Every finding on record at Complete Care at the Boulevard

Based on interview and record review the facility failed to ensure that one resident (R1) was free from physical abuse when R2 struck R1 in the face during an altercation in their shared room. This failure affected one of three residents reviewed for abuse. Findings include: R1 has a diagnosis which includes but not limited to opioid dependence, unspecified acute conjunctivitis right eye, and adjustment disorder with depressed mood. R1's Brief Interview for Mental Status (BIMS) dated 5/22/26 shows a score of 11 which indicated that R1 has some cognitive impairments. R2 has a diagnosis acute respiratory failure with hypercapnia, respiratory conditions due to smoke inhalation, hyperlipidemia, injury unspecified, reduced mobility, chronic obstructive pulmonary disease, and primary insomnia. R2's Brief Interview for Mental Status (BIMS) dated 4/24/26 shows a score of 8 which indicated that R1 has some cognitive impairments. R1's progress notes dated 6/14/26 authored by V4 (LPN) documents in part: At approximately 5:30 am resident roommate was seen hitting him by staff, staff then came and notified writer . No redness, cuts or bruising on either resident. R2's progress notes dated 6/14/26 authored by V4 (LPN) documents in part: At approximately 5:30 am resident was seen hitting roommate by staff, staff then came and notified writer. The facility's Initial Reportable Incidents dated 6/14/26 at 11:37 am, documents in part: R2 made inappropriate contact with R1. Investigation initiated. Final Report to follow. The facility's Final Reportable Incidents dated 6/22/26 at 8:58 pm, documents in part: 6/14/2026 at approximately 6:00 am altercation occurred between roommates. R2 and R1 in room [ROOM NUMBER] Prior to altercation, a verbal disagreement occurred between the residents. Following the alleged interaction, R1 activated his call light to request assistance. The assigned (Certified Nursing Assistant CNA responded Immediately to the room. Upon arrival, R1 reported that R2 had made physical contact with him following the verbal disagreement. The interaction here concluded prior to staff arrival. CNA immediately notified the assigned nurse and remained present while further assessment and intervention were initiated to prevent further interaction between the residents. The facility's document dated 6/14/26 and titled Statement Form shows R2's statement as follows He was talking foolish and crazy to me. So, I came over to his side of the room because I am definite (definitely) not scared and yes I hit him. He shut his mouth after that, but staff moved me to a different floor. I feel better in my new room. On 7/6/26 at 1:26 pm, R1 stated that he recalls the incident with R2 about one month ago. R1 explained that he was in his room lying in bed and asked R2 to turn the television down. R1 further explained that R2 began cursing at R1, R1 started cursing back at R2 and R2 then walked over to R1's bed and hit R1 on the left side of his face. R1 further explained that he activated his call light on and began yelling out for the nurse to come into the room. R1 stated that the nurse came into the room with the police and the police made R2 move to another room upstairs. R1 stated that he still sees R2 during smoke breaks, has not had any further confrontations with R2 and feels safe in the facility. R1 denied having any injuries and also denied that R1 and R2 had any confrontations prior to the incident on 6/14/26. On 7/6/26 at 1:37 pm, R2 stated that he recalls the incident with R1 about a month ago however does not recall how the incident began. R2 stated that he recalls R1 yelling at R2 and that R2 then hit R1 in the face. R2 further explained that R1 then called the local police after R2 hit R1 in the face and once the local police arrived, they moved R2 to the third-floor unit. R2 explained that R2 and R1 were roommates for one year, argued all the time and never got along. R2 also stated that he has seen R1 during smoke breaks and denied any further altercations with R1 at the facility. R2 stated that he is happy in his new room and that he feels safe at the facility. On 7/7/26 at 9:02 am, V5 (Certified Nursing Assistance, CNA) stated that she has a worked at the facility for one year. V5 explained that she cares for R1 and R2 frequently and was R1 and R2's CNA the 11:00 pm, - 7:00 am shift on 6/14/26 the day of their incident. V5 explained on 6/14/26 around 5:00 am, she was doing rounds when she heard R1 yelling very loudly with the call light on from his room. V5 then explained when she went into R1 and R2's room, R2 was walking around the room near the doorway, and R1 immediately reported that R2 hit him while R2 confirmed R1's statement by stating, Yes I hit him. V5 then explained that R1 was laying in his bed and that she did not observe R1 with any injuries. V5 stated that she got in between R1 and R2 beds and yelled out for V4 (Licensed Practical Nurse, LPN) who came into the room and asked what happened in which R1 informed V4 that R2 hit him in the face. V5 then stated that V4 instructed R2 to leave out the room and R2 stated he wasn't leaving until he got his things. V6 then explained that she stayed with R1 and R2 while V4 went to call the local police and waited in the room until the police arrived. V5 further explained that once the police arrived, they let R2 pack up his belongings and R2 was moved upstairs to a room on the fourth-floor unit. V5 explained that she had previously cared for R1 and R2 prior to the incident and would hear R1 and R2 occasionally argue about the window being open or air condition being on and that she would report their arguments to the nurse on duty at the time and they would reply by saying I will handle it. On 7/7/26 at 9:54 am, V4 (LPN) stated that she no longer works at the facility and that she recalls being R1 and R2's nurse on 6/14/26 when R1 and R2 had an incident in their shared room. V4 explained that V6 (CNA) inform her that R2 hit R1 in the face as well as threatened and yelled at R1. V4 stated that she recalls the incident being around 5:00 am, and that V6 came to V4's medication cart to inform her that the residents were in the room having an altercation. V4 then explained that she immediately went to the room and that R2 was sitting on the edge of his bed still yelling and admitting to hitting R1. V4 stated that she instructed R2 to come out of the room and that he would move to another room however R2 refused. V4 then explained that she did not know who the abuse coordinator for the facility was, that the facility did not have a director of nursing at the time and that she texts the facility on-call phone to notify a supervisor of the incident and that she was calling the local police. V4 then explained that she called the local police due to R2's refusal to willing move out of the room and once the local police arrived, they stayed until R2 got his belongings and the police escorted R2 to another floor. V4 then explained that she went back to assess R1, R1 had no injuries and that R1 stated that he felt safe now that the roommate (R2) was gone. V4 also explained that she called R1's and R2's physician regarding the incident. V4 then stated that she had previously cared for R1 and R2 and denied that she was ever made aware of them having any past confrontation. On 7/7/26 at 11:35 am, V2 (Director of Nursing, DON) stated that she has been the DON since May 18, 2026, and that she does not recall the incident with R1 and R2 on June 14, 2026. V2 explained that the facility has on call weekend managers who staff inform of any concerns or issues and that V2 was not directly involved with R1 and R2's incident. V2 explained that V1 (Administrator) is the facilities abuse coordinator and was directly involved with R1 and R2's incident. On 7/7/26 at 11:44 am, V1 (Administrator) stated that he is the facility's abuse coordinator and abuse is reported immediately to V1. V1 stated that he recalls the incident regarding R1 and R2 and was informed by one of the facility's managers regarding the incident a few weeks ago. V1 explained that he was informed that there was a verbal altercation that turned into R2 hitting R1 without any injuries. V1 stated if a resident strikes another resident with the intention to harm them that is considered physical abuse. V1 explained that the facilities protocol is to separate the residents immediately, make sure the residents are safe with no injuries, notify the appropriate parties and report the incident to the abuse coordinator to initiate