated the housekeeper is responsible for wiping down the outside of the refrigerator and upon request they will clean the inside of the refrigerator once it has been emptied. V30 stated it is not the housekeeper's responsibility to label or date food inside the refrigerator or discard food when it has gone bad.On 08/12/26 at 1:51 PM, V48 (Regional Registered Dietitian) stated via telephone interview that family is allowed to bring in food from the outside the facility for the residents within their dietary constraints. V48 stated all items in resident's personal refrigerators should be labeled and dated with the date it was received and this is important for general food safety. V48 stated if the food items are not being labeled with a date this could potentially lead to food spoilage which could cause vomiting, diarrhea, and other GI symptoms if a resident was to consume it. V48 stated manufacturer guidelines for expiration dates or use by dates should be followed and all food should be covered and discarded to prevent attracting pests or bugs and from the items being given to a resident.R3's diagnosis which includes but not limited to Quadriplegia, Type 2 Diabetes Mellitus Without Complications, Anxiety Disorder, Neuromuscular Dysfunction of Bladder, Chronic Obstructive Pulmonary Disease, Contracture of Muscle, Left Shoulder, Contracture of Muscle, Unspecified Forearm, Heart Failure, Pressure Ulcer of Sacral Region, Stage 4, Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed, Carrier of Carbapenem-Resistant Acinetobacter Baumannii. R3's MDS (Minimum Data Set) dated 05/28/26 BIMS (Brief Interview for Mental Status) indicates intact cognition and on therapeutic, non-mechanically altered diet.R4's diagnosis which includes but not limited to Cerebral Palsy, Morbid (Severe) Obesity, Heart Failure, Localized Edema, Primary Osteoarthritis. R4's MDS dated [DATE] BIMS indicates intact cognition and is on a mechanically altered, therapeutic diet.R18's diagnosis which includes but not limited to Heart Failure, Quadriplegia, Acquired Absence of Other Right Toe(s), Acquired Absence of Other Left Toe(S), Primary Open-Angle Glaucoma, Bilateral, Chronic Obstructive Pulmonary Disease, Spinal Stenosis, Pulmonary Fibrosis, Carrier of Carbapenem-Resistant Acinetobacter Baumannii, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Type 2 Diabetes Mellitus. R81's MDS dated [DATE] BIMS indicates intact cognition and, on a therapeutic, non-mechanically altered diet.Facility provided policy titled, Resident Refrigerators dated 10/01/24 which documents in part, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators, and leftovers shall be dated upon receipt and discarded within three days, foods with use-by dates shall be discarded accordingly, any food with potential concerns (i.e. smell, packaging, appearance, frozen foods are not solid to touch) shall be discarded, food shall be in covered containers or securely wrapped.Facility provided document titled, Safe Storage & Handling of Outside Food - Information for patients, families and friends dated 2025 which documents in part, there can be a risk of food borne illness when food is not properly prepared, transported or stored. This can have serious consequences for the resident and any food which is not going to be consumed immediately must be covered and labeled with the resident's name and date the food was brought into the facility and placed into the unit refrigerator.

Based on interview and record review, the facility failed to follow the plan of care and provide verbal cues for one resident (R7) who was assessed as having a high risk for falls. This failure affected one of three residents reviewed for falls. This failure resulted in R7 falling to the ground and sustaining a hip fracture. Findings include: R7's medical diagnoses include but are not limited to extrapyramidal and movement disorder, dementia, hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease. R7's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 10, indicating R7's cognition is moderately impaired. R7's Minimum Data Set (MDS) dated [DATE] functional abilities section GG documents in part, Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. 04. Supervision or touching assistance. R7's progress note dated 07/01/26 at 1:56pm documents in part, At about 10:20am resident was observed sliding unto the floor and on her buttocks, when attempting to sing in the bench in the patio while outside for a smoke. denied pan on interview but expressed pain by groaning on ROM (range of motion) assessment.911 was called and resident transported to ER (emergency room). R7's progress note dated 07/01/26 at 4:14pm documents in part, Call placed to hospital, spoke with RN (Registered Nurse) who reported that the resident was diagnosed with a right femur fracture. Resident is being transferred to.hospital for surgical intervention. On 07/14/26 at 12:47pm V23 (Smoke Monitor) stated that he was present in the facility's smoking area and witnessed R7's fall to the ground. V23 stated that R7 had multiple items piled up on R7's rollator when R7 attempted to sit down on the rollator and fell. R7's Fall Risk assessment dated [DATE] documents in part, Category: High Risk for Falling. Score 65. On 07/15/26 at 12:13pm V34 (Restorative Director) stated that R7 was high risk for falls. V34 stated that on the fall risk assessment, a score of 45 or higher indicates that the resident is a high risk for falls. V34 stated R7 required reminders to lock her rollator walker before standing and sitting down. V34 stated R7's supervision assistance requirement was the reminder to lock the rollator. V34 stated sometimes R7 needed reminders to look back before sitting down. On 07/15/26 at 1:15pm V23 (Smoke Monitor) stated that he had never told R7 to lock her rollator walker before R7 would sit down. V23 stated that no one has ever told him that he needs to tell R7 to lock R7's rollator before she sits down. R7's hospital records dated 07/03/26 documents in part, 1. Closed displaced fracture of right femoral neck. 2. Ground level fall. Assessment: Patient is 81 YO (year old) female admitted [DATE]. Current Impairments: Pain, decrease LE (lower extremity) ROM (range of motion), decreased LE strength, decrease standing balance, decrease activity intolerance, decreased safety awareness during mobility, decreased cognition. Impact on Functional Ability: Difficulty with bed mobility, difficulty with transfers, difficulty with ambulation, difficulty with stair negotiation, increased fall risk in home. Functional Status: This is a decline from the patient's pre-admission status. R7's care plan with revision date of 05/06/26 documents in part, Falls: R7 is at risk for falls related to weakness. R7 is noted with ambulating with rollator. R7 has a steady gait and balance. R7 requires cueing and encouragement to complete tasks. R7 will not sustain any injury related to falls by next review. educate R7/family/caregivers about safety reminders and what to do if a fall occurs. Facility's policy titled Accidents and Supervision revised 10/07/25 documents in part, Policy: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:. 3. Implementing interventions to reduce hazards and risks. Policy Explanation an Compliance Guidelines: the facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 3. Implementation of Interventions - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff. B. Assigning responsibility. C. Providing training as needed. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. B. Based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on observation, interview and record review, the facility failed to provide physician ordered dressing changes to one resident (R2) with a history of pressure ulcers. This failure affected one resident (R2) out of three residents reviewed. R2's medical diagnoses include but are not limited to quadriplegia, essential hypertension, colostomy, acquired absence of left leg above knee. R2's [NAME] data set dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R2's cognition is intact.On 06/12/26 at 10:31 am surveyor observed R2 with soiled, partially attached bandage to R2's left buttock and left ischium.On 06/12/26 at 10:31 am R2 stated that no one comes in to change his bandage. R2 stated he has requested a bandage change, but no one has come to change it.On 06/12/26 at 10:35am V3 (Certified Nursing Assistant/CNA) stated she is assigned to R2 almost daily and R2 has not had his bandage changed. V3 stated she has not informed anyone that R2's bandage is soiled because she expects wound care to do their job.R2's physician's order dated 09/27/25 documents in part, Wound site monitoring: are wound dressings clean, dry and intact? Every shift please complete PRN (as needed) dressing change if dressing is observed loose, soiled or removed. R2's treatment administration record has an entry dated 06/12/26 at 9:24am Y (yes), indicating R2's dressing is clean and intact.On 6/12/26 at 12:57pm V6 (Licensed Practical Nurse/LPN) stated he did not assess R2's bandage and does not know why he (V6) documented that he (V6) assessed R2's bandage documented that R2's bandage was intact.R2's treatment administration record has a physician's order dated 05/12/26 documents in part, Skin: Left posterior thigh cleanse base with 0.9% (percent) NSS (normal saline solution), apply . paste with menthol then cover with foam dressing for protection every day shift every Tue (Tuesday), Fri (Friday). R2's treatment administration record dated 06/05/26 and 06/09/26 has a check, indicating administered with V7 (Wound Care Coordinator) initials.On 06/12/26 at 2:40pm V7 (Wound Care Coordinator/WCC) stated R2 has a protective treatment ordered to protect R2's scarred area from a previous wound R2 had. V7 stated R2's treatment is to be changed two times per week. V7 stated she does not change R2's treatment and R2's treatment is either done by the other wound care nurse or the floor nurse. V7 stated she did not change R2's bandage this week and did not change R2's bandage last week. When V7 asked by surveyor why R2's treatment administration record shows documentation that V7 changed R2's bandage on 06/05/26 and 06/09/26, V7 recanted statement and stated V7 did change R2's bandage with the assistance of V8 (Wound Care Tech).On 06/12/26 at 3:19pm V8 (Wound Care Tech) stated she has not been in R2's room this week. V8 stated she did not assist V7 (WCC) with R2's dressing change and is unsure if V7 changed R2's bandage.On 06/13/26 at 1:47pm V2 (Director of Nursing/DON) stated staff should not be documenting anything that they did not do. V2 stated it is expected for physician's orders to be implemented as ordered.R2's Skin and Wound Evaluation dated 05/12/26 documents in part, Describe: 1. Type: Moisture Associated Skin Damage (MASD). 22. Left Post (posterior) thigh. 23. Acquired: In-House Acquired. E. Peri wound: 2. Surrounding Tissue: 11. Fragile: Skin that is at risk for breakdown. 15. Scarring.R2's care plan dated 03/21/26 documents in part, R2 has potential for alteration in skin integrity related to the following factors that include but is not limited to: age, decreased bed mobility, moisture, hx (history) of pressure injury and has multiple dx (diagnoses) that include: quadriplegia, hemiplegia and hemiparesis, L AKA (left above knee amputation) . R2 will not develop any skin alteration by the next review date. Keep R2's skin clean, dry and intact. Report any skin alteration noted to the unit nurse. Skin checks during care, daily and as needed.Facility's policy titled Documentation of Wound Treatments dated 10/14/25 documents in part, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines. 3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift.Facility's policy titled Wound Treatment Management dated 10/14/25 documents in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 3. Dressing changes may be provided outside the frequency parameters in certain situations: b. The dressing has dislodged. c. The dressing is soiled otherwise.

Based on interview and record review, the facility failed to ensure one (R13) resident of three in a sample of 22 residents had sufficient representation to advocate for their needs. Findings include:R13's initial admission date to the facility is 11/18/24. R13 is a [AGE] year-old resident with diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; type 2 diabetes mellitus; depression; dementia; atherosclerotic heart disease; tachycardia; bipolar disorder.5/12/26 at 1:56 PM, V28 (Certified Nursing Assistant) stated, (R13) understands when we talk to them and follows commands. (R13) cannot respond verbally. I think it's from a stroke.5/12/26 at 2:10 PM, Surveyor called the language line to communicate with R13. The translator attempted to communicate with R13. Surveyor asked the translator to ask R13 for their name. R13 did not respond. R13 observed looking at surveyor and around the room. R13 did not verbally respond during interview attempt.5/13/26 at 10:05 AM, V1 (Administrator) stated we do not have a policy regarding guardianship, POA (Power of Attorney).5/13/26 at 12:24 PM, V2 (Director of Nursing) stated, I am familiar with (R13). He has a cousin on the face sheet. If you telephone them and leave a message they will call back. Whoever is on the face sheet is making decisions for (R13). (R13) has family, the two people listed on the face sheet. They can advocate for (R13) because they are emergency contacts. (R13) does not have a guardian. 5/13/26 at 1:20 PM, V26 (Licensed Practical Nurse) stated if a resident is nonverbal, not able to make needs known, then they should have a power of attorney or guardian. They need someone to advocate for their needs. 5/13/26 at 1:28 PM, V16 (Social Worker) stated, I am familiar with (R13). They do not have a POA or guardian. (R13) has a brother and cousin that are listed as emergency contacts. I don't know who gave consent to them being emergency contacts. It was like that when I started here. I've been here for a year. There are no documents saying that they are (R13's) POA. Being an emergency contact does not give authority to make decisions for the resident, especially taking medications. (R13) is not able to make their needs known. A resident that is non-verbal, cannot make their needs known requires a POA or guardian. (R13) cannot advocate for themselves, especially when it comes to making decisions regarding their medical needs. The Administrator (V1) is starting the paperwork for state guardianship for (R13). For as long as I have been at the facility, at least a year, (R13) has not been able to make their needs known.5/13/26 at 2:05 PM, V1 (Administrator) stated, I am familiar with (R13). (R13) is not verbal or able to make their needs known. (R13) does not have a POA or guardian. (R13) should have a POA or guardian. (R13) should have a POA or guardian because they are not able to make their needs known. For residents that cannot make their needs known, cannot talk, they need a POA or guardian to have someone to make decisions on their behalf.Psychosocial progress note, 2/3/26 16:13, reads in part: R13 presents as alert and oriented x1 with mental function fluctuating throughout the day. R13 experiences frequent episodes of confusion and forgetfulness. R13 has a communication deficit; often does not respond to staff when approached and demonstrates limited comprehension during interactions. Due to cognitive limitations, a staff assessment completed for BIMS (Brief Interview for Mental Status) which resulted in a score of 00/15 indicating severe cognitive impairment. R13's hearing is adequate however speech is unclear and ability to comprehend and express information is significantly compromised.R13 has a care plan that reads in part: R13 has a diagnosis of dementia. R13 is forgetful and requires guidance and cues, initiated 8/24/20.R13 has care plan that reads in part: R13 has a communication problem related to language barrier (primary language is *******). Require cues, initiated 4/13/2018.

Based on observation, interview, and record review, the facility failed to prevent and protect resident's right to be free from misappropriation of resident property. This failure affects one (R9) resident out of five residents reviewed in a total sample of twenty-two residents. This failure places the resident at risk for more than minimal harm.Findings include:On 05/12/2026 at 12:34 PM, R5 was sitting on his bed and then ambulated to open the privacy curtains, alert, responsive, and in no apparent distress. R5 stated, I can go out on pass independently. I have all my documents; I have a bus pass.On 05/13/2026 at 1:17 PM, R9 was lying on her bed, awake, responsive, and in no apparent distress. R9 stated, They did an inventory of my (R9) belongings, and they saw items were missing, and I haven't heard anything since. I was missing hoodies (sports team), and I didn't send them to the laundry. The social worker came to do it, and she said they were going to get the things back, and they didn't get back to me, so it is unresolved as of today. When asked if R9 had any idea of what happened to R9's missing items, R9 stated. I think (R5) took them, I've (R9) caught him in my room several times trying to steal from me, I yelled out and I told them to take him out of here. R9 stated the male CNA (certified nursing assistant) during the evening shift helped R9 to have R5 get out of R9's room. R9 stated R5 was by R9's closet. R9 stated, And another time in the morning he came around 4:00am, and the CNA said I thought he was a family member. He was in the dark, I don't remember her name. event happened more than a couple of months ago. R9 stated she cannot recall the exact dates. R9 stated the last time R5 came into R9's room was recently like the beginning of this month. R9 stated the male CNA is African American and no longer works for the facility but R9 couldn't remember his name.On 05/13/2026 at 11:12 AM, V18 (Registered Nurse) stated V18 has worked for the facility as a registered nurse since October 2025 and prior to V18 worked as a certified nursing assistant for the facility for ten years. When asked V18 if there is a concern with R5 is stealing items from residents, V18 nodded yes. V18 stated she denied ever witnessing R5 taking anything or stealing from other residents. V18 stated staff must tell R5 to leave the floors R5 is not supposed to be on alone.On 05/13/2026 at 3:11 PM, V31 (former employee/Certified Nursing Assistant) stated, I (V31) worked there but I no longer work there, I stopped working for the facility in February. V31 stated V31 is familiar with R9. V31 stated, I (V31) used to deliver food to (R9) since (R9) preferred female workers to provide (R9) with care. There was one occasion when (R9) was screaming because a tall black guy went into her room, and he was not supposed to go in there. V31 stated he was a tall guy from the 6th floor, because a few residents complained he was stealing (money) and taking things from them. V31 stated V31 thinks the resident's name was R5. V31 denied witnessing R5 stealing any items. V31 stated he was not supposed to go to the residents' rooms. V31 stated, All I (V31) know she shouted so I came, and I told him she does not want you here and you need to leave the room, and he left. I (V31) looked at his hand and he didn't have anything. V31 stated he could not remember the date this happened. V31 stated V31 cannot remember if this happened this year or last year at the end of the year. V31 stated he had reported this to the nurse but could not remember who the nurse was.On 05/13/2026 at 3:27 PM, V16 (Social Worker) stated allegedly R5 is stealing residents' items. V16 stated, You just hear it around when other residents are talking about it. I've (V16) never seen him steal or witness it. V16 stated R9 did complain the last time the state surveyor was here. V16 stated is why I had taken out everything that R9 had in her closet and V16 cleaned it out personally and completed an updated inventory list. V16 stated V16 was on vacation when R9 filed a grievance dated 03/28/2026 regarding missing clothes.On 05/13/2026 at 3:34 PM, with R9's permission, V16 opened R9's closet and R9 was noted with one Chicago team's hoodie, black hoodie, [NAME] hoodie. R9 stated she is missing another Chicago team blue hoodie, blue sports team hoodie. V16 stated there was no blue Chicago team's hoodie and a blue Chicago hoodie found. This surveyor did not observe any sports team hoodies.R9's inventory list dated 03/17/2026 documents in part, R9 was noted with five hoodies.On 05/13/2026 3:53 PM, V1 (Administrator) stated R9 has complained R5 stole her hoodies and coffee when the last state surveyor investigated this. V1 stated that is why there is a report regarding it. V1 stated, Only thing we can talk about is he (R5) has a behavior of wandering in between floors, but no one has come forward he has taken or stole anything.On 05/14/2026 at 1:46 PM, V30 (front desk) stated she has worked for the facility for a couple of months. V30 stated she is familiar with who R5 is and R5 normally comes to the front desk and goes through the log out book to check if R5's friend stepped out. V30 stated, For the most part, I (V30) don't know much about him. (R5) walks around here and there asking for a pop, nothing too crazy.On 05/15/2026 12:01 PM, V2 (Director of Nursing) stated, (R5) is alert and oriented and no, I (V2) would not be considering (R5) a wanderer. In general for a resident to be consider a wanderer they might be pacing on the floors. V2 stated R5 is residing on the independent floor. V2 stated she was not aware of, the R5 was observed in R9's room without R9's permission. V2 stated staff were told to redirect R5 If they saw him on another floor, they would redirect him back to his floor.A grievance form dated 03/28/2026 documents in part R9 believes men are stalking R9 and coming around to take items out of R9's room.R9's MDS/Minimum Data Set, dated [DATE] documents R9 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating R9's thinking and memory are intact.R5's face sheet documents R5 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to nicotine dependence, cigarettes, uncomplicated, bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, generalized anxiety disorder, opioid dependence with other opioid-induced disorder, alcohol use, unspecified.R5's MDS/Minimum Data Set, dated [DATE] documents R5 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating R5's thinking and memory are intact.R5's care plan documents in part, the resident has a history of criminal behavior according to the criminal history report obtained.R5's note dated 04/05/2025 at 3:48 PM documents in part, resident (R5) was present on other floors and selling items. Writer (V16) educated residents on facility policies.R5's note dated 07/20/2025 10:54 AM documents in part, writer (V16) met with R5 to address entry into another resident's room without permission. R5 was educated on the importance of respecting personal boundaries and obtaining consent before entering another resident's space was emphasized.R5's note dated 03/16/2026 1:40 PM documents in part, staff observed and received reports from peers indicating R5 has continued to request money and personal items (e.g., coffee, cigarettes) from other residents. Peers stated R5 offered to repay them, which has resulted in misunderstandings when the exchanges were not completed. Peers have expressed discomfort with these interactions.Facility document dated 09/01/2024 documents in part abuse, neglect and exploitation policy, it is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.On 05/13/2026 at 11:09 AM, this surveyor, via email (electronic mail) requested the facility's abuse policy and procedure.On 05/13/2026 at 11:19 AM, V1 (Administrator) communicated to this surveyor via email V1 will electronically attach the documents requested.On 05/13/2026 at 11:56 AM, V1 sent other document attachments but the abuse policy and procedure were not included.

Based on interviews and record reviews, failed to follow their policy to ensure all special instructions and/or precautions such as treatment and devices (hospital bed, oxygen, implants, IVs, tubes/catheters) were in place prior to transfer to another facility for one (R7) out of three residents reviewed for discharge process in a sample of 22.Findings Include:On 05/12/2026 at 12:10 PM, R7 stated he transferred to a different facility. R7 stated his medications took a couple hours but was finally cleared up. R7 stated he was transferred with his CPAP (Continuous Positive Airway Pressure) machine. R7 stated he knows how to use his CPAP machine. R7 stated one of the items discussed during the meeting was that he needed a hospital bed. R7 stated his bed was never delivered. R7 stated he had to order his bed by himself. R7 stated it was very frustrating.On 05/13/2026 at 11:55 AM, V1 (Administrator) stated, As far as discharge process, we make sure medications are appropriately ordered, care plan meetings, who will be ordered and what needs to be done. We make sure all orders are in place for equipment, follow up doctor's orders and order for discharge are in place. We make sure the order is in place, and the necessary equipment is in place prior to the resident's discharge. V1 stated R7's bed was ordered. V1 stated she doesn't know if the bed was delivered. V1 stated there was no communication with outside agency whether R7's bed was delivered.On 05/12/2026 at 2:10 PM, V10 (Social Services Director) stated discharge planning is done by the interdisciplinary team. V10 stated, We make sure all the residents' medications, equipment such as bed, oxygen, and wheelchairs are ready at the new facility prior to discharge. We made sure everything was ready for (R7) prior to him leaving. V10 stated his bed was ordered and should have been delivered. V10 verified on R7's progress note it was not confirmed R7's bed was delivered at the other facility.On 05/13/2026 at 10:21 AM, V4 (Licensed Practical Nurse) stated, As a unit manager, once we get the order for a discharge order date. The doctor puts in an order for labs, workup, medical, physical. We will start the process with pharmacy. We make sure they have two weeks of medication before they leave. Bed and walker. We get the order from the doctor for discharge. The agency is an outside company we coordinate with to discharge a resident safely to the community. The outside agency and I would follow up to make sure everything is ordered. The outside agency can talk to unit manager and social services. V4 stated she did not follow up with anybody for R7 regarding R7's bed is appropriately delivered. V4 stated, I am not sure if R7's bed was delivered.On 05/13/2026 at 10:48 AM, V2 (Director of Nursing) stated, There is a discharge form they complete. We get a doctor's order. We see if they want labs, we make sure we give them a 14-day supply of medication before discharge. We encourage a follow up with their primary care provider in the community. Usually, social service works with the other facility to coordinate any equipment such as bed, oxygen tanks, etc. The accepting facility makes sure the orders, and the equipment is available at facility. The facility has to communicate with the other company to make sure the residents' equipment such as bed, wheelchair, oxygen tanks are delivered prior to discharge.R7's Minimum Data Sheet (MDS) Section C documents in part: R8 has a BIMS of 15. R7 is cognitively intact.R7's progress note on 04/14/2026 documents in part: Care plan conference done together with IDT, R7 and the outside agency team. This is a discharge planning for R7 who has a discharge date moved to 4/22/2026. The outside agency went over everything R7 will be needing for his discharge. Date and location was discussed, 14-days' worth of medication will be prepared for R7, script for the hydrocodone will be prepared by the nurse, settings for the CPAP will be noted on the discharge form and R7 will be discharging with about 2 boxes and 3 bagful of belongings. R7 will also be bringing his CPAP with him. A hospital bed will be ordered by the outside agency team for him.R7's progress note by V4 on 04/14/2026 documents in part: Resident hospital bed ordered awaiting delivery.R7's progress note by V4 on 04/14/2026 documents in part: R7 had a care plan meeting today. R7 follow up includes, medication and OTC for two weeks, hospital bed per Restorative to be ordered.Reviewed R7's progress note from 04/03/2026 to 04/22/2026. No documentation R7's bed was delivered.Facility's Transfer and Discharge Policy (03/10/2025) documents in part: For a transfer to another provider, the following information must be provided to the receiving provider; All special instructions and/or precautions for ongoing care such as treatments and devices (oxygen, implants, IVs, tubes/catheters). The facility will assist with transportation arrangements to the new facility and any other arrangements as needed.

Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident physical and verbal abuse; and failed to implement effective interventions to prevent recurrence of abuse resulting in repeated incidents between R1 and R2 resulting in (R1 and R2) engaging in multiple altercations involving derogatory remarks (racial slurs) and physical aggression (throwing coffee and hitting). The facility also failed to prevent and protect a resident (R3) from resident-to- resident abuse. These failures affected 3 of 3 residents reviewed for abuse.Findings include:1. R1 has a diagnosis which includes but is not limited to unilateral primary bipolar disorder in full remission most recent episode depressed, and generalized anxiety disorder. R1's Brief Interview for Mental Status (BIMS) dated 3/2/26 shows a score of 15 which indicated that R1 is cognitively intact. R2's Brief Interview for Mental Status (BIMS) dated 2/20/26 shows a score of 15 which indicated that R1 is cognitively intact. R2 has a diagnosis which includes but is not limited to violent bipolar, bipolar disorder, major depressive disorder, single episode, schizophrenia, schizoaffective disorder, and major depressive disorder. The facility's initial reportable to the state agency dated 4/10/26 authored by V1 (Administrator) at 12:58 pm, documents, in part: On 4/10/26 V1 (Administrator) was made aware that R1 alleged that she was physically harmed by R2. R1's primary care physician was made aware an investigation was initiated. On 4/10/2026 at 12:53 pm, R1 stated that she has had two altercations with R2 at the facility involving R2 hitting R2 and using derogatory remarks. Staff are aware and present, and feels that nothing was done regarding R1's being abused by R2. R1 admitted to initiating a confrontation with R2 about three weeks ago, on the first floor, outside of the dining room, near the elevator at the facility on 3/16/26. R2 explained that she called R1 a derogatory name (R1 reports calling R2 a A**hole and N****). She states, He is low status, irritates me and retarded (referring to R2). R1 further explained that after she called R1 the derogatory names R2 replied to R1 saying, Say it again B**** and began to wheel his wheelchair to R1's wheelchair at the elevator. R1 explained that she turned around to R1 at the elevator, threw her coffee at R2 and R2 began hitting R1 in the chest. R1 explained after R2 punched her in the chest three times she yelled out for help for V5 (Activity Director) to stop R2 from punching R1 in the chest. R1 explained V5 was sitting in the dining room next to the elevator where the incident occurred and when R1 yelled out for help V5 came to the elevator where R1 and R2 was having the altercation and stood in between R1 and R2 and stated Stop to both residents. R1 opened the elevator door and R1 got onto the elevator and R2 stayed on the first floor with V5. R1 explained when she returned to her room she looked at her chest and saw a red scratch on her chest that she contributed from the altercation with R1. R1 stated prior to the altercation with R2 at the elevator on the first floor on 3/16/26, R1 had an altercation with R2 near the bookkeeper's office and dietary door. R1 explained she was sitting adjacent to the bookkeeper's office next to the dietary door when R2 arrived and stated, Move to R1. R1 stated that she replied to R2 by saying, Say it nice and say please. R1 then explained that R2 replied back to R1 by saying, Move B*** and hit R1 across the chest. R1 then explained that V6 (Business Office Manager) came out of her office and asked R2 to stop hitting R1. R1 stated that she told V6 that R2 used a derogatory remark to R1 and hit R1 and separated R2 from R1. R1 stated that the punch from R2 on this encounter did not hurt, she did not sustain any injuries and that she is not afraid of R2 at the facility. R1 reported that she wants to stay at the facility and is not afraid to live at the facility with R2. On 4/10/26 at 1:10 pm, V4 (Psychiatric Rehabilitation Social Service Coordinator, PRSC) stated she has been R1's PRSC for the past nine months at the facility. V4 stated that a few weeks ago R1 came to V4 and asked if V7 (Social Service Manager) reported to V4 that R1 and R2 had name calling back and forth. V4 denied R1 mentioned any physical altercation and that R1 only informed V4 that R2 called R2 a B**** and that R1 responded to R2 calling R2 a N****. V4 stated she did not report R1 informing her of the derogatory language between R1 and R2 because R1 informed V4 that she (R1) made V7 aware and that V7 handled it. V4 further explained that she asked V7 regarding the incident and V7 stated that R1 and R2 had an altercation that consisted of R1 and R2 calling each other derogatory names and that the situation was handled. On 4/10/26 at 2:44 pm, V6 (Business Office Manager) stated she recalls R1 and R2 having an incident a few months ago when R1 was sitting adjacent to V6's office where the dietary door was and R2 was trying to knock on the dietary door to ask for something to eat. V6 explained that she could hear from her office the interaction with R1 and R2 and heard R2 call R1 a B**** followed by other people in the hallway (who V6 was unable to identify) say loudly Don't hit her. V6 stated she did not witness the hit but could hear several people in the hallway say, Don't hit her. V6 stated she then got up and went into the hallway where the incident was occurring and asked R2 if he hit R1 and R1 stated, Yes. V6 instructed R2 not to hit R1 again and directed R1 to move out of R2's way. V6 stated that neither resident appeared hurt nor had injuries. V6 explained that she immediately reported the incident to V7 (Social Service Manager). When V6 was asked if she reported the incident to V1 (Administrator) V6 stated that she informed V1 the next day in the morning meeting. On 4/10/26 at 2:53 pm, R2 stated that he has had several altercations with residents at the facility and recalls an incident where he hit a resident at the elevator (he did not know the residents name, however he described her as a white female) after the resident threw coffee in his face and called him a derogatory name. R2 stated he recalled an event when he was by the bookkeeper's office trying to get food from the facilities kitchen and the same resident (he described as a white female) would not let him get by and he called her a B*** and hit the other resident after she would not move out of his way. R2 explained that the same resident continues to call him a derogatory name N****. R2 explained that staff were present at both events and R1 feels that the staff did not address either incident. On 4/10/26 at 3:04 pm, V7 (Social Service Manager) stated R1 informed her that she (R1) initiated an incident with R2 by calling R2 A**hole. V7 then stated R1 explained that R1 and R2 had a back and forth with an exchange of words with derogatory remarks and had to be separated by staff (V7 is unsure of what staff separated R1 and R2) and denied being present during the incident or being informed regarding any physical hitting between R1 and R2. V7 denied that V6 (Business Office Manager) ever informed V7 of R1 and R2 having an incident near the dietary office where R1 and R2 exchanged derogatory remarks and R2 hit R1. V7 stated that abuse should be reported to the administrator immediately. On 4/10/26 at 4:20 pm, V1 (Administrator) stated that she is the facility's abuse coordinator and staff should report abuse immediately to V1. V1 explained when abuse is initially reported the person causing the harm should be immediately removed, remove the individual who is being harmed, report the allegation to the administrator, and the investigation is initiated. V1 stated if a resident hits another resident or throws coffee at another resident hitting the resident in the face they are both considered acts of physical abuse. V1 explained if staff do not report abuse the facility wouldn't know how to prevent the abuse from recurring. V1 explained if the staff does not report resident to resident abuse there is a possibility the resident could continue to abuse the other resident. V1 stated if a resident makes a derogatory remark calling another resident a N** because he irritates her that is considered verbal abuse. V1 stated if a resident calls another resident a derogatory remark B** after another resident has thrown coffee on them, she is not sure if it is considered abuse. V1 denied knowledge of staff reporting R1 and R2 having any incidents of making derogatory remarks towards each other, R1 throwing coffee at R1 or R2 hitting R1 at the facility. R1's progress note dated 3/16/26 at 3:23 pm, authored by V4 (PRSC) documents in part: Resident came into office to inform me of the incident with another resident on the floor. She states name calling and it was earlier reported to another social worker. Asked the resident if she felt safe in the facility and she answered that she did. IDT (interdisciplinary team) made aware. R2's progress note dated 3/19/26 at 8:39 am authored by V5 (Activity Director) documents, in part: During mealtime, [NAME] displayed verbal antagonistic and disruptive behavior toward a peer. Without observable provocation, she approached the resident and directed multiple derogatory marks remarks towards them, including calling the peer trash, loser, a piece of S*** in stating that they need to leave the facility. She appeared to attempt to provoke the individual into an argument. Staff intervened immediately, providing calm redirection and guiding R1 away from the interaction. The targeted peer remained cooperative and did not engage or escalate. R1 initially resisted redirection verbally, stating I don't care when redirected but eventually relocated to another area with staff. No physical aggression was noted. Staff continued to monitor R1 for the remainder of the meal, and no further incidents occurred. R2's care plan documents in part R2 demonstrated recurrent aggressive behaviors including yelling, threatening language, and physical contact such as pushing or striking staff/peers . Interventions/Tasks: Document all incidents objectively and notify appropriate staff. The facility's policy dated 9//1/2024 and titled Abuse, Neglect, and Exploitation documents in part: Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definition: Physical Abuse: Includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Verbal Abuse: Use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and or Mr. Treatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 2. R4 is no longer in the facility and was reviewed as a closed record. An attempt to contact R4 was made on 04/11/2026 at 2:09PM, no answer, left voice message, awaiting call back. R4's Facesheet documents R4 was admitted to the facility on [DATE] and discharged on 03/23/2026. R4's progress note dated 03/23/2026 at 3:25PM written by V1 (Administrator) documents Writer spoke with Dr. regarding R4 Writer informed Dr. that R4 was being sent to the hospital for aggressive and threatening behaviors and is a danger to the residents and the facility. Writer confirmed resident was being sent to hospital. R4's progress noted dated 03/24/2026 at 4:55AM documents Writer called hospital for update of resident health status, R7 has been admitted for Aggression behavior. R4's progress noted dated 03/25/2026 at 11:53AM written by V5 (PRSC/Psychiatric Rehabilitation Service Coordinator), documents, R4 was sent out to hospital and admitted for aggressive behavior, after bullying another resident. All clothing was packed, and she did take certain item of importance to her. All other items were packed and sent to storage for save-keeping. On 04/11/2026 at 10:42AM, V5 (Psychiatric Rehabilitation Service Coordinator/PRSC) states R4 was bullying another female resident (identified as R3) and R3 and R4 were former roommates. V5 stated she heard that R4 was following R3 throughout the facility constantly bothering R3. V5 stated R3 informed her that she did not want to be roommates with R4 anymore. V5 stated R3 informed her that R3 and R4 were getting into confrontations and R4 was making it uncomfortable for R3 to be in the room any longer. V5 stated R4 was pretty much forcing R3 out of their shared room because R4 wanted the room to herself. V5 stated R3 was then moved back to her old room and R4 started following R3 back to her old room pretending to visit another resident in R3's room. V5 stated she heard that R4 made physical contact with R3 and pushed R4 in the head. V5 stated due to R4's behavior, R4 was sent out to the hospital for psychiatric evaluation. On 04/11/2026 at 10:56AM, V16 (Medical Director) stated he was made aware R4 was sent out to the hospital for aggressive behaviors. On 04/11/2026 at 11:26AM, V1 (Administrator) stated R3 came to her office and reported to her that R4 pushed R3 in the face. V1 stated R3 told her that this altercation took place in the receptionist area on the first floor of the facility. V1 stated R3 told her that the receptionist was present as well. V1 stated she then remembered that the facility has video footage of the receptionist area. V1 stated she immediately reviewed video footage and saw that R3 was telling the truth. V1 stated she observed on the video footage that R4 pushed R3 in the face. V1 stated she reported the incident to the state department of health on 03/23/2026. V1 stated she then tried to call R4 because R4 was OOP/out on pass. V1 stated during that same time frame, she received an email from the facility's attorney, who informed her that R4 had made allegations that R4 was just body slammed and choked in the facility. V1 stated she was able to debunk that allegation because she had already reviewed the video footage and knew that R4 was confabulating that allegation. V1 stated since R4 was the aggressor, R4 was sent out to the hospital for aggressive behaviors. V1 stated this is standard protocol when the facility has direct evidence of behaviors and other specific details of an altercation. V1 stated since R4 made physical contact with R3 and R3 was afraid for her safety, it was decided that R4 could not return back to the facility and an involuntary discharge was initiated. On 04/11/2026 at 12:34PM, V17 (Licensed Practical Nurse/LPN) stated she is familiar with R4 and her behaviors. V17 stated R3 and R4 were former roommates and had an altercation. V17 stated R3's room was changed to another room. V17 stated she remembers R4 going to R3's new room unauthorized. V17 stated she told R4 she could not be inside of R3's room. V17 stated R4 was bothering R3 so much that R3 could not even go to her own room and take a nap. V17 stated R4 insisted she could go to any room she wanted to and threatened to call her lawyer and the state health department. V17 stated she still told R4 to leave R3's room and made sure she left and did not bother R3 again. On 04/11/2026 at 12:51PM, R3 stated she and R4 were former roommates and R4 had been bullying her. R3 stated R4 was upset that she told them about smoking and drinking. R3 stated R4 told her that she ain't $h!+ and R3 keeps up a lot of $h!+ R3 stated she left her room and went down to the first floor to cool off. R3 stated R4 then came down to the first floor where she was located. R3 stated she was located in the receptionist area when R4 came down and began saying these h*e$ gonna stop playing with me. R3 stated R4 then jumped up in her face and pushed her on the left side of her face. R3 stated she was not sure of the receptionist's name, but the receptionist came and stood in between herself and R4 after R4 hit her. R3 stated she reported the incident to V5 (PRSC) and V1 (Administrator). R3 stated V1 then looked at the camera footage and confirmed that R4 had pushed her. R3 stated V1 then called the police and R3 filed a police report. R3 then showed surveyor a copy of her police report. Surveyor observed a police report dated 03/22/2026 with police report number as #JK191552. Police report documents an incident of simple battery with R3 named as the victim against R4. On 04/11/2026 at 2:11PM, abuse assessments and aggression assessments were requested from V1 (Administrator). On 04/11/2026 at 2:32PM, V1 stated the facility does not perform individual abuse and aggression assessments; V1 stated this information is already included in the resident's care plan. R3 and R4's abuse and aggression assessments were not provided to surveyor during this survey. R3's MDS/Minimum Data Set, dated [DATE] documents R3 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R3 is cognitively intact. R3's care plan dated 03/18/2026 documents in part, R3 will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect) through next review. R4's care plan documents in part, R4 will repeatedly make false claims and interject herself into others conversations in an attempt to cause negative interactions between peers and staff. R4 attempts to manipulate staff to get her way. R4 attempts to make herself or others victims when her behaviors are redirected. R4 demonstrates manipulative behaviors characterized by making threats to contact or actually contacting the state Department of Public Health based on frivolous or unfounded concerns. These behaviors serve as coercive tactics to exert control, influence staff decisions, or retaliate, thereby disrupting the therapeutic environment, undermining staff authority, and compromising safety. These actions create unnecessary stress, erode trust, and destabilize the care setting. R4 demonstrates recurrent verbal aggression, including yelling, threatening language, towards staff and peers. Facility reported incident dated 03/23/2026 documents an incident involving R3 and R4. Facility policy dated 09/01/2024, titled Abuse, Neglect and Exploitation documents in part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Facility policy dated 2026 titled Resident Rights documents in part, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review the facility failed to ensure that allegations of resident-to-resident abuse were reported in accordance with facility policy and regulatory requirements. This failure affected 2 (R1, R2) out of 3 residents reviewed for abuse.Findings include:R1 has a diagnosis which includes but is not limited to unilateral primary bipolar disorder in full remission most recent episode depressed, and generalized anxiety disorder. R1's Brief Interview for Mental Status (BIMS) dated 3/2/26 shows a score of 15 which indicated that R1 is cognitively intact. R2's Brief Interview for Mental Status (BIMS) dated 2/20/26 shows a score of 15 which indicated that R1 is cognitively intact. R2 has a diagnosis which includes but is not limited to violent bipolar, bipolar disorder, major depressive disorder, single episode, schizophrenia, schizoaffective disorder, and major depressive disorder.On 4/10/26 at 12:17 pm, V1 (Administrator) stated that after the surveyor questioned staff at the facility regarding R1and R2 ever having an altercation at the facility V1 conducted an interview with R1 regarding concerns for abuse at the facility. The facility's initial reportable to the state agency dated 4/10/26 authored by V1 (Administrator) at 12:58 pm, documents, in part: On 4/10/26 V1 (Administrator) was made aware that R1 alleged that she was physically harmed by R1. R1 primary care physician was made aware an investigation was initiated. On 4/10/2026 at 12:53 pm, R1 stated that she has had two altercations with R2 at the facility involving R2 hitting R2 and using derogatory remarks. Staff are aware and present, and feels that nothing was done regarding R1's being abused by R2. R1 admitted to initiating a confrontation with R2 about three weeks ago, on the first floor, outside of the dining room, near the elevator at the facility on 3/16/26. R2 explained that she called R1 a derogatory name (R1 reports calling R2 a A**hole and N****). She states, He is low status, irritates me and retarded (referring to R2). R1 further explained that after she called R1 the derogatory names R2 replied to R1 saying, Say it again B**** and began to wheel his wheelchair to R1's wheelchair at the elevator. R1 explained that she turned around to R1 at the elevator, threw her coffee at R2 and R2 began hitting R1 in the chest. R1 explained after R2 punched her in the chest three times she yelled out for help for V5 (Activity Director) to stop R2 from punching R1 in the chest. R1 explained V5 was sitting in the dining room next to the elevator where the incident occurred and when R1 yelled out for help V5 came to the elevator where R1 and R2 was having the altercation and stood in between R1 and R2 and stated Stop to both residents. R1 opened the elevator door and R1 got onto the elevator and R2 stayed on the first floor with V5. R1 explained when she returned to her room she looked at her chest and saw a red scratch on her chest that she contributed from the altercation with R1. R1 stated prior to the altercation with R2 at the elevator on the first floor on 3/16/26, R1 had an altercation with R2 near the bookkeeper's office and dietary door. R1 explained she was sitting adjacent to the bookkeeper's office next to the dietary door when R2 arrived and stated, Move to R1. R1 stated that she replied to R2 by saying, Say it nice and say please. R1 then explained that R2 replied back to R1 by saying, Move B*** and hit R1 across the chest. R1 then explained that V6 (Business Office Manager) came out of her office and asked R2 to stop hitting R1. R1 stated that she told V6 that R2 used a derogatory remark to R1 and hit R1 and separated R2 from R1. R1 stated that the punch from R2 on this encounter did not hurt, she did not sustain any injuries and that she is not afraid of R2 at the facility. R1 reported that she wants to stay at the facility and is not afraid to live at the facility with R2.On 4/10/26 at 1:10 pm, V4 (Psychiatric Rehabilitation Social Service Coordinator, PRSC) stated she has been R1's PRSC for the past nine months at the facility. V4 stated that a few weeks ago R1 came to V4 and asked if V7 (Social Service Manager) reported to V4 that R1 and R2 had name calling back and forth. V4 denied R1 mentioned any physical altercation and that R1 only informed V4 that R2 called R2 a B**** and that R1 responded to R2 calling R2 a N****. V4 stated she did not report R1 informing her of the derogatory language between R1 and R2 because R1 informed V4 that she (R1) made V7 aware and that V7 handled it. V4 further explained that she asked V7 regarding the incident and V7 stated that R1 and R2 had an altercation that consisted of R1 and R2 calling each other derogatory names and that the situation was handled. On 4/10/26 at 2:44 pm, V6 (Business Office Manager) stated she recalls R1 and R2 having an incident a few months ago when R1 was sitting adjacent to V6's office where the dietary door was and R2 was trying to knock on the dietary door to ask for something to eat. V6 explained that she could hear from her office the interaction with R1 and R2 and heard R2 call R1 a B**** followed by other people in the hallway (who V6 was unable to identify) say loudly Don't hit her. V6 stated she did not witness the hit but could hear several people in the hallway say, Don't hit her. V6 stated she then got up and went into the hallway where the incident was occurring and asked R2 if he hit R1 and R1 stated, Yes. V6 instructed R2 not to hit R1 again and directed R1 to move out of R2's way. V6 stated that neither resident appeared hurt nor had injuries. V6 explained that she immediately reported the incident to V7 (Social Service Manager). When V6 was asked if she reported the incident to V1 (Administrator) V6 stated that she informed V1 the next day in the morning meeting. On 4/10/26 at 2:53 pm, R2 stated that he has had several altercations with residents at the facility and recalls an incident where he hit a resident at the elevator (he did not know the residents name, however he described her as a white female) after the resident threw coffee in his face and called him a derogatory name. R2 stated he recalled an event when he was by the bookkeeper's office trying to get food from the facilities kitchen and the same resident (he described as a white female) would not let him get by and he called her a B*** and hit the other resident after she would not move out of his way. R2 explained that the same resident continues to call him a derogatory name N****. R2 explained that staff were present at both events and R1 feels that the staff did not address either incident. On 4/10/26 at 3:04 pm, V7 (Social Service Manager) stated that R1 informed her that she (R1) initiated an incident with R2 by calling R2 A**hole. V7 then stated that R1 explained that R1 and R2 had a back and forth with an exchange of words with derogatory remarks and had to be separated by staff (V7 is unsure of what staff separated R1 and R2) and denied being present during the incident or being informed regarding any physical hitting between R1 and R2. V7 also denied that V6 (Business Office Manager) ever informed V7 of R1 and R2 having an incident near the dietary office where R1 and R2 exchanged derogatory remarks and R2 hit R1. V7 stated that abuse should be reported to the administrator immediately. On 4/10/26 at 4:20 pm, V1 (Administrator) stated that she is the facility's abuse coordinator and that staff should report abuse immediately to V1. V1 explained when abuse is initially reported the person causing the harm should be immediately removed, remove the individual who is being harmed, report the allegation to the administrator, and the investigation is initiated. V1 stated if a resident hits another resident or throws coffee at another resident hitting the resident in the face they are both considered acts of physical abuse.V1 explained if staff do not report abuse the facility wouldn't know how to prevent the abuse from recurring. V1 explained if the staff does not report resident to resident abuse there is a possibility the resident could continue to abuse the other resident. V1 stated if a resident makes a derogatory remark calling another resident a N** because he irritates her that is considered verbal abuse. V1 stated if a resident calls another resident a derogatory remark B** after another resident has thrown coffee on them, she is not sure if it is considered abuse. V1 denied knowledge of staff reporting R1 and R2 having any incidents of making derogatory remarks towards each other, R1 throwing coffee at R1 or R2 hitting R1 at the facility. R1's progress note dated 3/16/26 at 3:23 pm, authored by V4 (PRSC) documents in part: Resident came into office to inform me of the incident with another resident on the floor. She states name calling and it was earlier reported to another social worker. Asked the resident if she felt safe in the facility and she answered that she did. IDT (interdisciplinary team) made aware.R2's progress note dated 3/19/26 at 8:39 am authored by V5 (Activity Director) documents, in part: During mealtime, [NAME] displayed verbal antagonistic and disruptive behavior toward a peer. Without observable provocation, she approached the resident and directed multiple derogatory marks remarks towards them, including calling the peer trash, loser, a piece of S*** in stating that they need to leave the facility. She appeared to attempt to provoke the individual into an argument. Staff intervened immediately, providing calm redirection and guiding R1 away from the interaction. The targeted peer remained cooperative and did not engage or escalate. R1 initially resisted redirection verbally, stating I don't care when redirected but eventually relocated to another area with staff. No physical aggression was noted. Staff continued to monitor R1 for the remainder of the meal, and no further incidents occurred. R2's care plan documents in part, R2 demonstrated recurrent aggressive behaviors including yelling, threatening language, and physical contact such as pushing or striking staff/peers . Interventions/Tasks: Document all incidents objectively and notify appropriate staff. The facility's policy dated 9//1/2024 and titled Abuse, Neglect, and Exploitation documents in part: Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definition: Physical Abuse: Includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Verbal Abuse: Use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and or Mr. Treatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on interview and record review, the facility failed to provide sufficient nursing staff in accordance with the facility assessment to meet the needs of residents residing in the facility. This deficient practice has the potential to affect all residents residing in the facility who require assistance with activities of daily living, supervision, and timely care.Findings Include:On 2/25/26 at 11:04 AM, a resident council meeting was held. Residents R23, R38, R61, R126, R148, R7, and R170 attended. All residents stated that staffing is insufficient to meet their needs. They reported ongoing staff shortages. R23 and R170 stated that call lights are not answered promptly due to inadequate staffing. R170 reported that on some nights there was no CNA assigned to the sixth floor. R7 stated that he often waits extended periods for assistance getting out of bed because he requires two CNAs for transfers, and staff are frequently unavailable due to short staffing.On 2/26/26 at 9:34 AM, V25 (Staffing Coordinator) stated she is responsible for scheduling CNAs and nurses. V25 stated that the total staffing levels by shift per day are as follows: 19 CNAs (including Restorative Aides) and 8 nurses for morning shift, 14 CNAs and 8 nurses for evening shift, and 10 CNAs and 6 nurses for night shift. V25 stated staffing assignments are adjusted based on the facility census and divided among four resident floors. V25 stated the facility utilizes agency nurses and CNAs when needed; however, V25 stated that use of agency CNAs is rare. V25 stated the last use of an agency CNA was for one shift in January, and no agency CNAs worked in February. V25 stated there is always at least one RN scheduled each shift daily, with RNs alternating weekends and all shifts are eight hours in length. V25 stated she has not received any complaints regarding short staffing and believes the facility has sufficient staff, including on weekends.R23's clinical records show an initial admission date of 3/31/17 and Minimum Data Set (MDS) dated [DATE] shows R23 is moderately impaired with cognition with Brief Interview for Mental Status (BIMS) of 12.R38's clinical records show an initial admission date of 1/14/20 and MDS dated [DATE] shows R38 is cognitively intact with BIMS of 15.R61's clinical records show an initial admission date of 9/20/23 and MDS dated [DATE] shows R61 is cognitively intact with BIMS of 15.R126's clinical records show an initial admission date of 4/26/17 and MDS dated [DATE] shows R126 is moderately impaired with cognition with BIMS of 9.R148's clinical records show an initial admission date of 8/16/19 and MDS dated [DATE] shows R148 is cognitively intact with BIMS of 15.R7's clinical records show an initial admission date of 11/12/20 and MDS dated [DATE] shows R7 is cognitively intact with BIMS of 15 and is total dependent on staff's assistance with transfers.R170's clinical records show an initial admission date of 2/20/24 and MDS dated [DATE] shows R170 is cognitively intact with BIMS of 15.Review of the facility's Certified Nursing Assistant (CNA) time sheets for the dates 12/20/25-12/21/25, 12/27/25-12/28/25, 1/3/26-1/4/26, 2/1/26, 2/7/26-2/8/26, 2/14/26-2/15/26, and 2/21/26-2/22/26 shows the total number of CNA staff provided per shift did not align with the nursing services staffing levels identified in the facility assessment. PBJ (Payroll Based Journal) staffing data report FY (Fiscal Year) Quarter 4 2025 (July 1 - September 30) showed: triggered for excessively low weekend staffing and one star staffing rating.The facility's Facility Assessment dated 1/26 documents in part: The facility assessment will outline resources necessary to provide competent and resident centered care for our residents during day to day operations and emergencies. Total Nursing Services Staffing: 19 CNAs for days, 14 CNAs for evenings, and 10 CNAs for nights.