an abuse investigation. V1 also stated that he was not informed of R1 or R2 having any past altercations with each other prior to their incident on 6/14/26. V1 also stated that if two roommates are constantly swearing or arguing with one another staff should report the incidents to the social service department to determine if the residents should remain roommates or be placed in separate rooms. The facility policy dated 10/14/25 titled Abuse 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. Definitions: Physical Abuse: includes but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure that one resident (R1) received the correct prescribed medication. This failure caused R1 to experience symptoms of intoxication; (leaning over the table, weakness, inability to maintain upright sitting position or eat independently, decreased strength and limited ability to respond) and had to be sent out to the hospital for evaluation for receiving a medication used to treat opioid use disorder. This failure affected one resident R1 out of a sample of 3 residents. Findings Include:R1 has a diagnosis of but not limited to Spinal Stenosis, Spondylosis with Myelopathy, Hypertension, and Adult Failure to Thrive.R1 has a Brief Interview of Mental Status score of 13 that indicates intact cognition.Surveyor reviewed R1's Order Summary Report with Active Orders as of 5/14/2026 does not document a diagnosis of Opioid Dependence or an order for Suboxone Sublingual Film 8-2 mg (milligram) (Buprenorphine HCL{Hydrochloride}-Naloxone HCL{Hydrochloride} Dihydrate).R3 has a diagnosis of but not limited to Partial Traumatic Amputation of Left Great Toe, Hypertension, Opioid Dependence, Nicotine Dependence, Cocaine Use and Anxiety Disorder. R3 has a Brief Interview of Mental Status score of 15 that indicates intact cognition.R3's Order Summary Report with Active Orders as of 5/15/2026 does document a diagnosis of Opioid Dependence and an order for Suboxone Sublingual Film 8-2 mg (milligram) (Buprenorphine HCL{Hydrochloride}-Naloxone HCL Dihydrate) give 1 buccal system sublingually every 12 hours for Opioid Withdraw. On 5/14/2026 at 2:56pm R1 stated a nurse (V6, Registered Nurse, Former Employee) gave him a square film as his medication that V6 placed under his tongue that made me High as a [NAME], and my daughter had to make them (nurses) send me to the hospital. R1's progress note, authored by V6, dated 4/08/2026 at 11:22am, documents, in part, I (V6) went into (R1 and R3's shared room) to administer R3's medication. I walked into the room and called out for the resident in R3's bed (by room and bed number) and R1 (in the same room but a different bed) answered, and I gave the medication to R1.Surveyor tried to reach the nurse V6 (Registered Nurse) who administered the incorrect medication over several days (5/15 and 5/16) at different times with no success. Daily Census Report, dated 4/7/26, documents, in part, that R1 and R3 were residing in a shared room in the facility.Surveyor reviewed R1's local hospital record dated 4/08/2026 that documents, in part, altered mental status and ingestion of unknown medication, accidental or unintentional.R1's progress note dated 4/8/2026 at 12:25pm by V13 (Licensed Practical Nurse) documents, in part, R1 observed in bedroom leaning forward over bedside table, appearing weak and unable to maintain upright sitting position or eat independently. R1 noted to have decreased strength and limited ability to respond appropriately during assessment. Immediate evaluation performed; VS (Vital signs) BP (Blood Pressure)130/71, P (Pulse) 75, R (Respirations) 16, Temperature 98.3, O2sat (oxygen saturation) 96% RA (room air). V13 notified NP (nurse practitioner) and order received to send R1 to local emergency department for further evaluation and treatment.On 5/15/2026 at about 2:10pm V4 (Registered Nurse) and V13 (Licensed Practical Nurse) stated we are expected to identify the resident by checking the photo in facility's electronic charting system, ask the resident their name, and if the nurse is still not sure ask another staff member, who's familiar with the residents, to identify the resident. V4 stated we are to ensure the rights of medication administration are followed by making sure we have the right resident, right drug, right dosage, right route, and right time.On 5/15/2025 at 2:54pm V2 (DON) stated my expectations of the nurses when passing medication to prevent a medication error is to check the picture in facility's electronic charting system, check the name on the door and ask the resident, and/or ask the CNA's.On 5/16/2026 at 12:02pm via email V2 stated V6 verbally resigned on the morning of April 8, 2026, and did not return to work after that date.On 5/16/2026 at 1:27pm R3 stated V6 told R3 that R1 gets that medicine (sublingual Suboxone), and I (R3) told her, that was my (R3's) medicine, but she had given my Suboxone film 8-2mg (milligram) to R1.Medication Error report dated 4/08/2026 for R1 documents, in part, Incident Description: I (V6) went to (R1 and R3's shared room) to administer medications. I (V6) walked in the room and called out for the resident for (R3's room/bed number) and the resident in (R1's room/bed number) answered and I gave the medication to him (R1). After administering the medication, the (R3) let me know that he is the resident that I called out for and that I (V6) just gave the Resident (R1) next to him his medication.Medication Administration Policy with a revised date of 10/20/2025 documents, in part, Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice, 3. Identify resident by photo in the MAR (medication administration record) and 10. Ensure that the six rights of medication are followed: right resident, Right drug, and Right route.Undated Job description titled Registered Nurse documents, in part, may provide direct nursing care to the residents and prepares and administers medications as per physician's orders.

Based on observations, interviews, and record reviews, the facility failed to prevent neglect on a resident who required wound care treatment which was not completed and documented. This failure affected one resident (R1) out of three reviewed for neglect in the facility. Findings include: R1's admission diagnoses include but are not limited to cerebrum hemorrhage, atherosclerotic heart disease, colostomy, hypertension, COPD (chronic obstructive pulmonary disease), cocaine abuse, acute kidney failure, and depression.R1's Minimum Data Set (MDS) dated [DATE] documents, in part, Section C. Brief Interview of Mental Status (BIMS) score is 14. R1 is cognitively intact.R1's admission assessment dated [DATE] documents in part, 1. admission Details: c. Admitting Diagnosis CABG (Coronary Artery Bypass Graft) . 9. Skin Integrity: surgical scar post CABG. right lower extremity dressing.On 5/1/26 at 11:55 am, R1 stated, I would ask the nurses to change my leg wound dressing. The nurses would not change my dress so I would change it myself. The dressing would be dirty and bloody. I had some supplies I got from the hospital. I took pictures of my dirty dressing. The manager told me not to change my own wound dressing to let the nurses change it, but they would not do it.R1's (Active Orders as of 5/1/26) Order Summary Report, documents, in part, Order date 2/26/26, Wound care consult and treat as needed.R1's (Active Orders as of 5/1/26) Order Summary Report, documents, in part, Order date 4/10/26, Cleanse right medial leg with Dakin's pat dry pack with silver alginate and cover with dry dressing daily and PRN (As Needed).R1's wound care doctor visit dated 3/5/26 documents, in part, Wound location: Right medial Leg surgical incision. Wound Type: surgical. Wound Status: unknown. Exudate Amount; Low. Exudate Type: sanguinous (bloody). Odor: not malodorous. Treatment Recommendations: The plan for the surgical wound is to cleanse the area with normal saline. Primary Dressing: 1. Paint with Betadine. Secondary Dressing: 1. Bordered Gauze. This treatment will be done every other day until discontinued. Today's treatment will be done by the wound care team and other care performed by the staff of the facility.R1's wound care doctor visit dated 3/26/26 documents, in part, Wound location: Right medial Leg surgical incision. Wound Type: surgical. Wound Status: worsening. Exudate Amount; moderate. Exudate Type: sanguinous (bloody). Odor: malodorous. Treatment Recommendations: The plan for the surgical wound is to cleanse the area with Dakins (1/2 strength) solution. Primary Dressing: 1 Honey (Medial Grade) Gel. Secondary Dressing: Silver Alginate. This treatment will be done daily until discontinued. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility. Will check CBC (Complete Blood Count). Add Doxycycline 100 mg (milligram) po (by mouth) BID (Twice a day) for 7 days.On 5/1/26 at 11:48 am, V6 License Practical Nurse (LPN) stated that the nurses are supposed to change R1's leg dressing when the wound nurse is not working. The dressing is to be documented when completed. On 5/2/26 at 12:26 pm, V3 Director of Nursing (DON) stated, I just started working here but if a resident needs wound care and don't have an order for treatment, they should follow standard wound care, moist to dry dressing. The nurse should follow up with the Doctor and get orders. It is not appropriate for the residents to change their own wound dressing. The nurses are here to do that for them. Doctors do give verbal orders sometimes. If a doctor has some recommendations and does not write the order, the nurse should follow up and question it. Nurses are expected to carry out the Doctor's orders, and they need to verify that the orders are put into the computer (resident's electronic health record, EHR).On 5/2/26 at 2:15 pm, V4 (Wound Care Nurse) stated, I make rounds with the wound doctor. The wound doctor rounds twice a week. The wound doctor does tell me what the treatment recommendations are. The treatment recommendations on the notes are the doctor's orders; I normally put in orders from the treatment recommendations. I'm not sure why the order for March (3/5/26) is not in (R1's EHR). It was my omission. I did not do it. It was a lot going on at that time. I did not check the orders because I thought the orders already existed. He (R1) would ask the nurses to change his wound dressing, but no nurse came to me to say there were not any orders. I did see the recommendation for March 26th for daily dressing change, but I did not put that order into the computer. I was not aware of him (R1) needing any antibiotics. I only look at the measurement and the treatment recommendations from the doctor's notes. R1's Treatment Administration Record (TAR) for the month of March 2026, there were no documented wound treatments performed for R1's right medial leg surgical incision on the 7th, 11th, 14th, 18th, 22nd, 25th, 27th, 28th, 29th, 30th, 31st. R1's TAR for the month of April 2026, there were no documented wound treatments performed for R1's right medial leg surgical incision on the 1st, 3rd, 4th, 5th, 7th, 8th, and the 9th. R1's progress notes dated 4/2/26 documents, in part, Resident (R1) reported that he has been independently changing his own dressing using supplies kept in his room. Upon assessment, wound healing is not progressing appropriately at this time. Facility policy titled, Wound Treatment Management dated 2/10/26, 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 frequently of dressing change. 2. The absence of treatments orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on interview and record review the facility failed to a.) follow their policies and evaluate fall risk in accordance with professional standards of practice b.) provide supervision and assistive devices consistent with a resident's needs to prevent avoidable/reduce the risk of an accident for one resident (R6) out of three residents reviewed for accidents in a total sample of eight residents. This failure resulted in R6 sustaining a fall without significant injury. Findings include:On 05/03/2026 at 2:32 PM, R6 stated the CNA (certified nursing assistant) took me with my wheelchair to the shower room, and when she was assisting me to the shower chair, my foot got tangled, like I couldn't move, and I fell. R6 stated that she was sent to the hospital to get evaluated. R6 denied suffering any major injuries and denied any fractures.On 05/03/2026 at 2:25 PM, V12 (Certified Nursing Assistant) stated that R6 requires two-person assistant for transfers (when we transfer her from bed to wheelchair or to the shower chair). V12 stated that R6 is a fall risk and V12 stated that V12 was not here when R6 fell in March.On 05/04/2026 at 12:01 PM, V15 (Licensed Practical Nurse) stated that the day R6 fell (March 17th, 2026), V15 was called in by V16 (Certified Nursing Assistant) to the shower room and told V15 that R6 had a fall while V16 was trying to transfer R6 from the wheelchair onto the shower chair. V15 stated, it was just V16 and R6, no one else was in there. R6 had a skin tear on her right hand, I cleaned it with normal saline and applied a dry dressing. V15 denied that R6 had any bumps or significant injuries noted. V15 stated that after R6's fall, V16 was educated on proper transfer etiquette. V15 stated that prior to R6's fall, R6 was in stable condition and was not having any changes in condition.On 05/04/2026 at 1:11 PM, V17 (Restorative Nurse/Registered Nurse) stated that when a resident fall occurs, V17 investigates it and makes sure the care plan is updated with an intervention including reeducation to residents and staff. V17 stated that R6's post fall risk assessment was missed and V17 will need to update it. V17 stated that prior to R6's fall, R6 required maximum assistance and one personal physical assistance for transfers. V17 stated that in general, it is important for a resident's plan of care to be most up to date and accurate because staff look for types of preventions and if a situation like a fall would occur, it would allow staff to assess for the root cause and analysis. V17 denied witnessing R6's fall. With V17, R6's plan of care shower transfer in the last 30 days, and it documents R6 required dependent as well as maximum assistance. V17 stated that the CNAs shouldn't have documented dependent because R6 is maximum assistance. V17 stated that she has assessed R6 but V17 just didn't document it and V17 stated that if it was not documented, it was not done.On 05/04/2026 at 11:33 AM, this surveyor made an outbound call to V16 (Certified Nursing Assistant) and no answer, voicemail left.On 05/04/2026 at 11:43 AM, outbound call to V16 (Certified Nursing Assistant) and no answer.On 05/04/2026 at 11:59 AM, V3 (Director of Nursing) reported that she called V16 twice but there was no answer. V3 stated that she left V16 a detailed voicemail to contact this surveyor.R6's fall risk assessment dated [DATE] documents that R6 is high risk for falling.R6 does not have any fall risk assessments completed since 08/20/2025.R6's current face sheet document R6 is a [AGE] year-old individual admitted to the facility on [DATE] and current medical diagnosis are listed to include but not limited to: syncope and collapse, restlessness and agitation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, contracture, unspecified joint.R6's care plan documents in part, the resident has an ADL (activities of daily living) self-care performance deficit r/t dementia, Hemiplegia, Limited Mobility, Limited ROM (range of motion). Goal documents the resident will maintain current level of function in ADLs through the review date. Interventions document in part, transfer: The resident requires Mechanical Lift (Hoyer Lift) with two staff assistance for transfers. Date Initiated: 05/01/2018 Revision on: 08/10/2021.R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating R6 is cognitively intact.Facility document documents in part, certified nursing assistant job description, assist residents with or perform activities of daily living for resident in accordance with care plans and established policies and procedures.Facility document dated 10/07/2025 documents in part, fall risk assessment, it is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provide supervision and assistive devices to each resident to prevent avoidable accidents. The risk assessment will be completed by the nurse or designee upon admission, quarterly or when a significant change is identified.Facility document dated 10/07/2025 documents in part, each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status.a.Provide additional interventions as directed by the resident's assessment, including but not limited to:Assistive devicesWhen any resident experiences a fall, the facility will: Assess the resident.Complete a post-fall assessment.Complete an incident report.Notify physician and family.Review the resident's care plan and update as indicatedR6's documentation survey report for GG tub/shower transfer documents in part R6 required 01- Dependent -Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity on the following dates (03/06/2026, 03/07/2026, 03/08/2026, 03/12/2026, 03/15/2026).