Based on observations, interviews, and record reviews the facility failed to (a) post Enhanced Barrier Precautions (EBP) sign for two residents (15, R59); (b) ensure staff wore proper Personal Protective Equipment (PPE) upon entering a room for one (R13) resident on contact precautions; and (c) follow their 'General Immunization/Vaccination' policy. This has the potential to affect all the residents that reside in the facility.Findings include: On 2/25/2026 at 10:03 AM, V3 (Infection Preventionist) stated the facility does not screen residents for risk factors associated with hepatitis B and whether or not the residents were immunized against hepatitis B. V3 stated unless the resident admits with the diagnosis, the facility does not screen for it. V3 stated [V3] will verify with administration but it is not in their facility policy to do so. During the same interview, V3 provided a Vaccine Report from the last 12 months. There were no entries for any of the residents in the Shingles column. V3 did not know what the blank entries signified. V3 stated [V3] has not offered or administered the varicella-zoster vaccine. V3 stated will ask administration what the blank entries signify. (V3 did not provide an answer prior to the end of the survey). On 2/25/2026 at 10:39 AM, R185 was alert and oriented to person, place, and time. R185 stated wanting to receive the shingles vaccine but facility did not provide it. R185 stated informing V3 (Infection Preventionist) that [R185] wanted the shingles vaccine but V3 has not provided it. During a follow-up interview with V3 on 2/25/2026 at 3:23 PM, V3 stated the facility does not screen residents for risk factors associated with hepatitis B or provide residents education regarding risks associated with shingles and how to protect oneself against the varicella-zoster virus. V3 stated these were not part of the facility's policy to do so. On 2/26/2026 at 11:34 AM, V2 (Director of Nursing) stated infection control is not V2's role but will follow-up regarding the residents' screenings. Facility did not provide documentation at the completion of the survey. On 2/26/2026 at approximately 2:50 PM, survey team met with V1 (Administrator), V2, and V33 (Regional Clinical Director). V33 stated it is not part of their policies or procedures to screen. V33 stated [V33] was not aware of regulations regarding shingles education and hepatitis B screening. Facility's undated General Immunization/Vaccination policy documents in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such disease. Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance. Section 300.1060 Vaccinations of Illinois's TITLE 77: PUBLIC HEALTH, CHAPTER I: DEPARTMENT OF PUBLIC HEALTH, SUBCHAPTER d: LONG-TERM CARE FACILITIES, PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE documents in part: A facility shall distribute educational information provided by the Department on all vaccines recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (available at: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf), including, but not limited to the risks associated with shingles and how to protect oneself against the varicella-zoster virus. The facility shall provide the information to each resident who requests the information and each newly admitted resident. The facility may distribute the information to residents electronically. (Section 2-213(e) of the Act) A facility shall document in the resident's medical record that he or she was verbally screened for risk factors associated with hepatitis B, hepatitis C, and HIV, and whether or not the resident was immunized against hepatitis B. (Section 2-213(c) of the Act) All persons determined to be susceptible to the hepatitis B virus shall be offered immunization within 10 days after admission to any nursing facility. R13's face sheet shows admission date on 11/9/23 with diagnoses not limited to Essential (primary) hypertension, Unspecified asthma, Rheumatoid arthritis, Hyperlipidemia, Vitamin D deficiency, Schizoaffective disorder, disorganized schizophrenia, Gastro-esophageal reflux disease, Generalized anxiety disorder, Chronic systolic (congestive) heart failure, Type 2 diabetes mellitus, Other specified chronic obstructive pulmonary disease, Cystitis. MDS (Minimum Data Set) dated 12/17/25 shows R13's cognition was intact. R59 face sheet shows admission date on 1/21/26 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Nicotine dependence, Anemia in chronic kidney disease, Polyneuropathy, Nonischemic myocardial injury (non-traumatic), Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, Gout. MDS dated [DATE] shows R59's cognition was intact. On 2/24/26 at 9:28AM Medication administration observation conducted with V8 (Licensed Practical Nurse / LPN). Observed R13's door with signage indicating Contact Precautions and PPE (Personal Protective Equipment) supplies were available by room entrance. Contact precautions signage showed staff must put on gloves and gowns before room entry. On 2/24/26 at 9:41AM Observed V8 (LPN) went inside R13's room without wearing proper PPE (No gown, no gloves) and administered medications to R13. V8 stated her room assignment is from room [ROOM NUMBER] to 226. On 2/24/2026 At 11:4AM R59 observed up and about, ambulatory with steady gait, alert and oriented x 3, verbally responsive. Stated he is receiving dialysis in the basement every Tuesday, Thursday, and Saturday around 1PM. R59 showed his dialysis access catheter site at right upper chest with dressing in place. On 2/25/26 at 1:26PM V3 (IP / Infection Preventionist Nurse, LPN / Licensed Practical Nurse) stated she has been working in the facility since 2023 and IP role in September 2025. Stated Residents are placed under contact precautions that could be transmitted through contact, touching resident and environment. V3 stated R13 is placed on contact precautions due to ESBL (Extended-spectrum beta-lactamase) in urine. Stated whenever staff go inside the room of residents on contact precautions should be wearing proper PPE gowns and gloves to prevent transmission of organisms. V3 stated if staff were not wearing proper PPE and entered the resident's room on contact precautions could potentially carry the organism and affects resident, other staff and their environment. She stated staff should wear proper PPE when administering medication inside resident's room on contact precautions. V3 stated R59 is on EBP (Enhanced Barrier Precautions) due to dialysis access catheter. Stated there should be signage posted by the door / room entrance to alert staff to the precautions and to wear proper PPE when giving high care activities to resident. On 2/26/26 At 11:14AM V2 (DON / Director of Nursing) stated she has been working in the facility for 7 weeks. Stated resident on contact precautions, staff are expected to wear proper PPE such as Gown and gloves upon entry to resident's room to decrease the risk of transmission of organism. V2 stated if there is a physician order for contact precautions, staff are expected to follow the order and precautions should be implemented. V2 stated if staff is not wearing proper PPE upon entry to resident's room on contact precautions there is a risk of spread of infection or cross contamination for all the residents that staff is taking care of or assigned to. R13' POS (Physician Order Sheet) / order summary dated 2/24/26 shows active order not limited to: Isolation - Contact Precautions related to ESBL until 2/28/26. R59's POS dated 2/26/26 shows active order not limited to: Enhanced Barrier Precautions (EBP) related to Dialysis Access. Care plan dated 2/15/26 shows in part: R59 is on Enhanced Barrier Precaution related to presence of dialysis catheter. Place appropriate sign of precaution visible to everyone per facility protocol. Facility's staff assignment dated 2/24/26 shows in part: V8 (LPN) room assignment: 213 to 226. Facility's Census dated 2/24/26 shows 20 residents from room [ROOM NUMBER] to 226. Facility's contact precautions signage read in part: Staff must put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Facility's Transmission-Based (Isolation) Precautions dated 10/14/25 read in part: Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact: Gloves - Whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle. Gowns - Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle. On 02/23/26 at 12:45 PM, there was no Enhanced Barrier Precautions (EBP) signage posted outside R15's room and did not find an EBP sign on the floor near R15's doorway or inside his room. On 02/23/26 at 12:50 PM, V9 (Licensed Practical Nurse) stated R15 is a dual feeder and receives bolus tube feedings via a gastrostomy tube (GT). V9 looked outside R15's doorway and stated he does not see an Enhanced Barrier Precaution sign and there should be one because R15 has a GT. V9 stated the sign is important because it alerts the staff that they need to wear gloves and a gown when doing direct care tasks and all staff going in/out of R15's room need to do hand hygiene. V9 stated the Enhanced Barrier Precautions are for R15's protection because he is more susceptible to getting an infection because of his GT. V9 stated if the sign is not up the staff does not know what they need to do before entering his room and what PPE they need to wear, and this could put R15 at potential risk for developing an infection. On 02/24/26 at 1:50 PM, V2 (Director of Nursing) stated EBP should be for anyone with an indwelling medical device such as a feeding tube or for someone with a wound. V2 stated these precautions are in place to protect the residents from getting an infection from the staff/visitors. V2 stated there should be an EBP sign posted outside the residents' door so staff/visitors entering/exiting the room know they have to perform hand hygiene and gloves, and gown needs to be worn if doing any direct contact with the resident. V2 stated the purpose of posting the EBP sign is to make the staff/visitors aware the resident is on EBP and to provide a visual reminder of what the staff should do when entering the room. V2 stated she thinks the EBP sign on R15's door fell and that PPE can be shared between rooms, a separate PPE set up is not required at each door. R15's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Encounter for Attention to Gastrostomy, Unspecified Dementia, Dysphagia, Cachexia, Adult Failure to Thrive, Esophageal Obstruction, Alcohol Abuse, Gastro-Esophageal Reflux Disease Without Esophagitis, Wernicke's Encephalopathy. R15's Order Summary Report dated 02/24/26 documents in part enteral feeding order as needed change GT dressing PRN dated 05/02/25 and enteral feeding order five times a day Jevity1.5 calorie administer one carton bolus via gravity (240 ml five time per day) dated 05/09/25. R15 does not have an order for Enhanced Barrier Precautions. R15's MDS (Minimum Data Set) from 12/02/26 documents in part, R135 has a feeding tube and receives 51% or more of portion of total calories through feeding tube. R15's care plan documents in part (R15) is currently managed with a gastrostomy tube for nutrition and medication administration and interventions include but not limited to infection prevention measures. Facility provided policy titled, Enhanced Barrier Precautions dated 10/01/25 which documents in part, it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms and EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following including indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, hemodialysis catheters, PICC lines, midline catheters). Facility provided copy of Enhanced Barrier Precautions sign by the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents everyone must clean their hands, including before entering and when leaving the room and providers/staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use – central line, urinary catheter, feeding tube, tracheostomy.

Based on observations, interviews, and record reviews, the facility failed to (a) follow their policy, (b) follow physicians' orders, and (c) have the correct settings on four residents' (R3, R41, R43, R80) air loss mattresses for four residents out of a total sample of 35 residents. Findings include: 1. R3's admission Record documents in part a stage 3 pressure ulcer (full-thickness skin loss) to the right elbow. R3's 2/13/2026 Quarterly MDS (Minimum Data Set) assessment documents in part that R3's cognitive skills for daily decision making are severely impaired. R3 is dependent on staff for bed mobility rolling from left to right. R3's Care Plan Report documents in part that R3 is at high risk for further pressure injury development and other skin breakdown due to the following factors that include but are not limited to thin fragile skin and bony prominences and dependence on staff for turning and repositioning (last revised 11/21/2025). Interventions include but are not limited to pressure relieving/reducing mattress to protect the skin while R3 is in bed (last revised 5/26/2023). R3's Order Summary Report documents an active order for Low-air-loss mattress in use (LAL/LAM) every shift for check functioning - air mattress should be set at patient's weight or per manufacturer instructions. Order date is 11/17/2025. R3's Weights and Vitals Summary documents in part that R3 weighed 122.2 lbs. (pounds) on 2/10/2026. 2. R43's 1/14/2026 Quarterly MDS assessment documents in part that R43's mental status is severely impaired. It documents in part that R43 requires partial/moderate staff assistance to roll from left to right. R43's Care Plan Report documents in part that R43 has a potential for alterations in skin integrity related to bed mobility, fragile skin, and incontinence (last revised 7/21/2025). Interventions include but are not limited to pressure relieving/reducing mattress to protect the skin while R43 is in bed (last revised 8/10/2021). R43's Order Summary Report documents an active order for Low-air-loss mattress in use (LAL/LAM) every shift for PREVENTION Ensure settings are set to patient's weight or set per manufacturer's instructions. Order date is 11/12/2024. R43's Weights and Vitals Summary documents in part that R43 weighed 185.6 lbs on 2/10/2026. On 2/24/2026 at 10:50 AM, R3 was lying on an air loss mattress. The power was on and the setting was on static (orange light indicator was on). The weight setting was on the weight range for 320 lbs. On 2/24/2026 at 11:13 AM, R43 was lying on an air loss mattress. The weight setting was near the 400 lbs. mark and set on firm. On 2/24/2026 at 11:15 AM, V7 (Wound Care Tech) entered R43's room stating [V7] needed to make sure R43's bed settings were good. V7 stated R43's current weight is 185 lbs. V7 stated the bed is currently on 400lbs but should be on 185 lbs. V7 adjusted R43's bed settings. Surveyor and V7 then went to R3's room. V7 stated R3 is currently 132 lbs. V7 stated R3's bed is on 320 lbs. and is not correct. V7 also said that R3's bed is not supposed to be on static mode and turned it off. On 2/26/2026 at 12:14 PM, V29 (Wound Nurse) stated the residents' air loss mattresses should be set based off their weights. During at follow-up interview at 12:55 PM, V29 stated that R3's bed should not be on static setting. V29 stated that static means that the mattress pressure is stable. V29 stated R3's bed should be on dynamic mode which means that the mattress pressure alternates between the sides of the mattress. Facility's undated Use of Support Surfaces policy documents in part: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Except for the facility's standard mattresses and wheelchair cushion, support surfaces will be utilized in accordance with physician orders. 3. R80's face sheet shows admission date on 4/28/23 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Chronic embolism and thrombosis of unspecified deep veins of right lower extremity, Dysphagia following cerebral infarction, Ataxia following cerebral infarction, Aphasia following cerebral infarction, Essential (primary) hypertension, Contracture right hand, Encounter for attention to gastrostomy, Atherosclerotic heart disease of native coronary artery, Anemia, Unspecified convulsions. MDS (Minimum Data Set) dated 1/28/26 shows R48 was rarely / never understood. On 2/24/26 at 11:30AM R80 observed resting in bed, on moderate high back rest with carrot device on right hand. R80 is non-verbal. Observed R80 lying on air mattress, setting display showed 400lbs (pounds) normal pressure. R80's POS (Physician Order Sheet) dated 2/24/26 shows active order not limited to low-air-loss mattress in use every shift for check functioning. Ensure settings are set to patient's weight or set per manufacturer's instructions. R80's weight as follows: On 2/7/26 = 181.3 Lbs. On1/1/26 = 182.0 Lbs. On 12/1/25 = 181.2 Lbs. On 11/1/25 = 185.5 Lbs. On 10/1/2025 = 186.4 Lbs. Care plan dated 2/28/25 shows in part: R80 has potential for alteration in skin integrity related to bed mobility and incontinence. On 2/26/26 at 11:14AM V2 (DON / Director of Nursing) stated she has been working in the facility for 7 weeks. Stated air loss mattresses could be used for residents with Stage 3 or 4 pressure ulcers or it also is used as preventive measures. V2 stated wound care team is expected to check the setting of air loss mattress. She stated correct setting of air loss mattress should be maintained so there is a correct flow / circulation to the skin of the resident. On 02/24/26 at 11:08 AM, observed R41 lying on low air loss mattress. R41 stated his bed is very uncomfortable. R41 complained that his bed is very hard, and he does not think it is set properly. Observed low air loss mattress set between 360-400 pounds based on the dial control on the machine. R41 stated the last time he was weighed he weighed 224 pounds. Surveyor felt R41's low air loss mattress which was very firm and did not give when surveyor tried to press fingers into the mattress. The mattress stayed tight and smooth. R41 stated he has wounds on his legs. On 02/24/26 at 11:27 AM, V8 (Licensed Practical Nurse) stated the low air loss mattress is set based on the resident's weight and the purpose of the low air loss mattress is to redistribute the resident's weight to prevent wounds from developing and/or to prevent wounds from getting worse. V8 stated the nurse, or the CNAs set the low air loss mattress. V8 stated R41's last weight in his electronic health record was obtained on 02/07/26 and he weighed 239.6 pounds. On 02/24/26 at 11:31 AM, V8 observed R41's low air loss mattress setting set between 360-400 pounds and stated R41 does not weigh 380 pounds. V8 stated the weight setting is not correct, it is set too high. V8 stated if the setting is set too high it will make the mattress extra firm and it will be too hard. On 02/25/26 at 1:45 PM, V2 (Director of Nursing) stated low air loss mattresses are utilized to help with offloading to promote wound healing and as a preventative measure if the resident has a history or is at risk for developing skin alterations. V2 stated the wound team assesses the resident and determines the appropriate interventions such as use of a low air loss mattress. V2 stated the low air loss mattress is set based on the resident's weight unless specified otherwise. V2 stated the low air loss mattress setting ordered by the physician should be followed as ordered. V2 stated R41 weight is 239-240 pounds so his low air loss mattress should be set around 240 pounds. On 02/26/26 at 12:21 PM, V29 (Wound Registered Nurse) stated R41 has MASD (Moisture Associated Skin Damage) on his left thigh. V29 stated use of a low air loss mattress is a protective measure due to R41's co-morbidities, very fragile skin and to prevent skin breakdown because there is a possibility of the MASD area developing into a pressure wound. V29 stated the low air loss mattress helps transfer the residents' weight so they are not sitting in one position for an extended period. V29 stated the air loss mattress is set by the resident's weight. V29 stated the low air loss mattress should not be super soft and it should not be very firm. V29 stated if the low air loss mattress is too firm then there is a possibility that it could lead to the development of a pressure ulcer. 4. R41's diagnosis includes but not limited to the following Spinal Stenosis, Lumbar Region Without Neurogenic Claudication, Lymphedema, Not Elsewhere Classified, Acquired Absence Of Left Leg Below Knee, Chronic Systolic (Congestive) Heart Failure, Opioid Dependence, Polyneuropathy, Peripheral Vascular Disease, Bilateral Primary Osteoarthritis of Hip, Morbid (Severe) Obesity Due To Excess Calories, Primary Insomnia, Hyperlipidemia, Vitamin D Deficiency, Long Term (Current) Use Of Aspirin, Long Term (Current) Use Of Anticoagulants, Paroxysmal Atrial Fibrillation, Chronic Kidney Disease, Unspecified Protein-Calorie Malnutrition, Pulmonary Fibrosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Gastro-Esophageal Reflux Disease Without Esophagitis, Chronic Obstructive Pulmonary Disease R41's MDS (Minimum Data Set) from 02/05/26 documents in part, R41 is cognitively intact, is dependent on staff for all self-care activities except eating and oral hygiene and is dependent on staff for mobility. R41's MDS indicates he is frequently incontinent and always incontinent of bowel. R41's MDS also indicates he is at risk of developing pressure ulcers/injuries, has Moisture Associated Skin Damage (e.g. incontinence-associated dermatitis, perspiration, drainage) and skin/ulcer treatments include pressure reducing device for bed. R41's Wound Chart Details dated 02/20/26 documents to left posterior thigh dermatitis (10x6x0.1) partial thickness and Moisture-Associated Skin Damage to the left posterior thigh is present, noted with denuded skin, dermis. R41's Order Summary Report dated 02/24/26 documents in part, Low Air Loss Mattress every shift for prevention ensure setting are set to patients' weight or set per manufacturer's instructions dated 11/06/24. R41's Weight Summary printed 02/24/26 documents in part, (02/07/26) 239.6 pounds, (01/06/26) 240.6 pounds, (12/01/25) 242.2 pounds.

Based on observation, interview, record review, the facility failed to follow their policy to (a) properly date / label multi dose inhalers and nasal sprays after opening, (b) properly discard multi-dose inhalers and nasal sprays, (c) medications were separated from juices or other refreshments in the refrigerator. These failures could potentially affect all residents residing on 5th floor reviewed for medication storage and labeling in two of four medication carts and one of two medication storage rooms. The findings include:On 2/24/26 at 10:15AM 6th floor team 2 cart inspected with V21 (LPN / Licensed Practical Nurse) and found R104's multi dose fluticasone nasal spray opened with no date. On 2/24/26 at 10:21AM 6th floor medication storage room inspected with V21 (LPN). Inside the refrigerator with medications such as insulin pens, insulin vials, Trulicity injection, Prevnar injection. Observed inside the same refrigerator with 1 can of ginger ale, cranberry juice, Glucerna and protein supplement mixed with multiple refrigerated medications. On 2/24/26 at 11:59AM 5th floor Team 2 medication cart inspected with V23 (RN / Registered Nurse) and found the following: R108's multidose Fluticasone nasal spray date opened 8/10/25. R98's multi dose Albuterol sulfate inhaler 90mcg with open date on 8/10/25. R84's multidose Albuterol sulfate 90mcg inhaler opened with no date.On 2/26/26 At 10:10 V27 (Pharmacist) stated multi dose nasal sprays and inhalers preferably should be dated once opened. He stated there should be a specific refrigerator for food / drinks separated from medications. If food / drinks are mixed with medications potentially it could spill and cause damage to the medications so it should be in 2 separate fridges. On 2/26/26 At 11:14AM V2 (DON / Director of Nursing) stated nurses are expected to label date once medication was opened and label use by or expiration date to make sure medication is still effective as it could possibly decrease effectiveness if beyond use by date. V2 stated Nasal sprays and inhalers usually are good / effective for 28 days once opened. She stated after 28 days it should be discarded and reordered to the pharmacy. V2 stated potentially effectiveness is decrease if use after 28 days after opening. She stated best practice if refrigerated medications and food / drinks are separated. V2 said if refrigerated medications, soda / juice, supplements are mixed in the same refrigerator it is okay, there is no harm. She stated 5th floor refrigerator in the medication room is used for all residents residing on the 5th floor. Facility's census dated 2/24/26 shows 50 residents residing in the 5th floor.Facility's Pharmacy Policies and Procedures Manual dated 5/1/18 shows in part: Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating.

F700Based on observation, interview and record review, the facility failed to follow their policy to obtain informed consent and physician's order for the use of bed rails. These failures could potentially affect four (R32, R47, R80 and R129) residents reviewed for Accidents in a sample of 35. The findings include:R32's face sheet shows admission date on 12/10/21 with diagnoses not limited to Essential (primary) hypertension, Type 2 diabetes mellitus, Hyperlipidemia, Iron deficiency anemia, Bipolar disorder, Anxiety disorder, Atherosclerotic heart disease of native coronary artery, Irritable bowel syndrome, Cervicalgia, Unspecified osteoarthritis, Extrapyramidal and movement disorder. MDS (Minimum Data Set) dated 1/22/26 shows R32's cognition was intact.R47's face sheet shows admission date on 9/16/20 with diagnoses not limited to Polyneuropathy, Hyperlipidemia, Low back pain, Major depressive disorder, Bilateral primary osteoarthritis of knee, Anemia, Generalized anxiety disorder. MDS dated [DATE] shows R47 with severe cognitive impairment.R80's face sheet shows admission date on 4/28/23 with diagnoses not limited to Presence of other vascular implants and grafts, Hypospadias, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Chronic embolism and thrombosis of unspecified deep veins of right lower extremity, Dysphagia following cerebral infarction, Ataxia following cerebral infarction, Aphasia following cerebral infarction, Essential (primary) hypertension, Encounter for attention to gastrostomy, Atherosclerotic heart disease of native coronary artery, Peptic ulcer, Anemia, Unspecified convulsions, Hyperlipidemia. MDS dated [DATE] shows R48 was rarely / never understood.R129's face sheet shows admission date on 11/21/19 with diagnoses not limited to Epilepsy, Epilepticus, Other idiopathic peripheral autonomic neuropathy, Hypothyroidism, Schizoaffective disorder, Bipolar disorder, anxiety disorder. MDS dated [DATE] shows R129 with severe cognitive impairment.On 2/24/26 At 11:09AM R129 observed resting in bed with both upper bed rails up, alert and verbally responsive. She said she cannot walk.On 2/24/26 at 11:18AM Observed R32 sitting on the side of the bed, alert and verbally responsive. Observed right upper bed rail was up. He said his right upper bed rail is always up. On 2/24/26 At 11:26am Observed R47 resting in bed, alert and verbally responsive. Stated he has been residing in the facility for 6 years and he prefers to stay in bed most of the time. Observed both upper half bed rails were up. He said his bed rails are always up. On 2/24/26 at 11:30AM R80 observed resting in bed, on moderate high back rest with carrot device on right hand. R80 is non-verbal. Observed both upper bed rails were up. On 2/25/26 at 9:54AM R47 observed resting in bed, both upper half rails were up. On 2/25/26 at 10:02AM Observed R32 resting in bed, right upper rail was up. On 2/26/26 At 9:51AM V26 (Restorative Director, LPN / Licensed Practical Nurse) stated bed rails use should be assessed upon admission, quarterly and as needed. She stated bed rails could be full length or upper halves. V26 stated bedrails are used to help residents enable bed mobility, make lesser assistance with bed mobility. She stated informed consent is needed prior to use of bed rails and discuss regarding the use. V26 stated informed consent is kept electronically in resident's health record. She stated there should be a Physician order for bed rail use. Reviewed EHR (Electronic Health Record) of the following residents with V26 and stated: R32's Side Rail Evaluation dated 1/22/26 showed Side Rail(s) are not indicated at this time. V26 stated there is no physician order for bed rail use found in the R32's EHR. R47's Side Rail Evaluation dated 2/25/26 showed Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. V26 stated there is no informed consent and no physician order found for bed rails use in R47's EHR. R80's Side Rail Evaluation dated 2/25/26 showed Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. V26 stated there is no informed consent and no physician order found for bed rails use in R80's EHR.R129's Side Rail Evaluation dated 2/25/26 showed Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. V26 stated there is no physician order found for bed rails use in R129's EHR. There was informed consent for bed rail use in R129's EHR.On 2/26/26 At 11:14AM V2 (DON / Director of Nursing) stated she has been working in the facility for 7 weeks. Stated bedrails are used for mobility bars. V2 stated there should be an assessment to see if residents are appropriate or not for bed rail use. She stated if bedrails are not recommended upon assessment could potentially cause entrapment to the residents. V2 said, I don't know what else is expected with regards to bedrail use. She stated Restorative follows up after assessment. V2 said, it is not my department.Reviewed R32's Side Rail Evaluation dated 1/22/26 shows in part: Side Rail(s) are not indicated at this time. No informed consent and no physician order for bed rails use documented in R32's EHR. Reviewed R47's Side Rail Evaluation dated 2/25/26 shows in part: Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. No informed consent and no physician order for bed rails use documented in R47's EHR. Reviewed R80's Side Rail Evaluation dated 2/25/26 shows in part: Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. No informed consent and no physician order for bed rails use documented in R80's EHR.Reviewed R129's Side Rail Evaluation dated 2/25/26 shows in part: Side Rail(s) Indicated to Promote Mobility and Independence. Two Side Half Rails Indicated as an enabler. No informed consent and no physician order for bed rails use documented in R129's EHR.Care plan dated 4/4/23 shows in part: R47 requires use of Non-Restrictive Side Rail(s) to enhance/enable and/or maintain functional bed mobility independence and promote skin integrity. R47 is enabled to become more self-sufficient in: Positioning and Turning. In Bed Mobility (Movement and getting up from the bed).Care plan dated 3/7/22 shows in part: R80 requires use of Non-Restrictive Side Rail(s) to enhance/enable and/or maintain functional bed mobility independence and promote skin integrity. R80 is enabled to become more self-sufficient in: Positioning and Turning. In Bed Mobility (Movement and getting up from the bed).Care plan dated 10/21/21 shows in part: R129 requires use of Non-Restrictive Side Rail(s) to enhance/enable and/or maintain functional bed mobility independence and promote skin integrity. R129 is enabled to become more self-sufficient in: Positioning and Turning. In Bed Mobility (Movement and getting up from the bed).Facility's proper use of bed rails policy dated 10/7/25 read in part: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.