Based on record review and interview, the facility failed to ensure there was sufficient qualified dietary staff available to cook meals. This failure has the potential to affect 127 residents who received meals from the kitchen. Findings Include: On 03/28/26 at 10:47 AM V5 (Former Dietary Aide) stated V12 (Dietary Aide) and V14 (Dietary Aide) were cooks and dietary aides. V13 (Dietary Aide) has her certification but 3 other cooks are there with no certification. They tried to force me to bake but I am a dietary aide. I was scared because the oven is big and hot.On 03/28/26 at 07:26 AM During the kitchen tour there were three staff members observed working in the kitchen. V6 (Dietary Aide) was cooking and plating breakfast. V9 (Dietary Aide) was observed covering the plates with the dome covers, putting the plate and utensils on the trays. V7 (Dietary Aide) was observed putting condiments, juice and milk on the trays, putting the trays on the food cart, covering then transporting the carts to the nursing units.On 03/28/26 at 07:26 AM V6 (Dietary Aide) stated V10 is the dietary Manager, and she is on her way. I have been here for 4 years, and I am the cook. I cook breakfast and lunch. There are only three of us working today. I guess we have gotten kind of use to it. We are team players and work together. I came in as a cook, we did not need the cook certificate with the old company, and they never asked. The new company said we do need the cook certification. Last week they told us we had to have a cook certificate. We were told the night cook has to do the baking. If it is not done the dietary aides in the morning have to come in and do it because I don't have time.On 03/28/26 at 07:33 AM V7 (Dietary Aide) stated They force us to bake the desserts. I come at 6 am on be on the line at 7 am and do the desserts.On 03/28/26 at 12:52 PM Per telephone interview V14 (Dietary Aide) stated I am a cook. I got whatever they told me to take. I work part time. At this time, I am not doing the cooking, but I am a fill in. You have to have a certificate to cook. All cooks need to be certified to be a cook is what was required.On 03/28/26 at 08:01 AM V10 (Dietary Manager) arrived in the kitchen. V10 stated I have worked here since 03/04/26. On Monday -Friday there is one cook, two dietary aides and I assist on the tray line as well.On 03/28/26 at 11:24 AM V10 (Dietary Manager) stated the qualified cooks are me and V9 (Dietary Aide). Everyone else is food handlers. Handling, touching and preparing food in the kitchen is done by the cooks. The dietary aides can also handle food. The food handlers cannot prepare food. I am aware that food handlers cannot cook the food. The food handlers do not take the classes to be able to prepare the food. V6 (Dietary Aide) is a food handler and is going next month on 04/07/25 for her cook certification. V9 (Dietary Aide) does not cook. V6 cooks breakfast and lunch Thursday - Sunday. I did not know the dietary aides were doing the baking also.On 03/29/6 at 08:29 AM V1 (Administrator) stated regarding the cooks we spoke with the third party all cooks should be certified tomorrow 03/30/26 or Tuesday 03/31/26.ServSafe Certification dated 02/09/22 document in part: V10 (Dietary Manager) for successfully completing the standards set forth for the ServSafe Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute Conference for Food Protection.Food Handler Certificate of Completion dated 01/18/25 document in part: V6 (Dietary Aide) is recognized for successfully completing the eFoodcard Food Handler Basics Course.Dietary Schedule Cooks Listed: V6 (Dietary Aide), V12 (Dietary Aide), V14 (Dietary Aide), V17 (Dietary Aide).Certificate of Achievement dated 04/09/23 document in part: This certificate is awarded to V12. Congratulation! You have completed ServSafe Food Handler Employee Food Safety Online Course and Exam.State Food Safet Certificate of Training dated 10/10/25 document in part: awarded to V14 (Dietary Aide) for successfully completing the Food Handler Essentials Course.Illinois Food Handler Certificate dated 03/04/25 recipient V17 (Dietary Aide).Dietary Schedules dated 12/28/25 - 01/31/26 document Cooks as V6 (Dietary Aide), V12 (Dietary Aide), V13 (Dietary Aide), V14 (Dietary Aide).Job Description: Position Title: [NAME] date 08/20 document in part: [NAME] will follow all applicable procedures to clean, prepare, and cook large batches of food that will be served to residents and guest. Education and experience, an equivalent combination of education, training and experience will be considered.The census was obtained from the facility roster of 131 residents with four residents being NPO (Nothing by mouth).Policy:Titled Safe Food Handling dated 09/01/21 document in part: All foods are prepared in accordance with the FDA (Food and Drug Administration) Food Code.

Based on observation, interview and record review the facility failed to ensure a dietary staff member performed hygiene after removing and changing gloves while in the dish room. This failure has the potential to affect 127 residents who received meals from the kitchen.Findings Include: On 03/28/26 at 09:18 AM V7 (Dietary Aide) returned to the kitchen with food carts. V7 was observed dumping/scraping the trays, placing the utensils, plates and cups in sanitizer. V7 said if there are 2 people I would run the dishes through the dish washer, and the second person will catch the clean dishes.On 03/28/26 at 09:36 AM V9 (Dietary Aide) entered the dish room to assist. V9 observed pushing the racks with the dirty dishes into the dishwasher. V9 then removed the clean trays and put the clean dishes on a cart without changing her gloves or performing hand hygiene. A hand-washing station was observed in the dish room. V9 continued to push the racks with the dirty dishes into the dish washer, changed her gloves without performing hand hygiene and removed the clean dishes from the dish washer. V9 then pushed two racks with the dome plate covers and three racks with trays into the dish washer changing gloves each time without performing hand hygiene before removing the clean domes and trays from the dish washer. V9 rinsed a rack with dirty trays and partitioned plates then changed gloves, pulled out plate domes and place them on the cart after changing gloves without performing hand hygiene.On 03/28/26 at 01:09 PM Per telephone interview V15 (Dietary Aide) stated dish washing is supposed to be 3 staff, but we only have 2. I go upstairs to pull carts down, scrap, load the dishwasher. We try to change gloves as much as possible. If you don't have a third person, it is kind of difficult.On 03/28/26 at 11:24 AM V10 (Dietary Manager) stated There should be 2 people in the dish room, and their responsibility is to go get the food cart, break down, scrap, set up for dishwasher and the dishwasher pull the clean dishes through. That is our process. Trays and domes are put in a tray to be put in the dishwasher. The second person pushes the dishes in the dishwasher and takes them out. Hand hygiene is done after the dishes are pushed through, change glove then grab clean dishes with new gloves. They should wash their hands for infection control because that would be considered as cross contamination.Document titled Cleaning and Sanitizing, Ware Washing 101 undated document in part: Mechanical Ware washing.Document Handwashing, document in part: Fight germs by washing your hands!In-Service Training dated 03/28/26 Regarding Hand Washing document in part: Hand washing must be done when moving from one assignment to another, after touching waste, trash or contaminated surfaces. If gloves are torn, soiled or wet inside. After leaving dish area. Remove gloves after touching soiled/dirty dishes, wash hands with soap/warm water for at least 20 seconds, dry hands, apply new gloves before handling clean items.The census was obtained from the facility roster of 131 residents with four residents being NPO (Nothing by mouth).Policy:Titled Cleaning and Sanitizing and Proper Hair Restraints dated 09/01/21 document in part; Food contact surfaces are properly cleaned and sanitized before and after use, in order to prevent food-borne illness and minimize bacterial growth.Titled Supplies and China dated 09/01/21 document in part: It will be the standard of this facility to provide safe and sanitary storage, handling and consumption of all food including food and beverages. Facility will provide meals on China along with proper silverware. 3. Food Preparation Procedures: i) Staff will practice good hygienic practices and techniques i.e. Handwashing, glove usage. ii) Staff must wash hands prior to putting on gloves and in between changing gloves.