Based on observations, interviews and record reviews, the facility failed to provide feeding assistance as order by the physician for one resident (R15) with aspiration and swallowing precautions, and failed to follow their policy and procedure to ensure smoking materials were kept secured and out of residents' reach when unsupervised for four residents (R55, R118, R149, R162) out of a total sample of 35 residents.Findings Include: R15's diagnosis includes but is not limited to Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Dysphagia, Cachexia, Adult Failure to Thrive, Unspecified Dementia, Esophageal Obstruction, Gastro-Esophageal Reflux Disease Without Esophagitis, Wernicke's Encephalopathy, Alcohol Abuse. R15's Speech Therapy Discharge summary dated [DATE] – 05/21/25 documents in part: recommended one-to-one pleasure feeding of puree/thin liquids via tsp (teaspoon) and Compensatory Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: alternation of liquid/solids, rate modification, no straws, bolus size modifications and general swallow techniques/precautions , along with the following maneuvers: upright posture during meals and upright posture for >30 mins after meals. pleasure feeding only. R15's Order Summary Report documents in part dietary orders for mechanical soft texture, thin liquids consistency. Slow rate, small bites, upright position and for 30 min after intake, liquids by spoon, check for pocketing, feeder have to request apple sauce /ice cream, stop feeding if decrease alertness (signs and symptoms) of aspiration related to Esophageal Obstruction order date 10/09/25. R15's Order Summary Report also had a separate order for Speech Therapy Recommendation dated 05/16/26 which documents in part, Resident is pleasure feed only, puree tsp (teaspoon) and thin liquids tsp (teaspoon), must have feeder/one to one supervision, feeder must request applesauce /ice cream from the kitchen, tray will not be provided. Please perform(ed) oral care prior to feeding. Please stop feeding if decreased alertness, increased s/s (signs or symptoms) of aspiration, occur and inform SLP (Speech Language Pathologist). R15's MDS (Minimum Data Set) assessment dated [DATE] documents in part R15 has severe cognition impairment and requires partial/moderate assistance with eating. R15's Care Plan Report documents in part (R15) requires assistance at meals and (my) diet has been altered due to dysphagia. On 02/24/26 at 12:55 PM, observed R15 feeding himself in his room. R15 was feeding self quickly and was coughing intermittently. Observed R15's meal ticket which read mechanical soft, ground, thin liquids. Instructions on meal ticket read slow rate, small bites, upright position and for 30 minutes after intake, liquids by spoon, check for pocketing, feeding have to request apple sauce/ice cream, stop feeding if decrease alertness s/s of aspiration. There was no staff in R15's room present while he was feeding himself. Juice was served in a cup. On 02/24/26 at 12:58 PM, V9 (Licensed Practical Nurse) observed R15 feeding himself from the hallway and stated R15 is allowed to feed himself. V9 said, he's okay like that. He does not need to be fed. He only gets assistance with set up and then he feeds himself his meal. On 02/24/26 at 1:06 PM, observed R15 in room lying down in his bed. The head of R15's bed was slightly elevated (appeared to be less than 45 degrees). R15's meal tray was still in his room on his bedside table. R15 had consumed 100% of the main entrée, 0% of the vegetables, 100% dessert and 100% juice (cup was empty). On 02/25/26 at 2:19 PM, V16 (Speech Language Pathologist/SLP) stated she has been working at the facility for eight months and was not the SLP who did R15's evaluation. V16 stated some residents require specific feeding guidelines which are recommended to keep the residents safe to reduce their risk of aspiration, pneumonia and/or choking. V16 stated aspiration is when food or drinks enter the lung instead of going into the esophagus and this can cause infection if the resident is not able to clear it from their lungs. V16 stated the safe feeding guidelines are specific to the residents depending on their needs. V16 reviewed R15's Speech Therapy Discharge summary dated [DATE] – 05/21/25 and R15's physician orders. V16 stated those safe feeding guidelines were put into place to prevent R15 from aspirating and based on the Speech Pathology recommendations and physician order R15 requires one to one feeding and should not eat in his room by himself. V16 stated all liquids should be given to R15 by spoon only and R15 should stay upright for 30 minutes after eating; not allowed to lie down in bed. V16 stated the tray notes on R15's meal ticket are there for the staff to serve as a reminder, so the staff knows what to do when feeding him. V16 stated the potential problem if R15 is not being fed by staff and if the feeding guidelines are not followed is it puts R15 at higher risk for aspiration and/or choking. On 02/26/26 at 10:14 AM, V24 (Registered Dietitian) read R15's diet order in R15's EHR (Electronic Health Record) and stated based on the physician order R15 should be fed by a staff member so that he does not choke or aspirate. Survey team requested facility policies on Feeding Assistance and/or Feeding Supervision. V1 (Administrator) stated the facility does not have such policies and provided policy titled Activities of Daily Living (ADLs) with revised dated 01/15/26. This ADL policy did not address residents who require one-to-one feeding assistance with aspiration or swallowing precautions. On 2/24/26 at 10:58 AM, R162 stated she's been residing in the facility for a little over one year and is a smoker. R162 stated she keeps her cigarettes and one lighter locked in her drawer. R162 further stated she goes to the smoking tent to smoke and that staff meet the smokers there and supervise them. On 2/24/26 at 2:10 PM, R118 stated he sometimes smokes. R118 showed surveyor a pack of cigarettes stored in his drawer. On 2/24/26 at 2:13 PM, surveyor observed R162 lying in bed. R162 stated she had just returned from a smoke break. R162 showed surveyor a lighter in her pocket and packs of cigarettes under her pillow. On 2/24/26 at 2:16 PM, R55's sitting on the side of his bed. R55 stated he's been in the facility for two years and is a smoker. Surveyor observed one lighter on R55's nightstand. R55 stated staff store his cigarettes; however, he keeps his lighter with him. On 2/25/26 at 1:47 PM, V13 (Social Services) stated that social workers complete a smoking assessment upon admission, quarterly, and as needed to determine whether a resident smokes independently or requires supervision. Staff document the assessment in the electronic medical record and care plan smoking residents accordingly. V13 stated the facility does not allow residents to keep smoking materials with them, especially residents who require supervision. V13 stated cigarette monitors maintain possession of all smoking materials for safety and distribute them to residents during scheduled smoke breaks. The monitors light cigarettes for residents and do not allow residents to keep lighters to prevent fire hazards. V13 stated that in the past, residents smoked in their rooms, and the facility implemented procedures to prevent this practice for safety reasons. V13 further stated that Social Services coordinates with CNAs (Certified Nursing Assistants) and nursing staff to conduct daily sweeps and confiscate smoking materials if residents keep them in their possession. Surveyor notified V13 of residents on the sixth floor keeping their own smoking materials unsupervised. R55's annual Smoking Safety Screen dated 1/22/26 indicates R55 has cognitive loss and needs facility staff to store lighter and cigarettes. It also indicates that R55 is not a safe smoker and requires supervision. R118's quarterly Smoking Safety Screen dated 12/5/25 indicates R118 needs facility staff to store lighter and cigarettes. It also indicates that R118 is not a safe smoker and requires supervision. R162's quarterly Smoking Safety Screen dated 2/23/26 indicates R162 needs facility staff to store lighter and cigarettes. It also indicates that R162 is safe to smoke with supervision. The facility's Smoking Policy – Residents, Staff and Visitors (10/14/25) reads in part: This facility shall establish and maintain safe smoking practices. Residents are not permitted to give smoking articles to other residents. Designated staff will store the facility provided lighting device in a secured location. Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. R149's face sheet shows admission date on 6/26/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Personal history of other mental and behavioral disorders, Essential (primary) hypertension, Hyperlipidemia, Paranoid schizophrenia, Bipolar disorder, Unspecified osteoarthritis, Atherosclerotic heart disease of native coronary artery, Gastro-esophageal reflux disease, Polyneuropathy, Extrapyramidal and movement disorder, Nicotine dependence cigarettes, other seizures. MDS (Minimum Data Set) dated 1/6/26 shows R149's cognition was moderately impaired. On 2/25/2026 At 10:05AM Observed R149 sitting up on wheelchair, alert and verbally responsive, holding 4 cigarette sticks on his left hand. He said he is a smoker, and he is keeping his own cigarettes. Care plan dated 9/18/25 read in part: R149 is a smoker. Instruct R149 about the facility policy on smoking: safety concerns. At 11:14AM V2 (DON / Director of Nursing) stated she has been working in the facility for 7 weeks. Stated residents are encouraged not to hold cigarettes for their safety. She said if cigarettes are in their possession, potentially they could use it and if there is a resident using oxygen, it is not safe.

Based on interview and record review, the facility failed to ensure advance directive or code status is consistent with the comprehensive care plan of one (R10) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted he is cognitively intact. R10's Electronic Medical Record (EMR) noted he was admitted to the facility on [DATE]. He is [AGE] years old with diagnoses not limited to chronic viral hepatitis C, spinal stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle, type 2 diabetes mellitus with other circulatory complications. Physician Order Sheet active/POS as of [DATE] noted Do Not Resuscitate/DNR dated [DATE]. On [DATE] at 2:22 PM, V31 (Social Worker) stated she has been in the facility for one year, she oversees the advanced directives care plan, and R10 has an order for a DNR code status upon admission dated [DATE] on file. She also stated that the comprehensive care plan should be consistent and reflect the actual DNR code status of R10 to prevent conflict of care, and inappropriate intervention in case of emergency. Surveyor with V31 reviewed R10' care plan documented that he is on a full code status. R10's DNR Form signed and dated [DATE] documents in part; No CPR: Do not attempt resuscitation. R10's Advance Directives Care Plan initiated [DATE] documents in part, focus; resident has an advance directive as evidenced by: Full Code and with goal last revision dated [DATE], R10's wishes will be honored. Comprehensive Care Plan Policy dated [DATE], documents read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights.Advance Directives Policy dated 12/2024, documents in part; The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) re-assessments were completed upon expiration for two (R97, R162) out of nine residents reviewed for PASRR compliance in a total sample of 35 residents. Findings Include: R162's face sheet documents an original admission date of 7/9/24 with diagnoses not limited to Other Psychotic Disorder and Major Depressive Disorder. Review of R162's Notice of PASRR Level II Outcome dated 10/26/25 indicates a short-term approval without specialized services, with an approval end date of 1/25/26. The notice states the short-term approval allowed a limited number of days in a Medicaid-certified nursing facility and required submission of a new Level I screen to Maximus no later than 10 days prior to the short-term approval end date if continued stay was needed. The facility failed to provide documentation that staff completed or initiated a new Level I PASRR screening prior to the expiration date of 1/25/26 for R162. R97's electronic health records (EHR) indicate R97 was admitted to the facility on [DATE] with diagnosis including but not limited to Anxiety Disorder, Unspecified Psychosis Not Due To a Substance Or Known, Physiological Condition, Major Depressive Disorder. R97's Order Summary Report dated 02/26/26 includes but not limited to Venlafaxine HCl 75 mg and 150 mg for depression related to Major Depressive Disorder order date 03/07/25. R97's MDS (Minimum Data Set) dated 02/12/26 documents in part, R97's active diagnoses include but not limited to Psychiatric/Mood Disorder including anxiety disorder, depression and psychotic disorder. R97's PASRR Outcome Explanation dated 10/27/25 documents in part, you are approved for short term nursing facility services and this determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen to Maximus. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. R97's Notice of PASRR Level II Outcome dated 10/27/25 documents in part: PASRR Determination: Short Term Approval without Specialized Services and Date Short Term Approval Ends: January 25, 2026. On 02/25/26 at 1:13 PM, V13 (Social Services) stated the purpose of PASRR is to determine if the resident is appropriate to live in a nursing home setting. V13 stated PASRR level I screens are done prior to the residents being admitted to the facility to make sure they are appropriate to live in a nursing home setting like ours. V13 stated a PASRR level II screen is required if the resident has a severe mental illness or intellectual disability to see if they need any additional services. V13 stated sometimes residents get short term approval on their PASRR level II screen and when this happens, they need to be re-evaluated on or before the approval date ends to determine if the resident is still appropriate to live in the nursing home setting and/or if they require any special services. V13 reviewed R97's Notice of PASRR Level II Outcome completed 10/27/25 and stated on or before January 25, 2026, R97 should have been rescreened to make sure he is still appropriate to live in the facility without specialized services. Facility provided document titled, Resident Assessment – Coordination with PASARR Program dated 2025 which documents in part, this facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for one (R13) resident out of eight residents reviewed for comprehensive care plan in a total sample of thirty-five. Findings Include: R13's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R13's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to chronic systolic congestive heart failure, unspecified asthma, chronic obstructive pulmonary disease, type 2 diabetes mellitus with unspecified complications. Physician Order Sheet (POS) active order as of 02/25/26 noted isolation; contact precautions related to Extended-Spectrum Beta Lactamase/ESBL from 02/14/26 until 02/28/26. On 02/25/26 at 12:09 PM, observed contact isolation sign on R13's door. R13 stated she has been on contact isolation for few days. On 02/25/26 at 2:42 PM, V2 (Director of Nursing/DON) stated she joined the facility in January 2026, and it is her expectation that a person-centered care plan for contact isolation is developed and implemented for R13. V2 stated a comprehensive care plan is necessary for R13 because ideally it is one of the ways transmissions of infection can be prevented. Surveyor and V2 reviewed R13's comprehensive care plan with no documentation of contact isolation. Comprehensive Care Plan Policy dated 3/1/25, documents read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.

Based on observation, interview and record review the facility failed to obtain physician orders for oxygen administration and to place oxygen in use signage on the door of one (R75) resident out of two residents reviewed for respiratory care in a sample of 35.Findings include:On 02/24/26 at 11:45 AM, observed R75 lying in bed wearing a nasal cannula with oxygen infusing. R75 appeared to be sleeping. R75's oxygen concentrator was set at five liters per minute. R75's oxygen tubing and humidifier bottle was dated 02/22/26.On 02/24/26 at 11:46 AM, R75 did not have an oxygen in use sign or no smoking sign posted in or outside his room.On 02/24/26 at 3:12 PM, V10 (Licensed Practical Nurse) stated R75 is receiving continuous oxygen via nasal cannula and the oxygen infusion rate is part of the physician order. V10 stated the infusion rate is usually set between two-three liters per minute but that R75 turns the rate up on his own and the staff turns it back down to the appropriate rate. V10 viewed R75 electronic health record orders and stated she does not see any orders for oxygen. V10 stated R75 should have physician orders for oxygen since R75 has been receiving it. V10 stated R75 requires oxygen because he has Chronic Obstructive Pulmonary Disease.On 02/24/26 at 3:15 PM, V10 observed the outside of R75's door and stated there should be an oxygen in use sign posted outside R75's door so that everyone is aware as a precaution to make sure oxygen does not come in contact with flames or smoke.On 02/25/26 at 1:48 PM, V2 (Director of Nursing) stated when a resident is on oxygen there should be a sign posted outside the door to alert people that oxygen is in use. V2 stated the purpose of the sign is for safety to prevent any flammable items coming in contact with oxygen because this could cause a fire. V2 stated if a resident is receiving oxygen they should have an order for oxygen. V2 stated the oxygen order should specify the rate, method of administration, and how often it is administered. V2 stated it was an oversight that R75 did not have an order for oxygen administration, he should have had an order.R75's diagnosis includes but not limited to Acute and Chronic Respiratory Failure With Hypoxia, Acute Pulmonary Edema, Chronic Obstructive Pulmonary Disease, Personal History Of Nicotine Dependence.R75's MDS (Minimum Data Set) dated 02/03/26 indicates R75 requires oxygen therapy while a resident.R75's Order Summary Report viewed on 02/24/26 at 3:15 PM does not include a physician order for oxygen therapy.Facility provided policy titled, Oxygen Administration dated 01/07/25 which documents in part, oxygen is administered under orders of a physician, except in the case of an emergency and oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.

F759Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for two (R23 and R164) of four residents reviewed for medication administration. There were 39 opportunities and 4 errors resulting in a 10.26% medication error rate. The findings include:On 2/24/26 at 9:18AM Medication administration observation conducted with V8 (Licensed Practical Nurse / LPN). Observed V8 (LPN) prepared the following medications for R164:Acidophilus with pectin 1 capsule Magnesium oxide 400MG 1 tablet.Senna plus 8.6 2 tabletsFerrous sulfate 325MG 1 tablet.Amantadine 100MG 1 capsuleGlipizide 2.5mg 1 tabletEzetimibe10mg 1 tablet Venlafaxine 37.5mg 1 capsuleMetoprolol 100mg 1 tabletMedications were counted in the medication cup with V8 and stated there were 10 medicines in the medication cup. Observed V8 administered prepared medications to R164 and taken by mouth.Reviewed R164's POS (Physician Order Sheet and MAR (Medication Administration Record) and shows order not limited to: Acidophilus with pectin 1capsule by mouth three times a day at 9am, 1pm, 5pmMagnesium oxide 400mg 1 tablet by mouth two times a day at 9am and 5pm.Senna plus 8.6 2 tablets by mouth two times a day at 9am and 5pm.Ferrous sulfate 325mg 1 tab by mouth two times a day at 9am and 5pm.Amantadine 100mg 1 capsule by mouth two times a day at 9am and 5pm.Glipizide 2.5mg 1 tablet by mouth one time a day at 9amEzetimibe10mg 1 tablet by mouth one time a day at 9amVenlafaxine 37.5mg 1 capsule by mouth every 12 hours at 9am and 9pm.Metoprolol 100mg 1 tablet by mouth every morning and at bedtime at 9am and 8pm. Olanzapine Oral Tablet 5 MG (Olanzapine) Give 0.5 tablet by mouth two times a day at 9am and 9pm. Risperdal Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth two times a day at 9am and 9pm.Olanzapine and Risperdal medications were not given or administered to R164 during medication observation with V8 (LPN).On 2/24/26 at 9:52AM Medication administration observation conducted with V9 (LPN) and prepared the following medications for R23:Abiraterone 250mg 1 tabletVitamin c 500mg 1 tabletVitamin d 25mcg 1000iu 1 tabletVitamin b12 1000mcg 1 tablet daily Escitalopram 10mg 1 tabletFerrous sulfate 325mg 1 tabletOyster shell calcium 500mg 1 tabletTamsulosin 0.4mg 1 capsuleThiamine vitamin B1 100mg 1 tabletZinc 50mg 1 tabletPrednisone 5mg 1 tabletIbuprofen 600mg 1 tablet due to R23's complaint of left knee pain.V9 (LPN) stated folic acid and Xarelto were not available.Observed V9 (LPN) administered prepared medications to R23 and were taken orally. Reviewed R23's POS and MAR and shows order not limited to:Abiraterone 250mg 1 tablet daily at 9amVitamin c 500mg 1 tablet daily at 9amVitamin d 25mcg 1000iu 1 tablet daily at 9amVitamin b12 1000mcg 1 tablet daily at 9amEscitalopram 10mg 1 tablet daily at 9amFerrous sulfate 325mg 1 tablet two times a day at 9am and 5pmOyster shell calcium 500mg 1 tablet two times a day at 9am and 5pmTamsulosin 0.4mg 1 capsule daily at 9amThiamine vitamin b1 100mg 1 tablet daily at 9am Zinc 50mg 1 tablet two times a day at 9am and 5pmPrednisone 5mg 1 tablet two times a day at 9am and 5pmIBU Oral Tablet 600 MG (Ibuprofen) Give 600 mg by mouth every 8 hours as needed for painFolic Acid Oral Tablet 800 MCG (Folic Acid) Give 1 tablet by mouth one time a day at 9amXarelto Oral Tablet 10 MG (Rivaroxaban) Give 1 tablet by mouth one time a day at 9am.Folic acid and Xarelto medications were not given to R23 during medication observation with V9 (LPN).On 2/26/26 At 11:14AM V2 (DON / Director of Nursing) stated she has been working in the facility for 7 weeks. She stated nurses are expected to follow the 5R's (right resident, route, medication, dose, time) in giving medications. V2 stated nurses must follow the medication administration record (MAR) or physician order in giving medications to the residents. V2 stated medications ordered by physicians should not be omitted or missed during medication administration. She stated if medication was omitted or missed, it could potentially cause adverse effects to the residents. If residents miss the medication, nurses are expected to call the doctor and should be documented in resident's health record. Reviewed R23's electronic health record, no documentation found that the doctor was notified regarding 2 missed medications (folic acid and Xarelto) observed during medication administration with V9 (LPN). Facility's Medication Administration policy dated 10/20/25 shows in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: Right resident, Right drug, Right dosage, Right route, Right time, Right documentation. Review MAR to identify medication to be administered. Report and document any adverse side effects or refusals.