Based on interview and record review, the facility failed to follow their policy to investigate and report an allegation of Abuse for one (R1) of three residents reviewed for Abuse.Findings include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Type 2 Diabetes Mellitus with other Specified Complication, End Stage Renal Disease, Peripheral Vascular Disease, Gangrene, Acquired Absence of Unspecified Foot, Essential (Primary) Hypertension, Dependence on Renal Dialysis, Cataract, Cataract, Obesity and Primary Insomnia. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.Care plan document in part: Focus: History of abuse: Comprehensive assessment reveals history of suspected abuse or neglect or factors that may increase R1's susceptibility to abuse, neglect. Date Initiated: 12/05/24. Interventions: Review assessment information. Emphasize treatment of causal factors & interventions designed to moderate symptoms make treatment of compulsive behavior, substance abuse, anger & mental health issues available to the resident as indicated Date Initiated: 12/05/24.Surveyor requested a copy of the Staff (V3 Former Dietary Manager) to Resident (R1) abuse reportable/investigation multiple times and was not provided a copy.On 03/38/26 V8 (Assistant Director of Nursing/Human Resources) stated we are trying to get the key to retrieve the reportable because V1 (Administrator) is not available until after sundown.On 03/28/26 at 11:55 AM R1 stated I have been here for 1 year. V3 (Former Dietary Manager) and I have bumped heads. One day in January, I am not sure of the date, I was sitting in the dining room talking to V11 (Certified Nurse Assistant) about something I saw on TV and asked V11 did you see that b**** on TV. V3 came from behind me, ran up and was in my face saying you calling me a b****. I don't know what that was about. I said I was not talking to you and that is what I told V1 (Administrator). I told my family to call into the state. It happened during breakfast time in the dining room on the first floor a little after 7 am because I went to dialysis at 7:30 am. I wrote a report on V3 and V1 also asked me to write a statement. I did not hear anything else about it, so I just dropped it and V3 got terminated. It was on camera and V1 showed V3 on camera.On 03/28/26 at 10:47 AM V5 (Former Dietary Aide) stated I was employed as a dietary aide for 5 1/2 months. Everybody in dining room with R1 witnessed the incident with V3 (Former Dietary Manager). I don't remember any names. R1 filed a formal complaint because V3 approached R1 backing R1up saying you called me a b****. It was reported to administration and R1's family reported it.Telephone interviews attempted x3 to contact the alleged perpetrator V3 (Former Dietary Manager) and V11 (Certified Nurse Assistant) that was a witness to the abuse allegation with no answer.On 03/28/26 at 12:44 PM Per telephone interview V13 (Dietary Aide) stated V3 (Former Dietary Manager) had quit a few run ins with R1. It was reported to administration, but I don't think I was there that day.On 03/29/26 at 08:29 AM V1 (Administrator) stated Basically, when the interaction between R1 and V3 (Former Dietary Manager) was reported to me it was a customer service concern/customer service issue. Yesterday after you (surveyor) requested a reportable, a follow up interview was conducted with R1, and they said R1 felt threatened by the interaction. We are going to treat that as a reportable and the initial report was sent yesterday 03/28/26. R1 said customer service in passing, V3 thought R1 called her a b****. V3's story was the same as R1's, she was walking by him and thought she heard R1 call her out her name. That was kind of the end of the interaction. I talked to anyone present in the area. At this point R1 said he is feeling threatened so now we are reinvestigating. There was a verbal counseling with V3 in real time, going over how to properly go over when V3 heard something, respond a certain way and V3 can come to me. (V1 did not provide documentation or names of individuals that were interviewed).On 03/29/26 at 04:29 PM V1 (Administrator) emailed a document titled: Long-Term Care Facility & IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Report dated 03/28/26 documenting in part: Initial, Alleged Abuse. Victim: R1, Wheelchair, interviewable. Involved in incident V3 (Former Dietary Manager) Terminated. Detailed Incident Summary: Resident R1 reported alleged verbal abuse by an employee (date and time unknown). V3 (Former Dietary Manager) is no longer employed with the company.On 03/29/26 at 04:29 PM an email was received from V1 (Administrator) documenting in part: Abuse Reportable (3 months) including R1 entire reportable. At the time of the occurrence, the situation was presented by the resident as a verbal misunderstanding related to perceived language. The matter was addressed in real time by staff through reeducation and de-escalation, and the staff member received immediate verbal coaching regarding professionalism and communication expectations. Based on the information provided at that time, the interaction was handled as a customer service concern. There were no immediate indicators of abuse, injury, or ongoing risk that would have necessitated escalation to an abuse concern at that moment. Yesterday R1 was reinterviewed, and consistent with R1's care plan, R1 provided alternate narratives of the previous exchange at which point the facility, to err on the side of caution initiated additional investigation out of an abundance of caution and respect for the severity of potential allegations regarding the same incident. Please also see brief overview of all steps that have either been initiated and are in progress and/or have been completed as far as the investigation process is concerned. The police have been contacted. The staff member in question is not on the schedule and no longer employed at the facility. The initial was sent yesterday. R1's care plan has been updated and potential for abuse assessment has been completed. Staff contacted to gather statements. Currently collecting resident statements regarding the alleged incident as well as any other potential instances involving customer service-related issues. On 03/28/26 at 07:26 AM V6 (Dietary Aide) stated V10 is the dietary Manager. V3 (Former Dietary Manager) used to work here but she has been gone for about one month.On 03/28/26 at 07:41 AM V9 (Dietary Aide) stated The new manager took over a month ago. The district manager was here until then.On 03/29/26 V1 emailed V3 (Former Dietary Manager) Corrective Action Documentation: documenting in part: Following a review of recent concerns related to workplace conduct and leadership expectations, it has been determined that your actions are not aligned with the Company's standards for professionalism, communication, and management responsibility. As a manager, your role requires maintaining a respectful, collaborative, and stable work environment, as well as fostering trust among staff and clients. Based on our assessment, there has been a breakdown in these expectations and in the level of trust required for your position. Due to the seriousness of this matter and the impact on team dynamics and operations, we are moving forward with separation of your employment, effective immediately. Delivered via phone 03/04/26.Policy:Titled Abuse, Neglect and Exploitation revised 11/14/25 document in part: 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. V. Investigation of alleged abuse, neglect and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occur. V1. Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protection services and to all other required agencies within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to develop a plan of care and assure that one resident (R1) at high risk for skin breakdown received the treatment and services to prevent the development and worsening of a new pressure ulcer. This failure resulted in R1's development and deterioration of a unstageable pressure ulcer, requiring hospitalization and surgical intervention for Sacral ulcer with underlying destruction of the coccyx.Findings include:R1's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, essential hypertension. R1 admitted to the facility on [DATE].R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 12, indicating R1's cognition is moderately intact. R1's Braden scale dated 08/13/25 has a score of 12, indicating R1's risk for skin breakdown is high.R1's care plan dated 05/29/25 documents in part, The resident has potential/actual impairment to skin integrity with possible complications.I will not experience any additional skin breakdown or other complications.Assist me with my general hygiene and comfort measures. (No interventions noted after skin impairment reported on 8/3/25.)R1's orders include Turn and Reposition every 2 hours dated 5/6/25 (no change after development of new skin impairment.) R1's progress note titled Heath