Based on interview and record review, the facility failed to provide adequate supervision for a resident while at the facility. This failure affected 1(R1) resident out of 5 residents reviewed for supervision. R1 incurred a full thickness burn on his left leg with a surface area of 136.90 cm^2 .Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When V10 saw him (R1) in the dining room, he (V10) said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) could not stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound. He got the wound somewhere upstairs, on the floor.On 09/18/2025 at 3:27pm, V11 (Agency Registered Nurse) stated she remembers that day. She was supposed to leave at 3pm and while she was waiting for the incoming nurse to come, the resident was brought upstairs, and she saw a skin tear behind his leg. V11 said she was thinking the tear happened while he (R1) was downstairs. V11 stated residents move around a lot, she did not know when he (R1) went downstairs and did not know where he (R1) went downstairs, and R1 came back through the elevator. V11 said she did not know what happened and he (R1) is nonverbal. V11 stated his (R1) wound did not happen while he was on the floor. On 09/18/2025 at 12:56pm, V6 (Wound Care Doctor) stated he has been treating him (R1) for a while. V6 stated he talked to (V3-R1's family member) about his wound and the treatment plan and to get consent for the debridement of the wound. On 09/23/2025 at 2:56pm, V6 (Wound Care Doctor) stated it is a serious injury because it is a full thickness burn. All the layers of the skin, including the epidermis, dermis, and subcutaneous tissue are damaged and because of the size of his wound. On 09/22/2025 at 1:03pm, V2 (Director of Nursing) stated she was not notified of R1's injury on 07/29/2025. V2 could not recall V11 notifying her of R1's injury. V2 said if notified, she would need to investigate it, she would need to talk to any witnesses who potentially working with him (R1) before and after the injury was observed, she would be auditing documentation to make sure family and doctor were notified, make sure the nurse reach out to the doctor for a treatment plan and if in place, to make sure the facility is following the treatment plan, do an in service with the nurses to make sure they are doing the right procedure. V2 stated 'Yes', it is required of the facility to report to the State injury of unknown origin or a major injury. V2 said the timeframe for reporting is within 24 hours. Injury of unknown origin should be investigated as an allegation of abuse. There should be an abuse investigation. V2 stated she did not know about R1's injury of unknown origin and there was no investigation done, and it was not reported to the State.On 09/22/2025 at 3:30pm, V19 (New Administrator) stated abuse include injury of unknown origin. The procedure is to report it immediately within 2 hours and to initiate the investigation immediately. Immediately means, as soon as the initial reportable was sent to the State, then she (V19) would start interviewing any party that is involved. V19 said anybody who work with the resident who may have in contact with the resident. The purpose is to see the root cause of this and to rule out abuse. V19 stated she sent the reportable today (09/22/2025). V19 said, It means his (R1) injury of unknown origin was not reported and was not investigated. Yes, it should be reported and investigated because facility didn't know how the resident got the injury, and per policy, it should be reported and investigated. V19 (New Administrator) stated a burn is a serious injury. On 09/23/2025 at 4:04pm, V15 (Assistant Director of Nursing) stated she has been at the facility for 1 1/2 years and she sees him (R1) around. (R1) goes up and down the floor using the elevator and he (R1) never uses the stairs. V15 said the nurses and the CNAs are supposed to supervise R1 while he is on the floor. V15 stated she does not know how and still asking herself how the wound happened. V156 said she is not sure if he is supervised while in the elevator because he (R1) knows where he is going and when to comeback on the floor. V15 stated she wishes she could explain how it happened. V15 stated with an injury like that, somebody should know and should report it. V15 said it is not expected of a resident to be injured at the facility, and no one knew about it and somebody should know. V15 stated if no one knew how the injury happened, he (R1) was not supervised adequately. R1's admission Record documented that R1's diagnoses (include but not limited to) deaf, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure. R1's (08/05/2025) Minimum Data Set documented, in part: Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. R1's (07/29/2025) Progress note documented, in part: Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels. Your facility must be safe.The (undated) Accidents and Supervision documented, in part Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in the sample of nine. R1 suffered a head laceration after being pushed to the floor.Findings include:R1's face sheet documents R1 is a 44 -year-old admitted to the facility on 11.3.2023, with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Diabetes, Convulsions, and chronic kidney disease. R1's MDS (Minimum Data Set of 5.22.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact.R2's face sheet documents R2 is a [AGE] year-old admitted to the facility on 11.15.2024 with diagnoses including but not limited to: Heart Failure, Peripheral Vascular Disease, Violent Behavior, and Non-Rheumatic Aortic Valve Disorder.R2's MDS (Minimum Data Set of 7.29.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact. On 7.29.2025 at 7:27 pm, R1 said, It happened about eight days ago. I finished smoking; I went into the elevator. It wasn't working, I jumped into the other one. I was in the corner. R2 gets on the elevator as well. My rollator was facing the door. R2 was trying to get out on the 2nd floor. He got in front of me. R2 yelled at me, you a*****e get the f***out of the way. R2 pushed my rollator causing me to fall out of the elevator. I fell down. I hit my head. I hurt my head. I had a bump and a little slash on my head. I had to go to the hospital. They called 911. R2 got sent out for psych. There was resident on the elevator who saw everything, I can't remember his name. I think he's on the 4th floor. A nurse saw it too. I feel safe here. I feel staff acted appropriately.On 7.29.2025 at 8:16 PM, R2 said, I did not push R1, my wheelchair hit him. I was trying to get out of the elevator.8.3.2025 at 1:58 PM, R6 said, I was in the elevator with R1 and R2. When the door opened, R2 rammed R1 with R2's wheelchair. R1 fell out of the elevator.8.3.2025 at 3:34 PM, V4 (RN-Registered Nurse/Restorative Nurse) said, I completed a fall assessment for R1. He had a scratch to his head. R1 told me he was pushed by R2, causing R1 to fall out of the elevator onto the floor.8.4.25 at 10:48 AM, V1 (Administrator) said, No one actually saw any shoving going on. R6 said R1 was not pushed. V5 (LPN-Licensed Practical Nurse) said she couldn't say R1 was pushed but did see him fall out of elevator. R1 insisted he was pushed. R2 said he moved R1's walker. He said he told R1 to leave him alone, that R1 was bugging him.8.4.2025 at 2:09 PM, V15 (Social Service) said, R1 was reluctant to say anything. R1 said he was pushed out of the elevator, but he didn't know who did it. R2 was reluctant to say anything. R2 said he didn't do anything. R6 confirmed that R2 did push R1. R6 said R2 took R2's wheelchair and rammed it into R1.8.5.2025 at 2:50 PM via telephone, V5 (LPN-Licensed Practical Nurse) said, I was at the 2nd floor nurses station, when the elevator door opened. I saw R2 push R1 with his hands (R2 was in his wheelchair). R1 landed on the floor with force.Facility's final incident report of 7.25.2025 documents in part, reported to (V1-Administrator) on 7/21/25 at 7:45pm that (V5 LPN-Licensed Practical Nurse) stated (R2) allegedly pushed fellow resident R2 causing him to fall. (R1) was noted on the floor outside of the elevator with a small laceration on his head. Residents were immediately separated and placed on 1:1 supervision. Doctors were contacted and orders were given to send both residents to the hospital for further observation. Laceration was cleaned and covered and head to toe assessment done with no further concerns noted.R1's progress note of 7.21.2025 at 9:04 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, convicted that he was punched and pushed off the elevator by another resident. Resident refused to give any other information concerning the incident. Resident was reassessed per this nurse. Open area noted to the right side of the head, small amount of bleeding with slight swollen noted.R2's progress note of 7.21.2025 at 11:03 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, resident denies that he punched and pushed another resident off the elevator. Resident refused to give any other information concerning the incident. NP (Nurse Practitioner) gave orders to petition resident out to hospital for further evaluation.Abuse Prevention Policy (October 24, 2024) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is 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. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to assess and immediately start CPR (Cardiopulmonary Resuscitation) for resident found unresponsive on the floor for one of one resident (R3) reviewed for CPR in the sample of sample of nine. This failure resulted in R3 being without vital signs and not receiving immediate CPR.Findings include:R3's face sheet documents R3 was a [AGE] year-old admitted to the facility on 9.12.2011, with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, and Hyperlipidemia. R3's Order Summary Report (active orders as of 5.28.2025) documents R3 was a full code.R3's progress note of 5.29.2025 at 7:55 AM, documents in part, at about 6:15 AM, while the writer was passing medication, one of the CNAs notified the writer that resident was on the floor in the bathroom. The writer immediately called out the resident's name but he was not responding well. A code blue was indicated through the receptionist and CPR was started. 911 was called during the CPR the vitals are B/P 113/94, pulse 126, R-22, and the blood sugar is 356mg/dl at the time resident transfer to hospital.R3's death certificate documents cause of death as asthma. The immediate cause of death is complete heart block.On 8.4.2025 at 1:10 PM, via telephone, V14 (Former LPN-Licensed Practical Nurse) said, That day I believe I gave R3 her 6:00 am med. I left the room. After a while, a CNA came to tell me R3 was on the floor. I stopped what I was doing and went to R3. She fell in the shower room. Prior to the fall, she was able to walk, she was up and about on the unit. I went there to assess her. We pulled her out of the shower room because she is a tall lady. We started CPR. We called 911. They (911) took her out. I can't remember what time the CNA came to get me; it was during my morning med pass. The first thing I did was to call her name. She did turn her head but did not talk. She looked pale. I called for help but the CNAs that are working with me were with patients. I called a code blue at the nurses' station then went back to her. I checked her. She was not responding well. I called code blue. Me and my coworker did CPR. I don't remember taking vital signs. I don't remember if my coworker did. Somebody started CPR, not me. (Local fire department) came, they took over, and they took her out. I don't remember what time the CNA got me.On 8.4.25 at 2:29 PM, V2 (DON-Director of Nursing) said, V14 (Former LPN-Licensed Practical Nurse) was terminated for not running a code properly. V14 did not bring crash cart or participate in Code Blue for her assigned resident (R3). The Code Blue was initiated, when the other nurses (V6 LPN-Licensed Practical Nurse/Nurse Supervisor and V10 LPN-Licensed Practical Nurse) came. There was no crash in the room. One of them got it. They also said V14 had not initiated CPR. V14 should have initiated CPR when she determined R3 had coded.8.5.2025 at 11:53 AM, via telephone, V2 said per V12 (HR-Human Resources) there is no CPR card in (Nurse) personnel folder.8.4.2025 at 5:54 PM, via telephone, V6 (LPN-Licensed Practical Nurse/Nurse Supervisor) said, At approximately 6:30 AM, I immediately responded to a code blue. I took the stairs; it took me a couple of minutes to get to the unit. V10 (LPN-Licensed Practical Nurse) was with me. R3 was on the ground. There were some CNAs (Certified Nursing Assistants). I didn't see the crash cart in the room. No one was doing compressions, I just wanted them to start compressions. I told them to start CPR. I never saw V14 do CPR. When someone is found unresponsive, you should assess for airway, breathing, circulation. Compressions should be started immediately to get the heart pumping, to get blood and air circulating.8.5.2025 at 2:27 PM, via telephone, V9 (R3's Physician) said, If the resident is a full code, call 911 and start CPR until 911 arrives. The purpose of starting CPR immediately is to get blood to the brain, to push blood to the brain. Compressions won't restart the heart. CPR is continued until 911 arrives and takes over, they can attempt to re-start the heart by administering medications such as epinephrine and shocking the patient. If CPR isn't started immediately severe anoxic encephalopathy (severe brain damage caused by a complete lack of oxygen) could occur.V10's Witness Statement (5.29.2025) documents, writer heard code blue 5th floor via overhead page. Writer along with housekeeping manager went to 5th floor. Writer along with other nurses assessed resident, no pulse noted, CPR initiated. 911 called by nursing staff. (Local Fire Department) on scene and noted vitals and pulse. Resident transferred to ER (Emergency Room) by (Local Fire Department). V10 (LPN-Licensed Practical Nurse) was not available for interview.V14's employee folder (Employee Action/Discipline of 5.29.2025) documents employee called a code blue on a resident but did not bring over needed materials for code and did not participate in code blue for her own assigned resident.Cardiopulmonary Resuscitation (CPR) policy (undated) documents in part, Procedure: 1. In the event a resident is identified unresponsive and upon a thorough A-B-C (Airway, Breathing, Circulation) assessment determines that there is no pulse or respiratory activity and the resident has declared a full code status, a licensed staff member will: a. Simultaneously with the initiation of chest compressions announce a full code per facility policy and direct a staff member to immediately retrieve the crash cart located on the nursing unit.

Based on interview and record review, the facility failed to ensure that a resident had routine preventative screening for 1 resident (R3) out of 3 residents reviewed for routine screenings. This failure resulted in R3 not receiving recommended annual breast mammograms while residing in the facility, which resulted in R3 being diagnosed with stage 4 breast cancer which metastasized to other parts of her body. Findings Include:R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Neutropenia, malignant neoplasm of unspecified site of right female breast, secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, secondary malignant neoplasm of mediastinum, secondary malignant neoplasm of other specified sites. Minimum Data Set Section (MDS) section C (dated 09/26/2024) documents R3 has an Interview for Mental Status (BIMS) score of 11, indicating that R3 had moderate cognitive impairment. Care plan (dated 09/05/2023) documents that R3 has potential for pain related to Dx of left breast cellulitis, bilateral breast mass and right breast cancer with metastasis to right axilla, retro pectoral, mediastinum, spleen, left axilla and liver. Mammogram Policy (revised February 2025) documents in part: Female residents 55 and younger will have mammogram screenings conducted annually unless otherwise indicated by physician. On 07/16/2025 at 11:03AM, V2 (director of nursing) stated R3 was admitted to the facility 07/15/2004. R3 complained of breast pain on 05/30/2023. R3 was assessed due to complaining of tenderness and pain in the right breast. R3 was seen by the nurse practitioner due to pain in the right breast, on 05/30/2023, the same day she complained. Upon assessment, the nurse on the floor noted the right breast to be bigger than the left breast and hardening of the right breast. On 05/30/2023, the nurse practitioner ordered a breast ultrasound for R3 to be done in the hospital, and a consultation with the oncologist. On 06/27/2023, resident was taken to the hospital for the ultrasound appointment. That same day, the radiologist recommended a CT scan of the chest for further evaluation, which was done the same time as the ultrasound. The CT of the chest showed cancer which metastasized to the spleen, liver and axillary area. When R3's breast cancer was found, it was already spread to other parts of the body. R3 was admitted to the hospital from the appointment due to right breast cellulitis. R3 was seen by the oncologist at the hospital while she was admitted . R3 was receiving weekly chemotherapy treatments. When R3's cancer was found, it was treated right away. The breast exams are performed when a resident complains of pain or tenderness at the breast site. The facility's protocol is to perform breast exams when there is a concern voiced by the resident. According to the facility's policy, residents who are [AGE] years old and younger should have a breast mammogram every year. V2 stated, (R3) had a breast mammogram in 2017, and I don't see any mammograms for R3 after the one she had in 2017. (R3) had mental health co-morbidities and she often refused to be touched, refused examinations a lot of the time, and refused tests. (R3) was verbal and a lot of the times she would state that she was fine and refused assessments and examinations. Residents [AGE] years of age and under should have a routine mammogram every year. The only mammogram for (R3) that there is on record is from 06/07/2017, and (R3) was [AGE] years old at the time. (R3) should have had another mammogram after 2017, however, I cannot find a mammogram for (R3) from 2018. (R3) did not pass away in this facility. (R3) was sent out to the hospital on [DATE] for a mental health evaluation, and she did not return to this facility. I don't know where (R3) discharged to. She was receiving weekly chemotherapy treatments and going to see the oncologist on a regular basis while she resided here. On 07/17/2025 at 10:10AM, V12 (nurse practitioner) stated, The last time I seen R3 was on September 24, 2024. On 05/30/2023 R3 complained of breast pain, tenderness and swelling. I placed an order for antibiotic because the breast was swollen and tender and it was suspicious for mastitis. I also ordered an ultrasound of the breast and I ordered R3 an appointment with an oncologist, because I was suspecting breast cancer based on the presentation of the breast. R3's breast appeared to be tender, red, and swollen and I immediately suspected breast cancer. From then on, the oncologist picked right up, and he planned the treatments for R3, and we followed the oncologist's direction. When I see a change of status, take action right away, so I placed interventions for R3 immediately when her right breast was swollen. I do not believe that R3 had a mammogram prior to her breast being tender. The first mammogram for R3 that I know of was 06/20/2023. R3 should have had an annual breast mammogram prior to 06/20/2023. R3 was supposed to have a routine yearly mammogram. There was a breast mammogram done for R3 back in 2017, and it was negative, and it was recommended for R3 to have a repeat mammogram in 2018. From the records that I am looking at, I do not see a mammogram performed for R3 in 2018. The dangers of not performing routine annual breast mammograms are breast cancer and missed diagnosis. If R3 would have had the routine breast mammograms yearly, we would have caught the breast cancer earlier. R3's Mammography Report (dated 06/07/2017) documents in part: No suspicious masses, calcifications or other abnormalities are seen. Routine follow-up mammogram in 1 year is recommended. R3's Progress Note (dated 05/30/2023) documents, Resident reported having pain in the right breast, upon assessment the right breast was noted to be bigger than the left breast and hard to touch. NP notified and came to assess resident with orders for right breast ultrasound and follow up with Dr. C. at community hospital for further evaluation. R3's Progress Note (dated 05/30/2023) documents, A [AGE] year-old AA female with past medical history listed below was seen and examined today 5/30/2023 due to RN reporting that patient is complaining of tenderness and pain of right breast and to follow up on chronic medical conditions management. Patient is observed to be in the hallway and starts yelling and screaming upon trying to assess the right breast lump. RN and social worker assisted during assessment. Patient is known to be non-compliant with medical regimen despite education. Patient denies fever, chills, cough, sore throat, congestion, hoarseness, shortness of breath, HA, chest pain, abdominal pain, NVDC, burning and tingling during urination, change in bowel habits. All available health notes reviewed. BREAST: Swelling, tenderness, hardness noted on right breast. No redness, bleeding, drainage, and dimpling noted. No swollen and hardened axillary lymph nodes palpated. Limited palpation study due to patient complaining of pain. R3's Hospital Records (dated 06/27/2023) documents in part: R-Mastitis, Non-lactational/R-Breast Malignant Mass with Metastasis. CT-chest/A/P showed metastasis to the LNs (axillary, retro-pectoral, mediastinal) spleen and liver. R3's Progress Note (dated 06/27/2023) documents, Resident went to oncology appointment and was admitted to community hospital with dx of Cellulitis to R Breast/Abscess to R Breast. Resident belongings in room. Medication in cart. Sister made aware. So noted. R3's Progress Note (dated 06/30/2023) documents, Resident is a 58 y/o female alert and oriented x 2. Resident has an admitting dx of right breast cellulitis and right breast malignant mass with metastasis to liver, spleen and axillary. Dx/HX of COPD, DM, Anxiety and OP. Resident is a limited assistance of one staff member for ADLs. Resident is continent of bowel and has occasional incontinence of bladder. Resident is able to ambulate without any assistive device. Resident requires cueing for task. Resident has dressing to right side of breast post biopsy. Resident is noted with appointment to follow up with oncology Wednesday. Resident is currently on Clindamycin 300mg every 8 hours for 7 days and Levaquin 750mg PO daily x 7 days. Resident sister informed of transfer in. Medications verified by MD. Resident is acclimated to room. Belongings brought down to new room. So noted.R3's Death Certificate (dated 02/18/2025) indicates that R3's cause of death as breast cancer with metastasis to brain.

Based on interview and record review the facility failed to ensure one resident (R4) was free from staff to resident physical abuse. This failure affected one resident (R4) in a total sample size of three residents (R1, R2 and R4) reviewed for abuse. This deficient practice resulted in harm for one resident (R4) experiencing physical pain and bruising. Findings include: R4's medical diagnoses include but not limited hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, chronic obstructive pulmonary disease, essential hypertension, contracture right elbow, major depressive disorder, anxiety disorder. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 3, which indicates R4's cognition is severely impaired. R4's physician order dated 11/07/24 documents in part, Behavior: Monitor for itching, picking at skin, restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, depression .Interventions: A. Redirection/Refocus B. Comfort objects .D Remove from situation .F. Offer choices. R4's care plan documents in part, Assessment reveals factors may increase his/her susceptibility to abuse/neglect .R4 will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect) .Assure R4 she is in a safe and secure environment .Provide all interaction and care to R4 with respect, dignity and free of mistreatment. On 11/18/24 at 1:07pm, V29 (R4 family member) stated she was informed by the facility her mom had a bruise on her leg. V29 stated R4 had a purple knot on her right thigh. V29 stated she feels someone from the facility beat her mom's leg. V29 stated she sent R4 back to the hospital two days later because R4 was still complaining of pain to her right leg. R4's hospital report dated 11/10/24 documents in part, Daughter reports the patient is occasionally aggressive and is concerned the nursing staff are hitting R4. R4 has a large bruise on her right thigh .patient with history as stated above presenting to the emergency department for right thigh hematoma and concerns for elder abuse .Diagnoses (Active) Elder abuse, hematoma. On 11/18/24 at 12:34pm, V28 (Certified Nursing Assistant/CNA) stated R4 was very combative when being cleaned and sometimes it took two staff members to clean her. V28 stated one staff member would hold R4 down to prevent R4 from kicking and scratching while the other staff member would clean R4. V28 stated while cleaning and holding R4 down, R4 would tell the staff they are going to jail. On 11/19/24 at 11:55am, V31 (CNA) stated he noticed a tennis size ball size raised purple area on R4's right thigh. V31 stated he had taken care of R4 the day before and the area on R4's right thigh was not there before. On 11/19/24 at 12:15pm V32 (Licensed Practical Nurse/LPN) stated she was informed by V31 of a bruise to R4's thigh. V32 stated she looked at the area and noticed a raised purple area to R4's right thigh. On 11/19/24 at 1:55pm V35 (LPN) stated he examined R4's right thigh and the area was purple and circular with some swelling. V35 stated he can't diagnose but the area reminds him of a hematoma. V35 stated R4 sometimes screams no, no, no when the staff area cleaning her. V35 stated most confused residents say no at the beginning when staff first start cleaning them, but they eventually stop saying no and just allow staff to clean them. On 11/19/24 at 10:55am V4 (Wound Care Coordinator/Nurse Manager) stated, We kind of have to brace her legs down to prevent her (R4) from kicking when we take care of her. On 11/20/24 at 11:50am V2 (Director of Nursing/DON) stated it would be considered abuse if a staff member held a resident down. V2 stated if a resident is saying no to care, then staff should stop caring for the resident and document refusal. Facility's policy dated 10/24/2022 titled, Abuse Prevention Policy documents in part, This facility, Uptown Care and Rehabilitation, affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment .This will be done by: .orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property .establishing an environment promotes resident sensitivity, resident security and prevention of mistreatment .assuring physical restraints are used sparingly and properly .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The term willful in the definition of abuse means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. Facility's undated job description titled Certified Nursing Assistant documents in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents .Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements, including JCAHO standards, when applicable. Facility's undated policy titled Statement of Resident's Rights documents in part, Each resident shall have the right to be free from verbal, sexual, mental, or physical abuse: free from corporal punishment and involuntary seclusion: and free from chemical and physical restraints, except those restraints authorized in accordance with applicable federal and state laws and regulations.

Based on interview and record review, the facility failed to follow the Care Plan and failed to provide adequate supervision to one resident (R1) who was assessed as a high fall risk which resulted in multiple falls for one resident (R1) reviewed for resident injury, demonstrating inadequate care. This failure resulted in R1 falling on 10/12/2024 and sustaining a head injury which required R1 to be sent to the hospital where R1 received 3 staples to close the laceration to R1's head and again falling on 11/05/2024 which required R1 to be sent to the hospital for evaluation and testing. Findings include: R1's hospital records, dated 10/12/2024, documents, in part, . [AGE] year-old male . brought in by EMS (Emergency Medical Services) for unwitnessed fall at the facility . The wound was irrigated copiously with normal saline or sterile water . Staples were placed using a surgical stapler with approximation of the wound edges. R1's hospital records, dated 11/05/2024, documents, in part, . [AGE] year-old male . brought in by EMS (Emergency Medical Services) for unwitnessed fall at the facility. Facility presented document listing R1's falls for the past year showing that R1 has had 6 falls within the past year. R1 had falls on 4/15/24 at 5:04AM, 6/5/24 at 12:30AM, 10/2/24 at 7:45AM, 10/8/24 at 2:00AM, 10/12/24 at 10:15AM and 11/5/24 at 7:32PM. On 11/18/24 at 1:35pm, with V8 (Activity Aide) interpreting for R1 due to R1's primary language being Spanish, R1 stated, I (R1) fell the day I was sent to the hospital (10/12/24) because I (R1) was trying to get up from the bed. Yes, the call light was by me. I (R1) don't need the call light. I (R1) can do for myself. I'm (R1) fine. They (staff) just need to let me be. R1's Face Sheet, documents, in part, that R1's diagnoses include unspecified lack of coordination; unsteadiness on feet; chronic obstructive pulmonary disease, unspecified; type 2 diabetes mellitus without complications; schizoaffective disorder, bipolar type; anxiety disorder, unspecified; bipolar disorder, unspecified; laceration without foreign body of scalp, subsequent encounter. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, R1's Brief Interview for Mental Status (BIMS) score is 03 which indicates R1's cognition is severely impaired. R1's Functional Status, shows R1 requires Substantial/Maximal Assistance for Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R1 requires Substantial/Maximal Assistance to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. R1's Fall Risk Assessment, dated 10/11/24, documents, in part, a score of 55 which is the category of High Risk for Falling with a history of previous falls. R1's Care Plan, date Initiated: 08/23/2019; revision on: 10/26/2024, documents, in part, FALLS: (R1) is at risk for falls r/t (related to) weakness . Resident is an extensive assistance of one staff member for transfer, bed mobility and toileting. Resident is supervision with set up for meals. Resident has functional incontinence of bowel and bladder. Resident ambulates with walker with slow and somewhat steady gait with staff for a short distance. Resident requires rest periods to complete task. Resident utilizes wheelchair as primary mode of transportation. Resident requires cueing for all tasks. Poor safety awareness present. Impulsive behavior presents with unknown cause. close monitoring needed. Care Plan interventions, documents, in part, Move closer to nurse's station. One on One monitoring d/t impulse poor safety awareness behavior. On 11/19/24 at 11:06am, V9 (Restorative Nurse/License Practical Nurse/LPN) said, I (V9) am the fall nurse . pretty much. Yes, I'm familiar with (R1). (R1) has been here for a while. First (R1) came and walked by himself (without assistance). Then he had to use a walker. Then he had to use the wheelchair. So, we're (staff) trying to get him (R1) walking using the walker and then without any assistive device. R1 is on monitoring, close monitoring, monitoring when engaging in activities. Everything is in his (R1) Care Plan. (R1's) bed is by the nurse's station for close monitoring too. (R1) mental status varies. He (R1) knows where he's at. He (R1) always knows when its Sunday and mealtime. Sometimes he knows where he's (R1) at. He (R1) knows familiar faces. That's pretty much how he's (R1) been since he's been here. On 11/19/24 at 12:02pm, V7 (License Practical Nurse/LPN) said, I (V7) had (R1) a few times. I (V7) on October 12th. After passing meds, we (staff) heard a sound from (R1's) room. We ran to the room and seen (R1) on floor on right side. Noticed skin alteration on head . R1 is a pretty confused man. We asked him, but sometimes he's hard to understand. On 11/19/24 at 2:28pm, V7 said, One on one monitoring is when we have a CNA (certified nursing assistant) scheduled for a patient that is fully observed and attends to every needs of a resident . The one on one observed is with the resident at all times . On October 12th, (R1's) room was close to nurse's station . I (V7) would say no, he (R1) was not receiving one on one monitoring. On 11/19/24 at 1:04pm, V16 (License Practical Nurse/LPN) said, He (R1) was my resident for a while. I (V16) worked October 12th when (R1) fell . I (V16) did work but I (V16) was not assigned to him (R1). I (V16) was at the nurse's station, heard a sound close to (R1's) room, ran to room, and seen (R1) on floor with bleeding from his head. We (staff) called an ambulance and sent him (R1) to the hospital. People are prone to fall. He's (R1) forgettable sometimes and forgets to pull call light. On 1/19/24 at 2:15pm, V34 (Nurse Practitioner) said, I'm pretty familiar with him (R1). Been taking care of him for the past 2 years. What I (V34) see in a lot of patients is steady decline. They (patients) don't understand that they're (patients) declining. During that transitional phase, they (patients) either forget or are noncompliant. I (V34) believe that (R1) is going through that right now. We (staff) have to do constant reminders and remind him (R1) to let him (R1) know that he (R1) needs assistance. He's (R1) one person assist. I (V34) wouldn't go for letting him (R1) walk by himself even with a walker. I (V34) do consider sutures serious and harmful to someone especially to the head. Falls can cause brain bleeding. Take it seriously. Any falls could cause fractures. We never know, that's why we take falls very seriously. On 11/19/24 at 2:52pm, V6 (Registered Nurse/RN) said, On November 6th, I (V6) was informed by CNA (certified nursing assistant) that he (R1) was found on floor. He's (R1) a fall risk. Sent him (R1) out to hospital. He (R1) was supposed to have a sitter, but the sitter left before the other sitter came. It (the fall) was not witnessed. One on one monitoring is when someone has to be with them to attend to their needs to maintain safety for the patient to prevent, for instance, issues like the one that transpired. I (V6) was not aware that he (R1) was not receiving his (R1) one on one monitoring. I (V6) did not know the CNA left. I (V6) knew that he (R1) had one on one. Sitter was not present. On 11/20/24 at 11:47am, V2 (Director of Nursing/DON) said, A resident who requires sutures is a serious injury. A resident who requires staples is a serious injury. Both should be reported to Public Health. One on one monitoring would be one person assigned to monitor that one person the whole shift. The person should be with resident at all times. There is no separate paperwork for one on one monitoring. I (V2) will have to find out if there is a policy on one on one monitoring. (R1's) did not have one on one monitoring on October 12th and November 5th due to staffing issues. We didn't have the staff for it. I (V2) believe he needs the one on one monitoring. On 11/20/24 at 12:32 pm, V2 said, I (V2) cannot technically say that (R1's) falls would have not happened if he (R1) had a one on one. He (R1) does get out of bed without asking for help. If they (staff) were doing a one on one I (V2) don't know if they (staff) would be able to catch him. I (V2) just don't know. On 11/20/24 at 12:17pm, V1 (Administrator) said, One on one monitoring is generally exactly that. A staff member that is focused on that one resident. Sometimes can be a group a room and several residents. When asked about the one on one monitoring in R1's Care Plan, V1 replied, So I (V1) was told. The Care Plan was not updated. Facility policy titled, Falls and Fall Prevention, date revised November 2024, documents, in part, 1. To ensure residents admitted are assessed for potential fall risk. 2. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment. 4. Residents who are assessed as at risk for falls will have a care plan initiated to include approaches for the prevention of falls as they apply to the individual resident. 13. The frequency of safety monitoring will be determined by the resident's risk factors and care plan. Facility policy titled, Comprehensive Resident Care Plans, revised August 2024, documents, in part, . Each care plan shall include measurable objectives and time tables to meet all resident needs identified in the comprehensive assessment. Facility presented pamphlet titled, Residents' Rights for People in Long-Term Care, revision date 11/18, documents, in part, . Your facility . must care for you in a manner that promotes your quality of life . Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source . Your facility must provide services to keep your physical and mental health, at their highest practical levels . Facility job description titled, Director of Nursing, undated, documents, in part, . The primary purpose of the Director of Nursing position . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Registered Nurse (RN), undated, The RN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Licensed Practical Nurse (LPN), undated, The LPN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times .

Based on interview and record review, the facility failed to develop and implement a policy to address strip/body searches of residents. This failure has the potential to affect two of three residents (R13, R4) reviewed for strip searches. This failure resulted in R13 feeling humiliated and ashamed; R4 feeling violated. Findings include: 1. R13's Face Sheet documents R13 is a [AGE] year-old admitted to the facility on 3.14.2024 with diagnoses including: Pain in Left Shoulder, Low Back Pain, Acquired Absence of Other Right Toe(s), and Acquired Absence of Other Left Toe(s). R13's MDS-Minimum Data Set of 6.12.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. On 8.20.2024 at 12:24 PM, R13 said approximately 1 1/2 months ago, he was subjected to a strip search because his former roommates credit card was missing. R13 said he was told by V25 (PRSC-Psychiatric Rehabilitation Services Coordinator) if he did not comply with the search, R13's parole officer would be contacted to obtain an order to return R13 to prison as R13 was on parole at that time. R13 said the search occurred in V25's office; V24 (Restorative Director) was also present. R13 said he took off his shirt, dropped his pants, underpants and bent over and coughed as instructed. R13 said V21 (Former Housekeeping/Laundry Supervisor) briefly stuck his head inside V25's office. R13 said the strip search made him feel humiliated and ashamed. 2. R4's Face Sheet documents R4 is a [AGE] year-old admitted to the facility on 2.8.2024 with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Alcohol-Induced Chronic Pancreatitis, and Iron Deficiency Anemia. R4's MDS-Minimum Data Set of 6.4.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. On 8.21.2024 3:00 PM, R4 said when she returned to the facility on 6.12.2024, staff at the front desk stopped her to search her purse, R4 refused. R4 said, later V4 (Social Service Director) and V24 (Restorative Nurse) conducted a strip search in V4's office. R4 said, I was told to lift up my shirt, to lift up my bra, they could see my ti**es. R4 said they had me unzip my pants. I felt violated, like she (V4) had all the power. On 8.15.2024 at 4:20 PM V4 (Social Service Director) said she is not aware of any strip searches of any residents. On 8.21.2024 at 11:47 AM V24 (Restorative Director) said, If I'm asked to by Social Service, I do assist to conduct strip searches. I assisted with strip searches of R4 and R13. V4 (Social Service Director) needed me to assist with search of R4's room and to be a witness to R4's strip search. We had R4 pull her shirt and bra away from her body and shake them. R4 was wearing skintight leggings; when she took down her leggings, she had no panties on. I assisted V25 (PRSC-Psychiatric Rehabilitation Services Coordinator) with R13's strip search. R13's former roommate accused R13 of taking his credit or debit card. R13 took off shirt, shook it and placed it on V25's desk; he wasn't wearing an undershirt. R13 took off his shoes/socks off, then took off his pants and boxers down to his knees, then she had resident cough. No contraband was found during the strip searches of R13 and R4. On 8.21.2024 at 12:04 PM V25 (PRSC 6th Floor) said, I do not conduct searches (strip) of resident's bodies; usually nursing does that. I did not complete a search of R13, a nurse (V24) did that when his former roommate said credit or debit card was missing. The search took place in my office because the room is pretty big. Neither V24 nor myself actually touched him. He removed his own clothing. I can't remember if he took his shirt off, I know he lifted it. He did pull his pants down, he had underwear on, he did not take his underwear down or off. If any instructions were given it would have been V24 said, I don't recall V24 telling him bend over and cough. Facility's Routine Resident Checks and Safety Room Checks policy (Reviewed 7/24) documents: 4. To provide safety to all residents, Resident Room checks for unsafe items (contraband such as Alcohol, Medications, drug paraphernalia, and/or items that may be used by resident or others to cause harm). Resident upon entering the facility from independent pass, the facility reserves the right to check bags or resident coat/jacket and pockets. If resident is observed with unapproved items, appears to be under the influence, and/or has a history of safety concerns such as alcohol, illegal substances, etc., the facility will conduct search, with resident present to ensure the resident and other residents in the facility are safe and free from harm. The policy does not address strip search of residents.

Based on observation, interview, and record review, the facility failed to provide timely care to three of five residents (R2, R3, R4). Two of these residents (R3, R4) had to hold their feces and/or urine for multiple hours before they were able to relieve themselves or receive care. This put residents at risk for harm due to holding their feces and/or urine. R3 had a swollen, distended stomach due to holding his feces, causing him severe pain. The failure affects three (R2, R3, R4) of five residents reviewed for neglect. Findings include: According to current POS (Physician Order Sheet), R2 is a [AGE] year-old female. R2's diagnoses are but not limited to quadriplegia, lung disorders, asthma, pressure ulcer of sacral region, lung clots, diabetes, high blood pressure, and high cholesterol. MDS (Minimum Data Set) dated 10/06/2023, notes R2 is alert and needs extensive assistance. According to current POS (Physician Order Sheet), R3 is a [AGE] year-old male. R3's diagnoses are but not limited to respiratory failure, lung disease, heart failure, kidney disease, pressure ulcer of the right heel, diabetes, heart disease, obesity, high cholesterol, depression, anxiety disorder, and constipation. MDS dated [DATE], notes R3 is alert and requires two-person total assistance. According to current POS (Physician Order Sheet), R4 is a [AGE] year-old male. R4's diagnoses are but not limited to cellulitis, clot in the right leg, lung disorder, heart failure, chronic lung clots, diabetes, major depressive disorder, kidney disease, fluid overload, and anxiety disorder. MDS dated [DATE], notes R4 is alert and requires total two-person assistance. On 11/18/2023, at 12:50 PM, R2 stated, The CNA (Certified Nursing Assistant) has not come to change me yet. On 11/18/2023, at 1:02 PM, V5 (Certified Nursing Assistant) stated, I came to check on R2 at 7:00 AM. R2 was sleeping. On 11/18/2023, at 1:10 PM, V5 came to change R2. No previous attempts to change R2 were made by V5 before 1:10 PM. On 11/18/2023, at 1:31 PM, R3 stated, I have been holding my urine and feces since this morning. No one wants to do their job. I hold my urine and feces all the time. My stomach is very swollen and it hurts. I would rate it a six out of ten. This has happened on many occasions. If one of the staff needs to go to the bathroom they can. I must wait for them. V5 had an attitude so I told her to get out. During this interview, R3's stomach was very swollen and full of flatus (gas). R3 rated R3's pain level high due to the gas. On 11/18/2023, at 1:45 PM, surveyor overheard V5 tell V6 (Registered Nurse) that V5 had not changed R4 yet. On 11/18/2023, at 1:51 PM, R4 stated, I have not been changed today. I have been asking to be changed for hours. Other days I always call the supervisors. The staff argues in front of my door. The staff that know what to do, they move them. If a person needed help, they would be dead. The other day they forgot to give me an aide. I was holding it. I need my bandage changed. I need someone to help me because I cannot walk. They need more than two people on this floor. There is a couple of times they have left me in my feces because they go home. This happens all night. The third shift sleeps. I have not seen my aide all day. They came in with an attitude this morning. I have not seen anyone, and I have not washed up. This happens frequently. I am just tired of it. I deal with this all the time. I just hold it because I just do not want to lay in my stuff. They take all my money, and I cannot get anyone in here to wipe my butt? My stomach hurts and I am just tired of all of this. On 11/18/2023, at 2:30 PM, surveyor asked V6 about care for the residents. V6 replied, Everyone is upset. What can I do? On 11/18/2023, at 3:04 PM, V7 (Lead CNA) stated, I expect staff to change the residents every two hours. On 11/18/2023, at 4:05 PM, V9 (Certified Nursing Assistant) stated, There are some residents that urinate frequently. We need to keep changing them. When I work on the second floor, I have eight residents that are total care. The facility is short staffed. On 11/19/2023, at 5:05 PM, V10 (Director of Nursing) stated, I expect the staff to round every two hours on the residents. They are also supposed to answer the call lights to see what is going on. Facility policy titled Abuse Policy, dated 1/23, notes each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview and record review the facility failed to ensure resident safety by allowing a resident (R1) out on a community pass unsupervised. This failure resulted in staff not following the proper protocol procedures for residents with community pass privileges, which allowed R1, who can only go out on community pass supervised, to sign out on community pass on 8/31/23 unsupervised. R1 has not returned to the facility. This situation was identified as an immediate jeopardy. The Administrator was notified and presented with the immediate jeopardy template on 09/12/2023. The immediate jeopardy began on 8/31/2023 and removed on 9/15/2023. The facility presented an acceptable removal plan on 9/15/2023. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings Include: R1's physician order sheet dated 5/2/23 denotes R1 may go out on pass supervised. On 8/31/23 R1 was allowed to sign out on community pass unsupervised but R1 is on supervised community pass privileges only. On 8/31/23 staff (V5) did not check R1's community pass privileges before allowing R1 to sign out and leave the facility. R1 has a diagnosis that includes bipolar disorder and paranoid schizophrenia and has not returned to the facility. R1 was also receiving treatment for a wound to R1's left foot and did not finish her wound care and antibiotic therapy. R1's was reported missing to the police department on 8/31/23. R1's whereabouts are unknown at this time. Facility incident report, dated 8/31/23, denotes staff member (V5) was covering the front desk for the regular receptionist when receptionist went on lunch. Staff member let R1 out of the facility. R1 did not have unsupervised pass privileges. Facility immediately took discipline action against employee. Police were called. R1's daughter was notified as well. R1's 8/31/2023 19:15 Nurses Note Text states: Staff reported seeing resident (R1) walking down the street on when she (staff) was out to lunch at approximately 1:20 pm. R1 remains out at this time. DON (Director of Nursing) aware. R1's 8/22/2023 10:13 Psychiatry Progress Note states: MENTAL STATUS EXAMINATION - Appearance/Behaviors: Consistent with stated age. Chief Complaint: Review psychosis symptoms response to a current psychopharmacology. History of Present Illness: (R1) has a psychiatric history of schizoaffective-bipolar type and nicotine dependence. Declares mood is OK. Denies changes in eating or sleeping patterns. The patient does not verbalize or exhibit any depression or anxious symptoms. There were no reports of psychotic or manic symptoms during this visit. Denies auditory or visual hallucination. Suicidal and homicidal ideation are both negative. Denies any paranoid thoughts. There are no reports of obsessive, intrusive, and persistent thoughts, or compulsive, ritualistic activities. Medication was well tolerated, with no reported side effects. R1's 8/24/2023 18:33 Health Status Note Text states: HISTORY OF PRESENT ILLNESS: (R1) was seen and examined today 8/24/2023 to follow up on wound culture results. Due to patient reporting toe pain and noncompliance to medication at times. To follow up on chronic medical condition management. Patient is observed to be walking around the hallway. Patient is calm and cooperative but withdrawn and not willing to engage in conversations. Calm Speech: Clear, normal volume, rate, and tone. Motor: no psychomotor agitation, no psychomotor retardation, no tics Thought Process: Linear Associations: Fair Thought Content: Denies SI, HI, AVH, no paranoid content elicited Mood: OK Attention: Fair Insight: Fair Judgment: Fair Sensorium: Alert Orientation: Self, place, time R1's 8/27/2023 15:46 Nurses Note Text reads: . continues ABT Cipro 750mg Q 12 hours till 09/21/23 for wound to left foot. No noted distress. Resident denies any pain @ this time. T=97.6 During interview on 9/6/23 at 9:25 am V12 (Wound Doctor) R1's wound on her left foot did not look infected and was at a week away from healing. V12 stated there is a chance it could close on his own or chance that it could deteriorate. V12 stated it all depends on how R1 takes care of herself. During interview on 9/6/23 at 9:45 am V8 (Nurse Practitioner) stated R1 had a wound culture that showed a bacterium which mean she had an infection or colonization of bacteria. V8 stated V8 wanted the antibiotics to be given to R1 four weeks prophylactically preventative. V8 stated the antibiotics were prescribed to help the wound heal. V8 stated she ordered the antibiotics to be given as prescribed for four weeks which were to be started on 8/24/23. During interview on 9/6/23 at 10:05 am V5 (Central Supply Director) stated he has been working at the facility for almost [AGE] years. V5 stated the last couple of years, when the main receptionist (V4) goes on break he covers the front desk. V5 stated when a resident wants to go out into the community on pass by themselves, V5 checks their pass card which is orange and has their picture on it. V5 stated when R1 came down to go out into the community R1 resembled another resident, that regularly goes out every day and V5 had R1 sign out. V5 stated while sitting at the front desk a few minutes later, another staff member (V9) reported they saw R1 outside the building. V5 stated he told V9 that it was not R1 but thought it was another resident that looked like R1. V5 stated immediately after speaking with V9, V5 was contacted by social services and the administrator. V5 stated he was told by management that V5 made a mistake letting R1 sign herself out. V5 stated the managers went outside and drove around to look for R1. V5 stated he knew he should for check for the community pass before letting a resident sign out but didn't and now has been not allowed to work at the facility. V5 stated he feels horrible and will be looking for employment elsewhere. State surveyor observed video on 9/7/23 at 12:15 pm in V2's office, showing R1 walk to front lobby at 1:08 pm on 8/31/23. V5 was observed sitting at front desk. R1 was seen to sign out, then leave the facility unaccompanied. During interview on 9/6/23 at 10:35 am V9 (Certified Nurse Aide) stated V9 was on lunch break driving and saw someone that looked like R1 walking down the street. V9 stated when she returned to the facility about 10 minutes later, V5 was sitting at the front desk. V9 stated V9 told V5 she might have saw someone that looked like R1 walking down the street. V9 stated the managers were informed, and they went outside looking for R1. V9 stated as of today (9/6/23) R1 has not returned to the facility. During interview on 9/6/23 at 10:55 am V10 (Social Worker) stated R1 has been in her caseload for a few months. V10 stated R1 can be lucid when having conversations. V10 stated R1 has delusions that R1 thinks R1 is a doctor or a lawyer. V10 stated R1 goes from being lucid to having delusions. V10 stated she assessed R1 for community access privilege and determined that she required supervision if she went on pass into community. V10 stated residents that require supervision into the community can go out with a staff or family member. V10 stated after residents are assessed to be able to go into the community with or without supervision, the nurses obtain a physician's order and put the order in the residents' electronic chart. V10 stated residents that can go out on pass unsupervised receive an orange card with their picture on it. V10 stated the card is supposed to be presented to the front desk staff so they know who can go out unsupervised. V10 stated on the day that R1 left, the aide (V9) told them she saw R1 walking down the street. V10 stated she approached V5 and asked him what happen and V5 told V10 that V5 thought R1 was another resident that normally goes out on pass every day. V10 stated the managers immediately went outside looking for R1 in different cars. V10 stated R1 never told V10 she wanted to leave or that R1 did not want to stay in the facility. V10 stated R1 had never tried eloping or leaving before without permission. During interview on 9/6/23 at 12:25 am V3 (Social Service Director) stated V3 has been working at the facility five months. V3 stated all residents with passes into the community are on a list that is given to the front desk. V3 stated the list includes residents with supervision and no supervision. V3 stated she updates the list every week and puts it at the front desk. V3 stated R1 has been in the facility for a few months. V3 stated R1 has some mental health diagnosis such as Schizophrenia and Bi-polar. V3 stated R1 was assessed to have a community pass with supervision only. V3 stated pass with supervision means that person is only allowed to go into the community with a family or staff. V3 stated residents that have unsupervised pass privileges are given an orange card that has their name and picture on it to show at the front desk when they want to go out into the community. V3 stated not too long after R1 left the facility a staff member witnessed R1 outside. V3 stated they then drove around the neighborhood for hours trying to locate R1. V3 stated they have a system in place that works but human error by V5 allowed R1 to elope. During interview on 9/6/23 at 1:15 pm V14 (License Practical Nurse) stated V14 has worked at the facility for [AGE] years. V14 stated R1 was pleasant, withdrawn to herself and liked to smoke. V14 stated R1 would at times get delusional but most of the time she made sense when she talked. V14 stated the day R1 left it was lunchtime and she asked for an Ensure (supplement drink) then went downstairs. V14 stated after lunch V9 reported to her and social service that R1 was seen outside. V14 stated they started looking inside and outside for R1 but could not locate R1. V14 stated from what she remembered R1 had an order in her chart for outside pass with supervision. V14 stated if an order is in the chart or medical records, they are to follow it. V14 stated social service made the determination that R1 needed supervision if she went out on pass. During interview on 9/6/23 at 1:35 pm V2 (Administrator) stated all the doors have alarms including the front door. V2 stated the only way out the front door is to be buzzed out or let out by the receptionist. V2 stated the only residents that go out the front door are residents with pass privileges. V2 stated the main receptionist (V4) was on break and another staff member, who is central supply (V5) normally covers for V4 when V4 goes on break. V2 stated V4 has been working at the facility over ten years and when V4 goes on lunch V5 covers the front desk which he has been doing for years. V2 stated V5 stated V5 knows to look for the orange card before a resident is allowed out of the facility. V2 stated he reviewed the building camera and it seemed that V5 did not check to see if R1 had an orange pass card. V5 allowed R1 to sign out of the facility. V2 stated they had to discipline V5 and V5 is no longer working at the facility because he did not follow the facility rules. V2 stated as soon as they realized R1 had left, staff went driving around looking for R1. V2 stated all pertinent people were notified including the police. V2 stated they have system in place that works and as long as staff follow the rules there are no issues. V2 stated they are replacing V5 and going to hire full time security guard that will check the residents in/out of the facility instead on receptionist. During interview on 9/6/23 at 1:45 pm V4 (Receptionist) stated he has worked at the facility for [AGE] years. V4 stated they had instituted the orange pass card system several years ago. V4 stated social service has been strict to make sure staff follows the rule of residents showing their orange card before they can go outside alone. V4 stated he has been taking his lunch break for years at the same time 1-2pm. V4 stated for the last five years, V5 would cover the front desk when V4 goes to lunch. V4 stated on 8/31/23 he went to lunch at 1:00pm and returned at 2 pm. V4 stated he was told R1 left the facility. V4 said he saw a lot of staff driving and walking around looking for R1. V4 stated he got off work at 3:00pm and still saw some of the staff driving around looking for R1. During interview on 9/6/23 at 2:10 pm V7 (Doctor) stated the staff felt from their assessment, that R1 needed supervision to go out on pass. V7 stated staff put the order in R1's electronic record. V7 stated typically if there is an order in a resident record the expectation is for staff to follow what the order says. V7 stated in the case with R1, R1 signed out on her own cognizant at the front desk and did not return. V7 stated in the medical community that it is called leaving AMA (against medical advice). V7 stated having a psyche diagnosis does not mean you cannot function. V7 stated R1 has Schizophrenia but was alert and oriented enough to still make her own medical decisions. During interview on 9/6/23 at 2:45 pm V11 (Psychiatrist) stated if a person is not cognitively impaired or does not have a guardian, he or she is able to make medical decisions. V11 stated residents with schizophrenia have good days and bad. V11 stated when he assessed R1, R1 was alert and oriented times three. V11 stated even though R1 had some psychiatric diagnosis, R1 was her own decision-maker from V11's perspective. V11 stated there was no justification in his mind, that R1 should have been in a locked unit in the facility or locked into the facility. V11 stated if R1 was demented or had dementia it would been a very serious thing that the facility allowed her to leave. V11 stated residents with Dementia must be, sometimes, in a secure or locked unit. V11 stated if the facility fails to keep a demented resident from leaving the facility it shows they failed to keep that resident safe. V11 stated if R1 wanted to leave AMA V11 would have to let her, and staff should have told V1 if they knew. Facility physician order policy denotes proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. Orders must be checked for completion including indication for use, or telephone order. Medication dosage, route of administration, number of days or doses, indication for use of PRN medication, date, and physician signature, time of day to be given, and any special instructions. Facility out on pass policy denotes physician order must be obtained indicating Pass Privileges. The Immediate Jeopardy that began on 8/31/23 was removed on 9/15/23 when the facility took the following actions to remove the immediacy: The Facility reasonably assures that the resident environment remains as accident free as possible. 1.) Immediate action taken following the incident on 8/31/23. a.) V5 is no longer an employer at the facility as of 9/1/23 b.) Administrator ensured community pass verification was re-initiated on 8/31/23 due to being informed it was not checked by V5 when R1 signed out of the facility to go on community pass. c.) Administrator immediately reviewed resident census with nurses of each floor and confirmed all residents accounted for. Confirmed with the front desk that they are ensuring all residents who are leaving the building have been assessed for community access, have orders that they can leave unsupervised, have shown the front desk their orange pass card and have checked off that they confirmed it. d.) The facility immediately notified the family, MD, law enforcement and IDPH about the incident. 2.) Statement regarding residents that have the potential of being affected. a) On 9/12/23 Administrator and Social Services Director reviewed the community pass assessments of all residents who are assessed as high risk for elopement, have diagnoses that make them unacceptable for community passes, have medical issues that render them unsafe to have a community pass or who have had their community passes revoked or limited will be identified and have their photo included in lists kept at every nurses' station and at the front desk. 3) Measures the facility will take to ensure the issue will be corrected and will not recur. In-Servicing and Staff Re-Education Initiated. In services were initiated on 9/12/23 and will conclude on 9/15/23. a.) From 9/12/23 on, the front desk employee will confirm that they observed and saw the resident's orange out on pass card for all residents who have out on pass privileges and check off on the resident sign out sheet that the resident showed the front desk employee their orange pass card. Administrator will monitor this for full compliance effective 9/12/23. b.) On 09/12/23, an in-service will be held with all Facility staff. The in-services will be conducted by the Administrator and/or designee CNA Supervisor to include: - Review of the requirement that the Facility reasonably assures that residents' environment remains as accident free as possible. - Review of the Facility's policies and procedures on community passes. - Review of how to check for community pass privileges. c.) Staff who work at the front desk, including the staff that cover for the main receptionist when he/she goes on break, will be in serviced immediately regarding the need to check the orange card pass of each and every resident to ensure they can leave unsupervised before they leave the facility, and to check off and confirm that they saw the orange card pass. All staff will be in-serviced regarding the community pass procedure by 9/15/23. d.) All staff will be in-service before they begin their next shift beginning 9/12/23 by Administrator and designee CNA Supervisor. e.) Any temporary personnel will be in serviced on these policies and protocols immediately before they begin their first shifts including those out sick and on vacation by Administrator and designee CNA Supervisor. 4.) The Administrator, or designee DON, will monitor continued compliance via the following Quality Improvement Programs: (QA met on 9/14/23). a) A QA tool will be developed to demonstrate the staff's knowledge of the facility's community pass procedures on a daily basis, for the next four weeks, during facility rounds, the Administrator, or designee, DON , will randomly quiz and monitor staff member on Pass Procedures 3 times per week for 30 days, and then once a week for an additional 30 days. Initiated: 9/12/23. b) The results of the monitoring completed will be submitted to the QA/QI Committee Quarterly for review and follow-up. Quality Assurance Committee will meet to assure that systems are in place and are effective in preventing residents from having community passes that should not have or who are susceptible to elopement. This will be done weekly for the first month, and then monthly for the next 3 months, then quarterly thereafter, unless additional meetings are deemed appropriate or necessary to prevent unauthorized community passes and/or elopement. The facility presented a plan to remove the immediacy on 9/12/23. The survey team reviewed the abetment plan and was unable to accept the plan to remove the immediacy. The abetment plan was returned to the facility for revisions. The facility presented a revised plan on 9/13/23 and 9/14/23. The survey team accepted the plan on 9/14/23. On 9/14/23-9/15/23 the surveyor, via observation, interview and record confirmed the implementation of facility's removal plan. On 9/14/23-9/15/23 observed staff checking for proper orange ID then sign off that they checked before residents were allowed to go out on pass. During interview on 9/14/23 at 2:00pm V4 (Receptionist) stated he had to be in-serviced on pass policy and how to check for community pass. V4 stated they must see the orange pass and sign that saw it. R2, R3, R6, R7, R8 on 9/15/23 at 10:30-10:45am stated they have to show their orange pass to the front desk before they can go out on pass. On 9/15/23 at 9:45-10am V9, V15, V16 (Certified Nurse Aides) stated they had an in-service on the pass policy and how to check for community pass. On 9/15/23 at 10:20 am V18 (Housekeeper) stated when he or his team cover the front desk for V4's lunch break they must see the orange pass and sign that saw it before resident can leave the building. V18 had in-servicing on the pass policy and how to check for community pass. On 9/15/23 at 10:30am V19 (Housekeeper) stated when they cover the front desk for V4's lunch break they must see the orange pass and sign that they saw it before resident can leave the building. V19 had in-servicing on the pass policy and how to check for community pass. On 9/15/23 at 10:45am V20 (Housekeeper) stated when covering the front desk for V4's lunch break they must see the orange pass and sign that they saw it before resident can leave the building. V20 had in-servicing on the pass policy and how to check for community pass.