Status Note dated 08/03/25 documents in part, While receiving incontinence care CNA (Certified Nursing Assistant) on duty alerted writer of some discomfort the resident was having. Upon assessment writer noticed resident's sacrum has an opening and both interior thighs have MASD (moisture associated skin dermatitis). Resident stated sacrum and inner thigh were painful and burning.R1's progress noted titled Skin/Wound Note dated 08/04/25 documents in part, Writer made aware by staff of resident observed with skin integrity issue to sacrum. Upon writer assessment resident observed with unstageable pressure ulcer to sacrum.Preventive measures in place plan of care remain in place.On 09/22/25 at 11:10am V3 (Licensed Practical Nurse/LPN) stated that R1 was a total assist and could not reposition herself. V3 stated that R1's sacrum was intact on admission, but R1 developed a wound to the sacrum while in the facility. V3 stated that R1 would have to be transferred to her wheelchair via mechanical lift. V3 stated that R1 would sit in her chair for greater than 2 hours at a time. V3 stated that R1 was compliant with care and did not refuse to be cared for.0n 09/22/25 at 11:31am V4 (Certified Nursing Assistant/CNA) stated that R1 was dependent on staff to be cleaned and repositioned. V4 stated that R1 was compliant and did not refuse care. V4 stated that R1 needed two staff members for transfers and repositioning. V4 said when R1 was in the chair she was not repositioned every 2 hours. V4 stated that R1's sacrum wound was small but grew bigger. V4 stated that R1's sacrum wound had an odor for approximately a week before R1 was sent to the hospital. V4 stated that all the nurses were aware that R1 had an odor to the sacrum wound.On 09/23/25 9:40am V8 (Wound care tech) said when I come in, I make sure that the residents are being turned every two hours. V8 said even if they are up in the wheelchair, they may get put back down to be turned. V8 said we would try to have R1 get up at 11:00am and would try to put her back to bed after lunch and she would refuse.On 09/23/25 at 11:00am V9 (Wound Care Nurse) stated that R1 had no wound to her sacrum upon admission on [DATE]. V9 stated that R1 developed an unstageable pressure ulcer to her sacrum while at the facility. V9 stated that R1 was a high risk for skin breakdown due to being incontinent, immobile, and sitting up for 4 hours instead of 2 hours. V9 stated that R1's daughter informed him that she felt the R1 was not being repositioned enough. V9 stated that he began to bathe and reposition R1 himself to make sure that R1 was being cleaned and turned. V9 stated that he was on vacation from 08/06/25 through 08/18/25, and R1's sacrum wound had necrotic tissue, but was stable before his vacation. V9 said for R1 preventive measures in place for her included turn and reposition. V9 said I put an order for her to be turned and repositioned under physician orders. V9 said I informed the staff to make sure that she was not sitting up in the chair when I wasn't here. V9 said the purpose of interventions are to help and resolve any skin integrity issues. On 09/22/25 at 3:44pm V5, CNA, said sometimes R1 would be in her chair when she came on shift at 3:00PM. V5 said R1 would stay up until around 6:15PM (greater than 2 hours).On 09/24/25 at 10:43am V2 (Director of Nursing/DON) stated that it is the expectation of the facility for the nurses to follow the physician orders. V2 said it is my expectation that staff reposition the residents at least every 2 hours or more. They should clean the residents when they come in in the morning time, and at least every 2 hours they should be checking the for incontinent episodes. V2 said a care plan should be in place if a resident refuses care. If should be documented first by the nurse if a resident refuses care. V2 said for a resident with wounds interventions should include repositioning and not sitting up too long on the wound. V2 said if a resident develops a new wound that means that the preventive measures are not working. V2 said when wounds are not changed as scheduled, they could deteriorate, and the nurse is not following the doctor's orders. V2 said I am not aware that R1 had no new interventions once she developed the new wound. V2 said R1's wound care plan is not complete and is the interventions are not individualized. On 09/24/25 at 11:58am V11, LPN, said for charting in the record, normally when I press 7, it's because the wound was already done by wound care nurse. I don't know if that was a generated note. I do recall changing the sacrum dressing before and changing the groin one week before. V11 said R1's wound was so painful to her she used to scream when we had to try to clean it.On 09/24/25 at 08:52am, V18 (Wound care doctor) stated that if R1 would have been turning herself in bed, that would have helped the MASD and prevented the sacrum wound from worsening.On 9/24/25 at 1:05pm V12, Social Service director said I never was told that R1 refused care or had behaviors. V12 said social services is notified of resident care refusals. Review of R1's record shows no documentation of sacrum wound before 08/03/25. R1's wound assessment dated [DATE] documents in part, Unstageable sacrum Full Thickness.Wound size (Length by width by dept) 2.5 by 3.5 by 0.3 cm (centimeters).R1's wound assessment dated [DATE] documents in part, Unstageable sacrum Full Thickness.Wound size (Length by width by dept) 4.1 by 4.2 by 0.7 cm (centimeters).R1's physician order dated 08/07/25 documents in part, Sacrum unstageable leptospermum honey apply once daily and as needed: If saturated, soiled, or dislodged.R1's treatment administration record (TAR) documents in part, Sacrum unstageable leptospermum honey apply once daily and as needed. On 08/09/25 R1's TAR shows a code of 7, which indicates to see progress note. R1's progress note dated 08/09/25 documents in part, No dressing change needed, dressing remain intact.R1's MDS dated [DATE] section GG for Functional Abilities has a score of 2 for Personal Hygiene, which indicates R1 requires substantial/maximal assistance to maintain personal hygiene, a score of 3 for rolling left and right, which indicates R1 needs partial/moderate assistance to roll from left to right and a score of 1 for chair/bed to chair transfer, which indicates R1 is totally dependent and helper does all of the effort.R1's progress noted dated 08/18/25 documents in part, Writer alerted by CNA on duty that the resident was not as responsive as usual. Upon assessment vital signs 98/54, P (pulse) 113, t (temperature) 101.9, R (respirations) 19, SPO2 (oxygen saturation of peripheral blood) 95% on room air. Notified NP (Nurse Practitioner) new orders to send to ER (emergency room).Progress note dated 8/19/25 document R1 admitted with diagnosis of Sepsis and necrotizing fasciitis in ICU intubated.Progress notes reviewed 7/30/25 - 8/19/25, no documentation that R1 refused repositioning or lay down. Review of wound care provider notes 8/8/25 and 8/13/25 do not identify R1 refusing care.R1's hospital record dated 08/18/25 documents in part, Patient presented to ED (Emergency Department) after being found to be febrile to 100.7, as well as hypotensive in her SNF (Skilled Nursing Facility). Upon arrival she was found to be afebrile, normotensive, although with leukocytosis to 33 and hyperglycemia to 388. Labs also significant for venous lactate to 2.2. Infectious workup showing sacral ulcer with underlying destruction of coccyx concerning for osteomyelitis with gas tracking into the R (right) gluteal musculature, R gluteal cleft, and perineum c/f (concern for) active infection. CT abdomen and pelvis: 1. Sacral ulcer with underlying destruction of the coccyx concerning for osteomyelitis. Additionally, there is gas tracking into the right gluteal musculature, right gluteal cleft, and perineum concerning for active infection. Given the extent of gas tracking along the subcutaneous tissues and into the right gluteal musculature there is concerning for developing necrotizing fasciitis. No drainable abscess. R1's hospital surgical report dated 08/18/25 documents in part, Findings: Stage 4 sacral decubitus ulcer with frankly necrotic surrounding tissue and malodorous murky grey output liquid output, probed to coccyx. Wide excision and debridement of wound to underlying healthy tissue. Anterior tracking along the R medial gluteal fold along anorectal junction. Wound base 14cm (centimeters) wide x 18.5 long x 3.5cm deep. R1's hospital records dated 08/19/25 documents in part, Patient intubated and sedated s/p (status post) emergent wound debridement on 8/18/25, unable to participate in interview.Facility's policy titled Turning and Repositioning dated 09/01/24 documents in part, Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management.Facility's policy titled Wound Treatment Management dated 09/01/24 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.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing.

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident using a mobility device. This failure affected one resident (R2) out of 5 reviewed for adaptive equipment use in the facility.Findings include:R2's face sheet shows that R2 has diagnoses which includes but not limited to benign prostatic hyperplasia, retention of urine, urogenital implants, hypertension, anemia, osteoarthritis, and pleural effusions.R2's Minimal Data Set (MDS) documents in part, Section C: Brief Interview of Mental Status (BIMS) score is a 9. R2 has moderate cognitive impairment. Section GG: Mobility devices: C. wheelchair. On 7/21/25 at 11:00 am, observed R2 in room sitting in wheelchair next to bed. R2 brought to surveyor's attention that the wheelchair R2 was sitting in was broken. R2's right brake on the wheelchair noted to be broken and was unable to lock. Surveyor inquired to R2 if staff assist with transferring to the wheelchair? R2 stated, No, I get in the wheelchair by myself.On 7/21/25 at 12:45 pm, Surveyor inquired to V7 CNA (Certified Nursing Assistant) how do they lock and secure the wheelchair when transferring R2 to the wheelchair? V7 looked at the wheelchair and stated, I (V7) was not aware of the wheelchair being broken. R2 gets into the wheelchair by himself. I will put it in the repair book that the wheelchair is broken.On 7/21/25 at 1:34 pm, V6 Maintance Director stated, Rounds is made every two hours and I (V6) look at the maintenance book or sometimes the residents or staff will say if something needs to be fixed. Surveyor inquired to V6 if V6 was aware of R2's wheelchair brake being broken? V6 stated, I am not aware.On 7/22/25 at 11:24 am, R2 in room sitting in wheelchair with right brake still broken.On 7/22/25 at 11:30 am, V4 LPN (License Practical Nurse) stated that R2's wheelchair is not safe, because R2 could fall with the brake being broken. The purpose of the brake is to prevent the chair from moving. It the chair move while transferring it could cause an incident. R2 is a one person assist. On 7/22/25 at 12:12 pm, (V6) Maintenance Director, stated, I (V6) did not look at the Maintance log today my assistant was supposed to have looked. I was aware that the wheelchair was broke yesterday, but I did not get a chance to go look at it. I got caught doing many things at the same time. It is not safe for the resident to have a broken brake on the wheelchair. They can fall and have to be sent to the hospital. The patient is the priority for safety.On 7/22/25 at 12:30 pm, (V16) Maintenance Assistant stated, I (V16) did not check the maintenance book.On 7/22/25 at 1:56 pm, V9 Restorative Director stated I (V9) went to R2's room yesterday to remove the broken wheelchair. I explained to R2 that one of the brakes is not good and we need to fix it. R2 was gesturing and did not want the wheelchair removed. I went to tell the maintenance that there is a request for the wheelchair to be fixed. Surveyor inquired to V9, is it safe to leave the wheelchair with the brake broken? V9 stated, Most times R2 doesn't use the chair. If R2 chooses to use the chair it should not be broken. Surveyor inquired to V9, should all equipment in the facility be functioning and in safe working condition? V9 stated, Absolutely, it was not safe to leave the wheelchair. Social service was supposed to be notify of the refusal. I did not notify social service.On 7/22/25 at 2:40 pm, V3 SSD (Social Service Director) stated, It was not brought to my attention that R2 was refusing to give restorative R2's broken wheelchair. The process is to notify social service with refusals. Our goal is to remove the chair because it is a safety hazard because the brake is not working.Facility's Maintenance Work Request Form dated 7/21/25 documents in part, work location: 205-2 wheelchair. Description of work/repair: residents wheelchair lock is broken on the right side.R2's (7/16/25) Fall Risk Assessment documents in part, R1 has a history of falling. Mental Status: Overestimates or forgets limits. R2's fall risk score is 55 which indicates that R2 is high risk for falling. (Morse Fall Scoring-High Risk 45 or higher).R2's (7/16/25) Functional Abilities Evaluation documents in part, Mobility: Chair/bed-to chair transfer is coded 1 for dependent.R2's care plan documents in part, Focus: The resident has limited physical mobility related to disease process, weakness, and impaired balance. Resident uses wheelchair as a primary mode of locomotion.Facility's policy dated 2016 and titled, Equipment Maintance and Repair dated documents in part, Policy: All equipment utilized in this facility shall be maintained, operated, and repaired as directed. Repair: If equipment shows signs of needing repair, staff shall immediately stop usage of the equipment and report it to maintenance. Facility's policy dated 11/24 and titled, Fall and Fall Prevention documents in part, Procedure: 9. Malfunctioning equipment will be immediately given to maintenance for repair or removal service.

Based on observation, interview and record review, the facility failed to notify the physician of one (R1) resident of change in condition of three residents reviewed. This failure resulted in delaying R1's transfer to the hospital for further evaluation for a contusion and bruised right eye in a total sample of three residents. Findings include: R1 is a [AGE] year-old individual whose medical diagnosis include but not limited to: dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild intellectual disabilities, chronic obstructive pulmonary disease, unspecified, disorganized schizophrenia. MDS (Minimum Data Set) section C Cognitive function, dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as ,d+[DATE] indicating R1 has severe cognitive impairment. R1's MDS section GG -Functional Abilities documents R1 requires supervision or touching assistance while eating, partial/moderate assistance with oral hygiene and upper body dressing, substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. Nursing progress notes dated [DATE], documents: Summary of the Fall: observes resident (R1) with raised area over right eyebrow with discoloration. R1 has raised area to right eye and broken blood vessel to right eye. Nursing progress notes dated [DATE], documents nurse to nurse report with admitting hospital stated R1 had CT(Computed Tomography) scan showed edema and hematoma and R1 was going to be admitted for fall and head contusion. R1's hospital record dated [DATE], documents: A contusion is a deep bruise. Contusions are the result of a blunt injury to tissues and muscle fibers under the skin. The injury causes bleeding under the skin.R1 presented to the hospital with bruised or swollen eye. Fall with right sided periorbital edema. Head CT shows there is hemorrhage and edema throughout the right supraorbital and periorbital region. On [DATE], at 10:43 AM, V5 (Licensed Practical Nurse-LPN) and surveyor observed R1 laying in bed. R1 was observed with a bruise on the right eye above and below the eyebrow. The bruise was below the eye and it was covering the whole lower part of the right eye from side to side. V5 described the bruise as black/reddish/purplish in color. V5 stated R1 does not get out of bed or try to get out of bed by herself and needs two staff when performing ADL (Activities of Living) care. V5 stated R1 is not able to hold the bedside grab bars to move herself and two staff move R1 from the bed to the wheelchair because R1 cannot assist with transfers. On [DATE], at 2:10 PM, V8 (Licensed Practical Nurse-LPN [Former]) via phone stated she worked with R1 on [DATE], on the 11:00 PM-7:00 AM shift. She was not aware R1 had a fall that day. But in the morning on [DATE], before the end of her (V8) shift, she observed R1 with a bruising above and below her (R1) right eye. The bruise below R1's eye was a long line running the length of the right eye. V8 stated she did not notify R1's physician or V2(Director of Nursing) about R1's change in condition. This delayed R1's care and that is why V8 was terminated because she is supposed to notify the physician as soon as a resident has a change in condition. On [DATE], at 3:00 PM, V10 (Certified Nursing Assistant- CNA [Former]) via phone V10 worked on [DATE], on the 3:00 PM-11:00 PM shift but he was not assigned to R1 when R1 fell . V10 stated V9 (Former Certified Nursing Assistant) came and got V10 to come help V9 to transfer R1 back to bed. Upon reaching R1's room, R1 was sitting on the floor on her bottom. V10 stated he did not know V9 had not informed the nurse on duty that R1 had fallen and was on the floor. The facility protocol is to let the nurse know first if a resident falls before touching the resident. V10 stated he was terminated for not informing the nurse about R1's fall. On [DATE], at 3:31 PM, V4 (Licensed Practical Nurse-LPN) via phone stated she worked with R1 on [DATE] on the 7:00 AM-3:00 PM shift. She went to R1's room to take her vitals around 9:00 AM and to give R1 her medications. She noticed R1's right side of the face by her eyebrow had a big knot. V4 stated she notified V2 who went and saw R1's bruise and told V4 to call 911, V13 (Nurse Practitioner) and R1's family and notify them. V4 stated 911 came, took report, and took R1 to the hospital. V4 stated during change of shift that morning, V8 did not report R1 had a knot below and above her right eye. V4 stated if a resident has a change in condition and a staff does not report it, that is neglect which is a form of abuse. On [DATE], at 4:48 PM, V1 (Administrator) stated on [DATE], V9 was doing ADL (Activities of Daily Living) care for R1, and R1 fell out of the bed. V1 stated V9 ran out of the room and went to get help from V10, and V9 and V10 rushed to R1's room past V8 who was at the nursing station. V9 did not notify V8 that R1 fell . V1 stated on [DATE], about 5:30 AM, V14 (CNA) noticed a swelling on R1's face and notified V8 but V8 did not do anything about it including notifying the physician, V2 or V13 (Nurse Practitioner). V9 left at the end of her shift at 7:30 AM.V1 stated V9 and V10 neglected R1 when