Based on Observation, Record Review and Interview the Facility failed to monitor, properly assess and prevent Pressure Wounds from becoming infected. Facility failed to follow proper intervention per Facility Policy to prevent worsening of Pressure Wounds for 1 of 3 residents (R1) reviewed in the sample of 3. These failures resulted in worsening of R1's Pressure Wound that became infected requiring hospitalization and death. Findings include: On 2/18/20 at 4:09 PM (Interview over the phone) V4 (Wound Doctor) stated that she saw R1 on 1/14/20 and ordered two antibiotics to be taken by mouth for pressure wound infection. Pressure wound on the left and right ischium, left leg wound has a heavy drainage and foul odor. Further stated that she saw R1's wounds on 1/9/20 and they had worsened on 1/14/20. On 2/21/20 at 9:59 AM. V3 (Wound Coordinator) stated that R1 transfers on her motorized wheelchair once she gets up around 10 or 11:00 AM. R1 stayed on her motorized wheelchair late, around 9:00 PM without being transferred to bed. Often times R1 gets soiled or wet and staff unable to change R1 because R1 is on her motorized wheel chair moving from location to location. I cannot say why her pressure wounds became infected. The wound doctor ordered two antibiotics for wound infection. I only see R1 when I do the treatment. Nursing staff needs to monitor R1's wound when Wound Care Team is not around. R1 being wet with urine or soiled with bowel movement is a factor or source of infection to her wounds. On 2/21/20 at 11:45 AM. V6 stated that she was the regular nurse on the 4th Floor. Also stated that R1 uses her motorized wheelchair often but since her assignment does not cover R1 she does not have any idea about R1's wounds. On 2/21/20 at 11:50 AM. V5 stated that she was one of the regular nurses who took care of R1. R1 was alert and oriented X3, was isolated due to infection but does not recall what specific infection. R1 was taking antibiotic, but cannot remember what the purpose was for R1 taking antibiotics. R1 wants to get up after lunch and will stay on her motorized wheelchair until around 7 to 7:30 PM when my shift ends. During those times the nursing staff does not transfer R1 out of the wheelchair. She cannot recall what R1's wound looked like since it was the Wound Care Team that does the dressing. When R1 transfers to her motorized wheelchair she will stay until bedtime. R1 MDS assessment dated [DATE] reads: On Section C BIMS Score was 15, Section G on Transfer, Bed Mobility and Toileting, R1 needs 2-person extensive assistance. R1 did not walk or ambulate and needs supervision during locomotion and Section M reads that R1 has 2 unhealed pressure wounds. R1 is at risk of developing pressure ulcers / injuries. Wound Assessment on 1/10/20, 1/17/20 and 1/19/20 reads that R1 has 8 total wounds. Two pressure wounds on right and left ischium and 6 trauma wounds left lateral leg, left posterior leg, left knee, right knee, right lateral leg and right anterior knee. R1 was transferred to the hospital on [DATE]. Hospital Wound Culture dated 12/8/19 reads: Left Hip, Knee and Leg, Right Leg were all positive of Staphylococcus Aureus infections. Discharge instruction reads that R1 has wound infection and to take Linezolid Solution 600 MG intravenous ordered for UTI and infected decubitus ulcers, Meropenem Solution Reconstituted 500 MG intravenous ordered for UTI and infected decubitus ulcers which also included and confirmed during admission on 12/9/19. Progress note reads: On 1/14/20 R1 was seen by V4 (Wound Doctor) and Keflex and [MEDICATION NAME] antibiotic was ordered due to wound infection. Physician order [REDACTED]. V4 (Wound Doctor) Wound assessment dated [DATE] reads: Left Ischium Stage 4, Heavy Serous, Slough 15%, Granulation Tissue 85%, Debridement procedure done to remove infected tissue. Right Ischium Stage 4, Moderate Serous, Slough 20%, Granulation Tissue 70%, Skin 10%. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. Debridement procedure done to remove infected tissue. V4 (Wound Doctor) Wound assessment dated [DATE] reads: Left Ischium Stage 4, Exudate Moderate Serous, Slough 15%, Granulation Tissue 85%, Debridement procedure done to remove infected tissue. Right Ischium Stage 4, Exudate Moderate Serous, Slough 20%, Granulation Tissue 70%, Skin 10%. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. Debridement procedure done to remove infected tissue. Keflex 500 MG and [MEDICATION NAME] 100 MG was ordered for wound infection. Facility Wound / Skin assessment dated [DATE], assessment reads: Left Ischium Stage 4 Full thickness skin tissue loss, no odor present, Exudate - Moderate Serous, Slough 0% and Granulation 100%. Right Ischium Stage 4 Full thickness skin tissue loss, no odor present, Exudate - Moderate Serous, Slough 0% and Granulation 100%. Facility Wound / Skin assessment dated [DATE], per V3 (Wound Coordinator) this was an assessment for 1/14/20 since R1 was discharged to the hospital on [DATE]. Assessment reads: Left Ischium Stage 4 Full thickness skin tissue, no odor present, Exudate - None, Slough and Granulation N/A. Right Ischium Stage 4 Full thickness skin tissue, no odor present, Exudate - None, Slough and Granulation N/A. V4 (Wound Doctor) Recommendation based on her assessments are the following: Reposition per facility protocol, off-load wound and limiting sitting to no longer than 2 hours at a time. R1's Care Plan date Initiated on 06/06/2019 reads: The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R1 received the following antibiotic medications for wound infections: Linezolid Solution 600 MG intravenous order date 12/11/2019 Meropenem Solution Reconstituted 500 MG intravenous order date 12/10/19 Keflex Capsule 500 MG by mouth order date 1/14/20 [MEDICATION NAME] Tablet 100 MG by mouth order date 1/14/20 On 2/21/20 at 10:34 AM. V2 (Assistant Director of Nursing) stated that both Electronic Antibiotic List and Infection Control Tracking Log for the months of November 2019, December 2019 and January 2020 does not show that R1 infections were being monitored for antibiotic treatments (Linezolid Solution 600 MG intravenous order date 12/11/2019 for UTI and infected decubitus ulcers, Meropenem Solution Reconstituted 500 MG intravenous order date 12/10/19 for UTI and infected decubitus ulcers, Keflex Capsule 500 MG by mouth order date 1/14/20 for infected decubitus ulcers and [MEDICATION NAME] Tablet 100 MG by mouth order date 1/14/20 for infected decubitus ulcers). V2 further stated that she does not know why R1's antibiotic was not included under Infection Control Tracking Log because it is part of the Facility's responsibility under Antibiotic Stewardship. Policy and Procedure of Antibiotic Stewardship dated 11/15/19 reads: 4. Antibiotic Stewardship Actions - Dose, duration, route, and indication of every antibiotic prescription must be documented in the medical record. Record will be reviewed monthly to assess compliance with the requirement. Policy and Procedure of Infection Control dated 8/11 reads: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The policies and procedures will also monitor Antibiotic Stewardship within the facility. Procedure 2. The objective of the infection control policies and procedures are to: a. Prevent, detect, investigate, and control infections within the facility. Surveillance will be completed on an ongoing basis. e. Maintain records of surveillance of infections, antibiotic stewardship, and incidents including related corrective actions. Both Electronic Antibiotic List and Infection Control Tracking Log for the months of November 2019, December 2019 and January 2020 does not show that R1's infections were being monitored for antibiotic treatment as to its effectiveness on treating wound infections. R1 Braden Scale dated 1/1/20 and 1/13/20 reads that R1 as a Moderate Risk for Pressure Sore. R1's Progress Notes read that R1 was transferred to the hospital by fire fighters on 1/14/20 and admitted with septic shock. Hospital Record dated 1/15/20 reads that admitting [DIAGNOSES REDACTED]. Septic Shock likely and/or UTI and/or possible wound infection and/or Bacteremia. Death certificate reads that cause of R1's death was primarily due to Bacteremia and secondarily to Non-Traumatic Decubitus Wound Infection or Pressure Wound Infection. Policy and Procedure for the Treatment and Prevention of Skin Breakdown dated 4/11 reads: Establish an individualized turning and repositioning schedule if the resident is immobile. While in bed not to exceed 2 hours and while a sitting position and/or if the Head of Bed (HOB) is greater than 30 degrees not to exceed 1 hour. If the resident is capable, they should push-up every 15 minutes while in a sitting position. Consider using a pouching system or collection device to contain urine or stool to protect the skin from urine or fecal contamination.

Based on observation, interviews and record reviews the facility failed to ensure that each resident receives adequate supervision to prevent accidents, for 1 resident in a sample of 35 (R5), who had a fall related incident that resulted in a head injury, which required emergency medical services; and failed to ensure that the resident environment remains free of potential accident hazards, by failing to properly dispose of sharp shaving equipment, for 2 of 35 residents in the sample (R248 and R82). Findings include: On 1/14/19 at 11:00 AM, R155 stated that while smoking on the smoking patio, R5 fell and cracked his skull and was bleeding profusely from the head. R155 stated that there was no staff on the smoking patio to supervise. R155 stated, It's a shame he did not have any shoes on and it was too cold for that. He only had on those nonskid socks. R155 also stated, There is almost never any staff to supervise residents on the smoking patio. Other residents come out there with gowns on, they pee and poop out there and everything. Some of these residents need more help than that because so many of them have psych issues and don't know what they are doing. R155 was asked to provide the times when is the smoking patio open. R155 stated, It closes from 2:00 AM until 6:00 AM. R155 was asked, does staff supervise the smoking patio at 12 midnight. R155 stated, Not all the time, mostly not. On 1/14/19 at 11:45 as resident was being prepared for transport to the local emergency room , he was placed on the gurney by EMS (Emergency Medical Services) staff. After R5 was placed on the gurney, staff was observed taking off R5's nonskid socks which were wet and black. R5's toes were also black with unknown debris. On 1/15/19 at 10:50 AM, no staff was observed on the smoking patio where 5 residents were smoking. During an interview on 1/15/19 at 11:00 AM, V31 (Smoking Monitor) was asked if he was supervising the smoking patio from 10:30 am to 11:00 am on 1/14/19. V31 stated, Yeah, but I was not here when the resident fell and busted his head. I went to take a resident upstairs and when I came back he was trying to get up. His head was bleeding and everything. V31 was asked was any other staff outside supervising while you went upstairs. V31 stated, No. V31 was asked, do you remember what R5 had on his feet. V31 stated, He had on those slipper socks. V31 was asked, what you do if residents come out to the smoking patio and they are not dressed properly. R31 stated, I send them back upstairs. During an interview on 1/15/19 at 11:05 AM, R82 was asked if staff always supervise smokers on the smoking patio. R82 stated, No staff is not always out there. On 1/16/19 at 10:00 AM, during an interview with V21 (Social Service Director), V21 was asked, if the smoking patio is always supervised. V21 stated, Yes, there is always someone out there with the residents. A review of the facility policy dated 11/28/16, titled Smoking Policy reads as follows, All residents will be under supervision while smoking. A. Residents must remain within eye sight of the smoking monitor. A review of R5's physician's telephone orders dated 1/14/1, reads as follows, Send resident to (Local hospital) for fall and CT (Computerized Tomography) of head. A review of the hospital emergency room Discharge Instructions dated 1/14/19, reads as follows, There is an uncomplicated diagonal laceration located over the parietal scalp which is 1 centimeter in length. This wound should be rechecked in 2 days. There is an uncomplicated diagonal laceration located over the parietal scalp which is 1 centimeter in length. Sutures to this wound should be removed in 7 days. A review of the facility incident report dated 1/14/19 reads as follows, Other info- Resident outside on patio wearing nonskid footies without shoes. A review of R5's most current Fall Risk Screen dated 1/8/19 rated R5 with a score of 75. The Fall Risk Screen tool indicates a high risk for falls is a score of 45 and higher. A review of R5's fall occurrences as listed on the care plan dated 1/15/19 indicates the following: The resident is high risk for falls related to [DIAGNOSES REDACTED]. o 3/5/18 o 4/13/18 o 4/16/18 o 4/17/18 o 6/1/18 o 6/18/18 o 8/12/18 o 12/22/18 o 1/6/19 o 1/14/19 Care plan interventions include the following: Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. A review of the care plan with an initiation date of 1/10/19 with a focus of: resident is a smoker, reads as follows; The resident will not smoke without supervision through the review date. The resident requires SUPERVISION while smoking. The facility failed to ensure that a resident identified as a 'High Risk for falls was supervised while in a resident area (smoking patio), which requires staff supervision. While unsupervised, the resident had a fall incident and was assisted by other residents on the smoking patio. The resident sustained [REDACTED]. On 01/14/19 at approximately 10:30 am, In R248's room four disposable shaving razors noted on the bed side table. V2 DON (Director of Nurses) stated the disposable shaving razor should not be left at the bedside table. 01/14/19 10:33 AM R82 was observed to have three disposable shaving razor blades at the bedside. V23 RN (Registered Nurse) who was present at the time, stated The CNAs who take care of the resident left them there and I will have to talk to them about it for safety reasons. 01/14/19 10:36 AM, in room [ROOM NUMBER] one disposable razor noted on the table. V2 stated it should not be left there. V2 statedTthey are kept in the clean utility room for safety reasons. On 1/14/19, 1/15/19 and 1/16/19 three days of the survey the facility was unable to present any policy on hazards or the facility protocol on shaving equipment. V2 stated they only have a policy on Incident and Accident, which did not cover this issue. On 1/16/19 as at 4:00 pm, V1 (Administrator) could not accurately provide the list of the residents who are actively mobile on the 2nd floor; and unable to identify residents who would be at risk.

Based on observation, interview and record review, the facility failed to follow its use of mechanical lift policy by not ensuring the resident has the proper size sling before a transfer for 1 of 3 residents R11 reviewed for mechanical lift use. This failure resulted in R11 falling to the floor sustaining a right trochanteric fracture, and non-displaced C7 fracture.The facility also failed to develop a plan of care with interventions to reduce or prevent frequent falls for 1 of 3 residents R16 reviewed for fall prevention. Findings include: On 10/11/18 at 12:00pm, this writer noted R11 in bed, alert and oriented to self, place and time. R11 stated, I am still waiting for someone to put me in a chair. They have to put me on a lift to transfer me. On (MONTH) 8, the CNAs (Certified Nursing Aides) put me on a smaller lift pad to transfer me instead of using my regular lift pad because my regular lift pad was soiled. One strap broke and my back landed on the wheelchair. Three CNAs tried to carry me, then the other strap broke and I landed on the floor. I broke my right femur and was hospitalized ,[DATE] days. Last week, one strap came off the hook when they were transferring me to the lift, luckily the CNA grabbed it before I fell . They were rushing and should have checked to make sure all the straps are secured before the transfer. On 10/13/18 at 1:32pm, during an observation of mechanical lift transfer, this writer noted R11 sitting on transfer sling leaning towards her left, staff did not reposition the resident prior to the transfer. This writer also noted staff did not physically check the straps prior to the transfer. On 10/13/18 at 1:35pm, V20 (CNA) stated, Prior to the transfer we should make sure all straps are in good condition and are connected to the hooks and to make sure the resident is repositioned so her weight is distributed evenly while sitting on the sling. We are not supposed to use the shower sling because she is a big lady and her back is wide. Prevention is important. On 10/13/18 at 2:13pm, V2 (DON-Director of Nursing) stated, R11 normally uses is a full size mechanical transfer sling. On the day of the fall, a shower sling was used because there is no back up slings available. According to the investigation, there was also a nurse in the room where the transfer occurred, she should have asked for the appropriate equipment, The CNAs there should have called the supervisor to obtain a backup sling. The shower sling is used when resident takes a shower but there is no evidence that R11 uses the shower sling safely prior to the fall. The measurement of the shower sling at the waist line is 24 (inches) and is 37-3/4 of the regular sling. The strap broke on the left side of the shower sling during the transfer. R11's Hospital record dated 7/8/18 reads, length of stay: 3 Surgical procedure: Right Intermedullary Nail Femur History of present Illinois: The patient admitted for right trochanteric fracture, and non displaced C7 fracture due to fall from hoyer lift while transferring to wheelchair to bed, hoyer lift broke and patient fell . Patient underwent surgery for [REDACTED]. Displaced comminuted [MEDICAL CONDITION] neual arch at C7, 2. Right femur fx (fracture), left dislocation of head of left femur Use of mechanical Lift policy dated 8/18 reads, Procedure: 2, Confirm the resident has the proper sling size available and appropriate o the task being assisted 10 Place the sling under the resident Visually check the size to ensure it is not too large or too small 12 c. Before resident is lifted, double check the security of the sling attachment. d.Examine all hooks, clips or fasteners. e. Check the stability of the straps 13. Lift the resident 2 inches from the surface to check the stability of the attachment, the fit of the sling and the weight distribution R16 fell a total of 27 times from 03/31/2018 to 10/05/2018. Two of those falls were witnessed by staff. The fall on 07/25/2018 resulted in hospitalization and injury. Physician documentation dated 08/06/2018 notes on 07/25/2018 R16 was at nursing facility when staff stated R16 fell but, it was unclear if R16 hit her head. After that R16 had a tonic-clonic [MEDICAL CONDITION]. R16 was found lying in her bed and had a couple of staring episodes. These episodes lasted for less than a minute and it is unknown if she had any shaking or loss of sphincter control at that time. Review of R16's reporting records after the fall and injury found the facility did not report an initial or final report to the state. Fall risk screen dated 04/06/2018 documents R16 is a high risk for falling. Care plan dated 08/07/2018 documents the following: need to attempt to anticipate R16's needs to go to the toilet before and after meals, at bedtime and as needed; ensure call light is within reach while R16 is in her room especially while in bed; frequent rounds while in bed to assure safety. Care plan dated 10/11/2018 documents that R16 potentially has mixed bladder function as evidenced by frequent falls related to toileting. On 10/12/2018 at 12:25PM, R16 was in bed alert and orient to self. R16 stated, I need to pee. R16 was asked to pull call light but the call light was behind R16's bed. R16 was unable to reach the call light. On 10/18/2018 at 12:49PM, V14 (Certified Nursing Assistant) stated, R16 is impulsive and you never know what she is going to do. R16 will jump up and pull the call light and go to the bathroom without assistance. R16's falls have to do with her going to the bathroom. CNA's have to really monitor her and check on her regularly. I have fourteen residents by myself and nine of them are total care. R16 needs to be monitored 24 hours a day, seven days a week. R16 should not be getting out of bed by herself. She is very unsteady.

Based on observation, interview and record review the facility failed to provide bathing resulting in magots in and around the vaginal area for 1 of 3 residents (R20) reviewed for bathing and personal care. The facility also failed to ensure that incontinence checks were conducted at least every 2 hours and as needed for 2 of 3 residents R12/R13 reviewed for incontinence checks frequency. This failure resulted in R20 being admitted to the local hospital and assessed with [REDACTED]. Findings include: Minimum (MDS) data set [DATE] documents that R20 has a BIMS (Brief Interview for Mental Status) of zero. R20 cannot make her needs known. R20 is an extensive assist for personal hygiene. R20 is always incontinent of bowel and bladder. Report dated 08/30/2018 documents V27 (Certified Nursing Assistant) was interviewed by V2 (Director of Nursing). V27 reported that R20's abdominal binder was removed during a bed bath that she provided. The binder was visibly soaked. The binder was used regularly to prevent R20 from trying to dislodge her [DEVICE]. V27 stated she regularly gave R20 extra full body baths, but did not document them on the bath records. Discharge summary dated 08/31/2018, from a local hospital, documents that R20 has superficial wounds at the sacrum, below her breast and her groin area, likely secondary to abdominal binder that was not cleaned properly in the nursing facility. Per V26 (Social Worker) from a local hospital, maggots were found near and in R20's vagina area on 8/28/2018 at time of admission. R20 was admitted [DATE] and discharged from a local hospital on [DATE]. ADL monitoring sheet, undated, was reviewed for the week of 08/21/2018 to 08/27/2018. No baths are recorded for R20. R20 was admitted to a local hospital on [DATE] and discharged from a local hospital on [DATE]. On 10/18/2018 at 2:12 PM, V27 stated, I consistently work on the 5th floor. Other shifts did not notice R20's abdominal binder. When I took care of R20, I gave her a bed bath daily, but I did not document the baths. On 10/18/2018 at 2:51PM, V2 stated, Staff try to give baths once a day and personal care whenever it is needed. I did not review the other months for R20 showers. Staff need to document what they do. Care plan dated 10/09/2018 documents that R20 has an ADL self-care performance deficit and R20 will be treated with respect, dignity, and reside in the facility free of mistreatment. Facility policy dated 08/15/2018, titled Activities of Daily Living, documents that documentation will be provided in the residents medical record of the assistance and amount of staff required to complete the task. The frequency of documentation will be determined by the individual resident's care needs. Facility policy dated 11/17, titled Abuse, Neglect and Exploitation, documents neglect as failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 10/11/18 at 2:22pm, this writer noted R12's incontinence brief was saturated with dark color urine. R12 has a suprapubic catheter and a [MEDICAL CONDITION] bag .Dark color stains inside of the empty catheter bag, [MEDICAL CONDITION] bag is full. V13 (CNA-Certified Nursing Aide) stated, On a good day, I am supposed to check incontinence brief and change it every two hour, the last time I checked was 11am. I am not aware that the resident has a catheter. On 10/11/18 at 2:40pm, V6 (LPN-Licensed Practical Nurse) confirmed R12's [MEDICAL CONDITION] bag is full and stated, his [MEDICAL CONDITION] bag is full and should have been emptied as needed. I changed his [MEDICAL CONDITION] bag at 7am today. On 10/11/18 at 3:30pm, this writer noted strong odor of bowel movement from R13, observed large amount of bowel movement in R13's incontinence brief. V10 (Unit Manager) stated, The resident's CNA has left for the day, I don't normally work on this floor but heard the commotion from the roommate and came. The CNA should be checking incontinence brief every two hours and as needed. Incontinence care plan dated 9/10/18 reads, check for incontinence every 2 hours and as needed On 10/18/18 at 1;35pm, V2 (DON-Director of Nursing) stated, Incontinence care should be provided according to resident's need. Everyone should be checked upon risen before and after meal and before bed time. The CNAs should be rounding every two hours and more frequently if the residents are unable to make their needs known.

Based on interview and record review the facility failed to document, monitor, and provide goods and services to three residents. The facility caused physical harm resulting in a stage 4 pressure ulcer behind the ear (R9) and maggots in and around the groin area (R20). This failure affects three residents (R9, R15, and R20) reviewed for ADL care in a sample of 23. Findings include: Minimum (MDS) data set [DATE] documents that R20 has a BIMS (Brief Interview for Mental Status) of zero. R20 cannot make her needs known. R20 is an extensive assist for personal hygiene. R20 is always incontinent of bowel and bladder. Report dated 08/30/2018 documents V27 (Certified Nursing Assistant) was interviewed by V2 (Director of Nursing). V27 reported that R20's abdominal binder was removed during a bed bath that she provided. The binder was visibly soaked. The binder was used regularly to prevent R20 from trying to dislodge her [DEVICE]. V27 stated she regularly gave R20 extra full body baths, but did not document them on the bath records. Discharge summary dated 08/31/2018, from a local hospital, documents that R20 has superficial wounds at the sacrum, below her breast and her groin area, likely secondary to abdominal binder that was not cleaned properly in the nursing facility. Per V26 (Social Worker) from a local hospital, maggots were found near and in R20's vagina area. R20 was admitted [DATE] and discharged from a local hospital on [DATE]. ADL monitoring sheet, undated, was reviewed for the week of 08/21/2018 to 08/27/2018. No baths are recorded for R20. R20 was admitted [DATE] and discharged from a local hospital on [DATE]. On 10/18/2018 at 2:12 PM, V27 stated, I consistently work on the 5th floor. Other shifts did not notice R20's abdominal binder. When I took care of R20, I gave her a bed bath daily, but I did not document the baths. On 10/18/2018 at 2:51PM, V2 stated, Staff try to give baths once a day and personal care whenever it is needed. I did not review the other months for R20 showers. Staff need to document what they do. Care plan dated 10/09/2018 documents that R20 has an ADL self-care performance deficit and R20 will be treated with respect, dignity, and reside in the facility free of mistreatment. Facility policy dated 08/15/2018, titled Activities of Daily Living, documents that documentation will be provided in the residents medical record of the assistance and amount of staff required to complete the task. The frequency of documentation will be determined by the individual resident's care needs. Facility policy dated 11/17, titled Abuse, Neglect and Exploitation, documents neglect as failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R9 is an [AGE] year old male admitted on [DATE] from acute care hospital with [DIAGNOSES REDACTED]. MDS (Minimum data Set) dated 4/24/18 reads Section G. Functional Status, G0110. Activities of Daily Living (ADL) Assistance: A. Bed mobility: 4 (Total dependence)/3 (Two+ persons assist), B. Transfer: 4 /3 Section H. Bladder and Bowel: H0300. Urinary Continence: 3 (Always incontinent), H400. Bowel Continence: 3 ar stage III physician's orders [REDACTED]. Hospital record reads, after visit summary: 5/29/18-6/1/18 . pressure ulcer 5/30/18 right posterior ear stage IV, pressure ulcer left posterior ear On 10/16/18 at 11:35am, V17 (Wound Care Coordinator) stated, the resident was on oxygen therapy with a nasal cannula. Prior to his hospitalization on [DATE], I was not informed of pressure ulcer behind his ears. The nurses should be checking behind the resident's ears daily and use the cushions with the tubing all the time to protect the skin behind the ears when residents are on oxygen. For the residents tend to lean on one side, more skin breakdown may develop overtime. His hospitalization is preventable had I been notified early. Redness of the skin could be an indication of a stage 1 pressure ulcer. R15 is an [AGE] year old male admitted on [DATE] from acute care hospital with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. On 10/11/18 at 1:15pm, this writer noted skin is slightly red behind right ear where the oxygen tubing is placed. V6 (LPN-Licensed Practical Nurse) stated, a cushion should have been placed with the tubing. On 10/16/18 at 12:10pm, V9 (LPN-Licensed Practical Nurse) confirmed there are no cushions with oxygen tubing for R15. V9 stated, the cushions should have been placed with the tubing to prevent irritation and skin breakdown. On 10/16/18 at 12:55pm, V2 (DON-Director of Nursing) sated, the nurses should be checking skin behinds residents ears to make sure there is no skin breakdown. If the residents are no able to remove their oxygen tubing, the cushions should be placed with the tubing to prevent pressure sores.

Based on interview and record review, the facility failed to use resident's insurance policy money for short stay rehabilitation services and instead used personal income without approval and failed to refund resident within 30 days of discharge until family persisted for one (R7) of 4 residents reviewed for admissions in the sample of 9 residents. This failure resulted in financial hardship for R7 who was maintaining an outside apartment and is on a fixed income. The findings include: R7 is a [AGE] year old, non-ambulatory patient who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7 requires extensive to total assistance with transfers, eating, dressing and hygiene/bathing. R7 was incontinent of bowel and bladder. R7 did score a 15 on brief interview mental score (BIMS) per the MDS. R7's physician orders [REDACTED]. R7 also had orders (12/14/17) to use a Bi-pap machine at night for sleep apnea. R7's physician order [REDACTED]. R7 was admitted to the facility under a medicare supplemental plan per the facility's New Referral Verification Checklist and R7's medicare insurance information. In R7's electronic clinical record under profile section, it documents admission type - short stay and Medicare coverage - Part A and B. Nurses' note dated 12/22/17 at 9:49 AM, R7 is asking staff why R7 is still in this facility. Nurses' note 12/22/17 documents that transportation to the other nursing home will be 12/23/17. Nurses' note 12/23/17 at 10:23 AM documents R7 leaving facility for other nursing home. On 3/27/18 at 11:15 AM, V18 stated that R7 was admitted to the nursing home for rehabilitation services which was to be short term. V18 stated that someone from the facility notified Social Security Administration (SSA) office on 1/7/18 that R7 wanted an address change and direct deposit of R7's Social Security check into the facility's address and bank. V18 stated that R7 never received R7's (MONTH) (YEAR) Social Security check. V18 stated R7 has yet to receive the requested Social Security Monies and any papers signed by R7 as of 3/27/18. On 3/29/18 at 11 AM, V5 (Assistant Manager of Business Office) stated that R7 signed papers allowing social security monies to be deposited into the facility's bank and allowing an address change. V5 stated she does not know why R7 used only R7's initials when it called for a signature but did say that R7 was tired and did not want to complete all the admission papers and presented documentation of the number of attempts V5 made to get R7 to sign the contract. V5 stated not to know who would of faxed R7's income (Social Security) information to SSA. V5 stated she does paperwork for so many residents it is hard to remember. V5 stated R7 was to be here long term and does not know why R7 was discharged from the facility. The documentation (the backside of the front page of the admission packet) presented by V5 were dates of 12/14/18 (admission) - 12/23/17 discharge, 12/15/17 - resident refused to sign anymore, saying I'm tired. 12/19/17 documents This writer (V5) checked in. Resident (R7) was asleep. 12/21/17 - resident (R7) wanted to re-schedule. R7 was not feeling well. On 3/30/18 at 10:40 AM, V7 (Corporate Business Office/Consultant) stated R7 was admitted with medicare coverage and presented R7's medical coverage. V7 stated she does not know why R7's Social Security monies were taken and why R7's business account was not closed when R7 was discharged from the facility. V7 stated she was notified by V18 on 3/2/18 about the facility receiving R7's social security monies. V7 provided emails in regards to R7's money owed and R7's financial statement. V7 stated that corporate office issued a reimbursement check dated 3/28/18 for R7's Social security monies. V7 stated she does not know why it took so long to reimburse R7. V7 stated that it was the corporate office in New Jersey that failed to close R7's account timely. V7's email confirms the 3/2/18 meeting with V18. Emails dated 3/20/18, 3/21/18, 3/23/18, 3/26/18 and 3/28/18 documents a back and forth dialog between V7 and V9 (Current Facility Business Manager) in regards to the status of a refund that is to be made to R7. R7's financial statement labeled Resident Statement Landscape documents a social security check for $1309 being deposited into the facility's resident fund management service on 2/14/18. $30 was automatically withdrawn from that amount on the same day. It documents that the account of a balance of $30.01 was closed out on 3/2/18. There is no documentation to support where the money was sent or given. On 3/3/18 at 1:05 PM, V9 stated she has been employed in the facility since 2/2/18 as the Business Manager. V9 stated that she does not know why New Jersey Corporate Office used R7's social security monies when R7 was here under her medicare coverage. V9 stated that V18 came into the office on 3/2/18 and said that the facility took R7's (MONTH) (YEAR) Social Security Check. V9 stated she told V18 that she would need to talk to billing. V9 stated V18 was okay with it. V9 stated she was not here on 3/28/18 when V18 was back in the facility asking again about R7's Social security monies owed. V9 stated that V18 met with V5 and does not know what was discussed. V9 stated she came to work the following day, Thursday 3/29/18 and saw the PDF file from corporate office for R7's check for money owed. V9 stated she printed it and sent it out with mail carrier. V9 stated she was unaware of any request for all R7's papers to be sent to V18. On 4/4/18 at 1:26 PM, V18 stated V18 has been given the run around by the facility staff on getting R7's money returned. V18 stated R7 received the check for $1279 this week but it is not the correct amount and it has not been cashed. V18 stated the check should be $1309. V18 stated that R7 really needs the money to maintain R7's apartment in the community and that it has caused a financial hardship for R7 who is on a fixed income. V18 stated that on 12/18/17, R7 wanted to be discharged . The facility staff was slow to respond to discharge request. R7 was discharged on [DATE] to another nursing home. V18 stated that V18 is surprised that R7 was able to sign anything because R7's hands were bad and R7 needed rehabilitation for the hands. V18 stated that there was no approval for R7's social security monies to be used for R7's rehab stay. On 4/4/18 at 2 PM, V5 stated that it was her previous boss, V19 (former manager of business office) who faxed R7's request to social security to change address and bank for direct deposit. On 4/4/18 at 3 PM, V7 stated that she was not aware that the whole amount of money owed was not given to R7. V7 stated that she will go to the currency exchange and get a money order for the difference of $30 dollars owed to R7. On 4/5/18 , V9 presented a Xerox copy of the $30 money order and certified mail receipt sent to R7. The facility's policy labeled Refunds documents when a resident is discharged or expires, it is the business office manager's responsibility to close the trust fund account. If the resident had any remaining funds in his or her account, these funds will be credited to the petty cash account and are to be refunded to the resident or legal representative within 30 days of discharge from the facility. This was not done. In the facility's contract, it documents that Medicare A will pay for a portion of inpatient skilled nursing or rehabilitation services provided in a participating nursing facility for up to 100 days after a 3 day qualifying hospital stay. The contract documents it is participating Medicare facility.

Based on interview and record review the facility failed to follow physicians orders and apply the [MEDICATION NAME] (narcotic pain reliever) every 72 hours for one resident (R2) of four residents reviewed for medication administration. This failure resulted in one resident (R2) having to be sent to the hospital, assessed to have on multiple [MEDICATION NAME]es, and assessed with [REDACTED]. Findings Include: The medical record documents R2 as a [AGE] year old resident with [DIAGNOSES REDACTED]. The Physicians Order Sheet ( POS) for R2 documents Z1 (Medical Doctor) ordered [MEDICATION NAME] 75 mcg (microgram) per hour patch to be applied one patch topically every 72 hours on 3/26/17. The Medication Administration Sheet ( MAR ) documents E4 Registered Nurse (RN) applied a [MEDICATION NAME] 75 mcg to R's right upper back on 4/9/17. Interview on 6/22/17 at 1:30 PM E4 stated, I administered a [MEDICATION NAME] to R2 on 4/9/17 at 6:00 AM. R2 did not have a patch on. The MAR indicated [REDACTED]. Interview on 6/22/17 at 9:15 AM E5 LPN stated, I remember R2 complaining of pain. I gave R2 [MEDICATION NAME] (patch) on the morning on 4/11/17. The site was the right deltoid (upper arm). I did a body assessment and did not see any [MEDICATION NAME]es. I gave it on 4/11/17, which was a day early because I didn't have the previous MAR. The new MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Facility Statement dated 6/22/17 written by E6 (nurse) documents in part, resident (R2) complained of pain, requested to have [MEDICATION NAME] applied, writer checked body, no old patch was found on the body, called MD, explained that resident MAR indicated [REDACTED]. The patch [MEDICATION NAME] (one) was applied on 4/13/17. Interview on 6/22/17 at 9:45 AM E2 Director of Nursing (DON) stated, It ([MEDICATION NAME]) was given to R2 on 4/11/17 by E5 LPN, this was one day early. The dose ([MEDICATION NAME]) was given to R2 on 4/13/17 by E6 LPN. R2 went out to the hospital the afternoon of 4/13/17. The Controlled Substances Proof of Use Log for R2 documents one [MEDICATION NAME] 75 mcg patches was signed out on 4/9/17 by E4, one [MEDICATION NAME] 75 mcg patch was signed out on 4/10/17 by E5 (nurse), and one [MEDICATION NAME] 75 mcg patch was signed out on 4/13/17 by E6 (nurse). Progress Notes dated 4/13/17 at 3:04 PM by E7 document, patient (R2) sent to local hospital for evaluation after change in mental status, lethargic, slurred speech, and slow to respond to verbal tactile stimulus. emergency room Notes from local hospital for R2 document in part; Neurological Assessment- patient (R2) was not responsive on arrival, but is talking to staff following [MEDICATION NAME] (narcotic reversal medication) administration. Patient is confused, oriented to person, confused speech. Nursing Assessment- patient transferred from ambulance stretcher to bed. A [MEDICATION NAME] was found on the patient, removed. Two liters oxygen via nasal prongs. A second [MEDICATION NAME] was found on the patient, removed. Patient is supposedly oriented to person, place and time, but today is only oriented to person. R2 takes pain patches at the nursing home. Denies chest pain, shortness of breath or abdominal pain. Patient was brought to emergency room (Z2) with history of altered mental status. Patient here with very shallow respirations. After [MEDICATION NAME] (narcotic reversal medication) patient woke up and started to talk and laugh. Respirations became normal.

Based on interview and record review, the facility failed to ensure medication administration as ordered by a physician and failed to notify the physician regarding missed doses of medication for one resident (R10) of 18 residents reviewed for quality of care in a sample of 30. This deficient practice resulted in critically low [MEDICATION NAME] blood levels and a [MEDICAL CONDITION]. Findings include: R10's Face Sheet documents a primary [DIAGNOSES REDACTED]. On 12/8/15, E22 (Nurse Supervisor) indicated that R10 was readmitted to the facility on [DATE] from a local hospital. R10's Physician order [REDACTED]. On 12/8/15, E22 indicated that [MEDICATION NAME] was ordered for R10 because of a history of [MEDICAL CONDITION]. R10's Medication Administration Record [REDACTED]. There is no documentation in R10's Nurses Notes which indicate that R10 refused the [MEDICATION NAME] on 11/22/15 and 11/24/15. The facility did not notify R10's physician regarding the missed doses of [MEDICATION NAME]. On 11/25/15, R10's blood was drawn for a [MEDICATION NAME] ([MEDICATION NAME]) level. The result: 6.2 Critically low. On 11/26/15, R10's POS documents that the [MEDICATION NAME] dose was increased to 300 mg in the morning and 200 mg in the evening. R10's MAR indicated [REDACTED]. There is no documentation in R10's Nurses Notes which indicate that R10 refused the [MEDICATION NAME] on 11/26/15. The facility did not notify R10's physician regarding the missed dose of [MEDICATION NAME]. R10's MAR indicated [REDACTED]. There is no documentation in R10's Nurses Notes which indicate that R10 refused the [MEDICATION NAME] on 11/30/15. The facility did not notify R10's physician regarding the missed dose of [MEDICATION NAME]. On 11/30/15, R10's blood was drawn for a [MEDICATION NAME] ([MEDICATION NAME]) level. The result: 8.0 Critically low. On 11/30/15 at 9:45am, R10's Nurses Notes document that R10 had a [MEDICAL CONDITION]. R10's MAR's were reviewed with E22 on 12/8/15 at 11:35am. E22 confirmed that the [MEDICATION NAME] had not been given on the dates when the medication was not initialed. E22 stated, With each dose that is missed or not given, then the physician should be notified. On 12/9/15 at 2:15pm, Z2 (Physician) stated, If patient is taking medication as prescribed, chances are much less for [MEDICAL CONDITION]. [MEDICAL CONDITION] medications are taken, [MEDICAL CONDITION] chances are less. If leaves on pass, then the medications should be given so they can take them. I'm aware of the times he didn't take [MEDICATION NAME] when not in the facility. That's all I know about. A review of R10's complete Care Plan, as submitted by E3 (DON-Director of Nursing), indicates that R10 does not have a Care Plan to address his [MEDICAL CONDITION]. A facility policy dated April 2010 and titled, Administering Medications documents, in part: POLICY: Medications shall be administered in a safe and timely manner, as prescribed. 3. Medications will be administered in accordance with the orders, including any required time frame.

Based on interview and record review the facility failed to provide the appropriate amount of assistance during a transfer for 1(R1) of 4 residents reviewed for transfers. As a result, R1 fell and sustained a displaced oblique fracture of the left mid femur which required surgery. Findings Include: Face Sheet document that R1 now [AGE] years old was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. Incident Report dated 10/8/2013 documents on 10/8/2013 at 10:50 am states, " staff was assisting resident in the washroom commode. Resident got up from the toilet, stated that she felt a sharp pain in her leg and lost her balance. Staff attempted to break her fall and lower resident slowly to the floor. Body assessment done, skin intact, no bruising or hematoma, complained of pain on the left leg with movement. As needed pain medication given. Vital signs are; blood pressure 107/64, temperature is 98.9, Pulse is 67 and respiration is 25. Physician notified, x- rays ordered. Family was notified. X- Ray report dated 10/8/2013 was taken at 8:54 PM and reviewed by the radiologist at 9:55 PM. The results were displaced oblique fracture of the left mid femur. Nursing Note dated 10/8/2013 at 10:48 PM states that the x- ray result was called into the facility and the doctor was notified to send R1 out to the hospital. Transfer Form dated 10/8/2013 at 10:36 PM documents to transfer R1 to the hospital for displaced oblique fracture of the left mid femur. Minimum Data Set were reviewed for 8/17/2013, 9/27/2013 and 10/3/2013 all of them document extensive assists with 2 plus persons for transfers and toilet use. The same MDS document that R1 had functional limitations in range of motion with impairments on both sides for upper and lower extremities. Care Plan dated 10/1/2013 for Risk of Falls documents that "R1 needs extensive of 1-2 staff to perform bed mobility, transfers and activity of daily living." Safe Lifting and Movement of Residents Policy revised on 10/2009 states, " Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Residents preference for assistance, resident ' s mobility, resident ' s size, weight- bearing, cognitive status, cooperation and resident's needs for rehabilitation, including restoring or maintaining functional abilities." Hospital Record dated 10/9/2013 through 10/15/2013 document that R1 was 250 pounds. Triage Notes document that left leg was noted shorter and rotated. Pedal pulse noted with pain and discomfort. R1's height is 5 feet 0 inches and 250 pounds. Physician Consultation dated 10/9/2013 notes that R1's left leg with shortening, tenderness and deformity. On 10/12/2013 R1 underwent open reduction and intramedullary nailing and was discharged to another facility on 10/15/2013. On 10/18/2013 at 2:36 PM, R1 (crying) was lying in bed at another facility. R1 stated, " My leg hurt so badly the day that I fell . I was in the hospital prior to the fall and when I returned to the nursing home I was very weak. On 10/8/2013 I needed to go to the bathroom. E6 (Certified Nursing Assistant) came to help me. E6 (CNA) is very small. I told E6 (CNA) you are so little please call someone to help you I am heavy and I just got out of the hospital. E6 (CNA) told me all you have to do is put your foot out. I kept telling E6 (CNA) to get help but she insisted she could do. I tried putting my foot out a little and she put her foot outside of mine and pushed on my foot I lost my balance and fell and she fell on top of me. Other staff came in to help; they knew I was in pain. I could not walk or move my leg. I had to go to the hospital and have surgery." On 10/22/2013 at 9:52 AM, E6(Certified Nursing Assistant) stated, " I have been a CNA for about 5 months and have employed here for about 4 months. I was assigned to R1 on 10/8/2013. I was getting R1 up at about 10:50 AM to go to physical therapy. R1 requested to go to the toilet. I took R1 to the toilet alone then R1 complained of pain on her leg. I told her to hold the bar. I placed my feet outside of the residents to provide balance and I gently eased the resident to the floor. E4(Nurse) then came to help me get her up." E6(Certified Nursing Assistant) could not respond on how R1 sustained a femur fracture from being gently eased to the floor. On 10/28/2013 at 2:29 PM, E8(Physical Therapist) stated, "R1 is very inconsistent and requires moderate to maximum to total dependence for activity of daily living. R1 could make her needs known. For residents with inconsistency we provide the safest way to get them to be consistent." On 10/22/2013 at 11AM, E7 (Medical Doctor) stated, " I cannot say how many staff is required to transfer a resident. The facility assesses for that."

Based on interview and record review, the facility failed to recognize, identify and manage a change in respiratory status; comprehensive assessments and care planning for 1 in a sample of 4 residents (R27)reviewed for respiratory status in a total sample of 30. This deficient practice resulted in a delay of emergency medical treatment. R27 was admitted to the hospital with [REDACTED]. Findings include, On [DATE] at 9:00am E14 Registered Nurse (RN), documented on nurses notes R27 had a change of condition: shortness of breath (SOB), congestion, nonproductive cough. E14 gave nebulizer treatment and placed resident on [MEDICAL CONDITION] machine. No documentation found in chart that physician was updated or notified about change of condition. On [DATE] at 11:50am E14 documented R27 had another change of condition. Vitals signs where: Blood Pressure ,[DATE], Pulse 112 per minute, respiration 28, pulse oximetry ,[DATE]% on [MEDICAL CONDITION] and 4 liters(L) nasal canula (NC) and lethargic. R27 was significantly SOB with the use of accessory muscles. On [DATE] at 12:02pm Z1 ,physician, was notified of R27 change of condition. Orders where received to send resident to local hospital for evaluation. Referring to nurses notes R27 was transferred to local hospital at [DATE]at 2:11pm. No care plans found in chart regarding respiratory status. On [DATE] at 8:50am E1 (Administrator) stated the facility has a contract with two ambulances. In an event a resident needs service of an ambulance to be transferred to emergency room depending on the situation the time varies of arrival but an hour would be too long of a wait. E1 stated in an event of an emergency 911 is called. On [DATE] at 11:50am E14 stated on [DATE] at 9:00am R27 was sitting up in the bed with SOB, hyperventilating, using accessory muscles. E14 was unsure of the respiratory rate at that time. E14 also noticed resident very congested with a nonproductive cough. Attempted to suction but did not obtain any secretions. E14 proceeded to assess and reposition R27 in bed and placed R27 on assistive breathing machine ([MEDICAL CONDITION]). No improvement observed at that time. E14 told Z2, Certified Nurse Assistant (CNA), at 9:30am to remain with resident due to his change in condition that it was time to pass medication. E14 did not notify physician at the time of change in condition in resident. E14 stated that at 10:30am she observed R27 in bed with deep breathing and was frequently monitoring him. No documentation provided to evaluate regarding the frequent monitoring. E14 did not notify anyone of the change in condition of resident at this time. E14 stated that around lunch time vitals signs where taken and despite the effort to wake up the resident he did not wake up. E14 does not remember notifying supervisor. E14 updated the physician regarding R27's condition and received an order to send R27 to local hospital emergency room for evaluation. E15, Assistant Director of Nursing (ADON) stated E14 notified her via telephone after lunch that R27 had a change of mental status and was concerned regarding R27's SOB. E15 stated R27 had frequent episodes of SOB and was continuously on oxygen due to resident noncompliance with [MEDICAL CONDITION] machine. E15 stated she told E14 to notify physician if she considered the change where to be significant. E15 further stated, "Vitals signs where normal. Resident was only sleeping; there were no acute changes to warrant a 911 call." On [DATE] at 2:00pm via telephone Z1 stated the nurses around 7:00am provide a daily telephone report regarding the resident status. No abnormal or unusual concerns where identified at that time. The next report received by the nurse was approximately between 12:,[DATE]:00pm of the resident's altered mental status. At that time, an order was given to send R27 to a local hospital. Referring to hospital records, R27 was admitted to a local hospital on [DATE] at 4:04pm. R27 was intubated and placed on mechanical ventilation in the emergency room (ER) and transferred to the intensive care unit (ICU). Admitting [DIAGNOSES REDACTED]. R27 expired on [DATE] at 5:02am.