they failed to notify V8 that R1 had fallen therefore V9 and V10 were terminated for failure to follow facility policy and protocol. V8 was also terminated for failure to follow facility policy when a resident has a change in condition which states the nurse notifies the physician right away. V1 stated on [DATE], around 9:00 AM or 10:00 AM, V4, who was assigned to R1, noticed R1 had a swelling on the right eye. V4 competed an assessment of R1, applied a cold pack, notified V2 and V13 and called 911 to take R1 to the hospital for further evaluation. On [DATE], at 5:44 PM, V2 (Director of Nursing-DON) stated on [DATE], about 10:00 AM, V4 called V2 to R1's room. When she got to R1's room, she (V2) stated wow! what happened because R1 had a big knot on the right forehead area. V2 stated she assisted V4 to assess R1 and put an ice pack on R1's forehead. V4 called 911, V13 and R1's family. R1 was taken to the nearest hospital and was admitted with head edema, hematoma, fall, and head contusion. V2 stated on [DATE], after she completed her investigation regarding R1's injury, she notified V1 of her findings. After discussing with V1, he gave ok to terminate V8, V9, and V10 for failure to follow facility's policies and procedures on reporting falls and notifying physicians of resident change in condition. V2 stated not notifying the physician when R1 was noted to have a swelling on the forehead caused a delay in care and R1 could have died of the head injuries sustained during the fall. R1 is on blood thinner medications which could cause bleeding in the brain and death. V2 stated R1 did not receive the care she needed in a timely manner and could have resulted in her death. On [DATE], at 6:45 PM, V15 (Restorative Manager) stated R1 is a two person assist for transfer and for bed mobility. R1 requires a two person assist during ADLs and incontinence care for safety to prevent falls. On [DATE], at 12:45 PM, V11 (Human Resources Manager-HR) stated HR does a background check before employing a perspective employee and annually thereafter. V11 stated the supervisors/administrator lets V11 know which staff has an offence. V11 and the manager who reported the offence go through the facility's policies and procedures to determine which policy the staff violated and if the employee will be terminated. V11 stated V8, V9, V10 were terminated because they did not follow policies and procedures of the facility. Policy titled Change in Condition dated ,d+[DATE] documents: -Residents will receive full assessment of status change with notification to physician and immediate medical emergency care via 911 if indicated. -Resident will be assessed by the charge nurse or nursing supervisor in response to any changes or deterioration in condition upon notification. Family and physician will be notified. Facility Reported Incident Report -Final, dated [DATE], 4:23 PM documents: -R1 was transferred to a nearby hospital after a fall with an above right eye raised area. R1 was unable to communicate what happened to her -R1's roommate (R2) was unable to state what happened to R1 -According to hospital report, R1 was admitted to hospital for fall and head contusion. -V8 (Licensed Practical Nurse-LPN), and V9, V10(Certified Nursing Assistants-CNAs) were terminated for not reporting the incident. V8's HR (Human Recourses) File documents: V8's Employee Termination Form dated [DATE], documents: -V8 was terminated for gross misconduct, not reporting a resident (R1 change in condition). R8's Employee Report dated [DATE] documents: -V8 failed to follow facility policy and procedures by not notifying provider of resident's change in condition. V9's HR (Human Recourses) File documents: V9's Employee Termination Form dated [DATE], documents: -V9-Gross misconduct- not reporting a fall, dishonesty, or theft V9's Employee Report dated [DATE] documents: -V9 failed to follow facility policy and procedure; did not report a resident (R1) fall to supervisor. V10's HR (Human Recourses) File documents: V10's Employee Termination Form dated [DATE], documents: -V10-Gross misconduct- not reporting a fall, dishonesty, or theft V10's Employee Report dated [DATE] documents: -V10 failed to follow facility policy and procedure; did not report a resident (R1) fall to supervisor. Facility policy titled -Fall Prevention Policy dated [DATE], documents: -If a resident experiences a fall, nursed will complete an incident report and document the fall in the resident record as well as the 24-hour report. Facility policy titled Change in Condition dated ,d+[DATE], documents: -Resident will receive full assessment of stats change with notification to physician and immediate medical emergency care via 911 in indicated. Resident will be assessed by the charge nurse or nursing supervisor in response to any changes or deterioration in condition upon notification. Family and physician will be notified.

Based on interview, and record review the facility failed to ensure there are enough nursing staff to respond to call lights in a timely manner. In a resident council minute meeting residents' complain that sometimes the facility only has one or two CNAs (certified nursing assistant) for the 2nd and 3rd shift. Review of staffing data submitted via the PBJ system revealed the facility was triggered for excessively low weekend staffing. This failure places all 104 residents in the facility at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. 02/05/25, 10:15 AM, residents agreed that the resident council meets regular, monthly. Residents' complain that sometimes they only have one CNA (certified nursing assistant) on the 2nd or 3rd shift and the call lights don't get answered for a long time. 2/5/2025, 3:43 PM, V26 (Staffing Coordinator) states that the facility wants her to staff nine CNAs (certified nursing assistants) for the morning shift, nine CNAs for the evening shift, and 8 CNAs for the night shift. V26 states that she schedules five nurses for the morning shift, five nurses for the evening shift, and three nurses for the night shift. V26 states that she has been the staffing coordinator since September 2024. V26 states that prior to being the staffing coordinator she was the wound care tech. V26 states that when the census goes up, then she would have to have more staff. V26 states that the facility uses an application where the staff can view open shifts and they can pick up and as well as be able to view their schedules. V26 states that if no staff are able to pick up a shift then she reserves to agency. V26 continues to state that if the agency do not pick up an open shift then V26 states that she will come in to work. Facility document dated 2/4/25, documents in part there are 104 residents (census) in the facility. Facility document dated 03/1/2024, titled facility assessment documents in part nursing services staffing should have 12 CNAs for day shift, 9 for evening shift, and 8 for night shift. Facility document dated 07/24/2024, titled resident council minutes documents in part CNAs on their cell phones during work hours and not answering the call light in a timely manner. Facility provided document 7/20/24-7/21/24 titled simplified time detail documents in part work short bonus, 8 CNAs worked morning shift on 7/20/24, 6 CNAs worked night shift on 7/21/24. Facility provided document 7/27/24-7/28/24 titled simplified time detail documents in part work short bonus, 7 CNAs worked morning shift on 7/27/24, 5 CNAs worked morning shift on 7/28/24.

Based on observations, interviews and records review, the facility failed to follow their policy on sanitation and food safety by failing to (a) dish washer temperatures not reaching recommended temperatures, (b) properly sanitizing dishes in the three-compartment sink, (c) properly wearing hair net in the kitchen, (d) date open food item with open date and use by date. This failure has the potential to affect 101 residents who are on an oral diet. Findings include: On [DATE], at 9:30 AM, V7 (Cook) was observed washing dishes in the three-compartment sink. The third compartment sink (Sanitizing) was observed with water that had whitish particles and the water was whitish cloudy. V8 (Dietary Manager) and surveyor observed V7 test the chlorine concentration on the third compartment sink with chlorine testing strips marked 10 P.P.M, (Parts per million) 50 P.P.M, 100 P.P.M, 200 P.P.M. The testing strips had color change marks from very light purple to black. V8 stated the black marking indicated the highest chlorine concentration. The testing strips did not turn color and remained white. V7 and V8 stated the chorine testing strips should turn blackish and at lease reach 100 PPMs to make sure the dishes are properly sanitized to prevent cross contamination which can make residents sick. The chlorine test strips were observed with an expiration date of [DATE]. V8 stated she was not aware test strips have an expiration date, and stated there are 101 residents on oral diet receiving food from the kitchen. On [DATE], at 9:36 AM, V10 (Dietary Aide) was observed assisting with loading the dish washing machine in the kitchen wearing a hair net that only covered the top of her hair bun, and the rest of her hair was observed without a hair net. V10 stated her hair is too big to fit in one hair net. V8 and V10 stated all staff in the kitchen should cover their hair completely to prevent hair from getting into resident food to prevent contamination. V10 stated she will wear two hair nets to cover the rest of her hair that was not covered. On [DATE], at 9:40 AM, dishes were being washed in the dish washer. After each wash, the next load was put in and the machine was run immediately. V8 put a test strip (yellow with a white strip) in the dish washer to test if the machine was washing and sanitizing dishes properly. V8 stated the center of the testing strips which is white is supposed to turn black indicating the machine is working properly. The test strip did not turn black. V8 run the machine again and the hot water gauge for hot water was observed to be approximately ,d+[DATE] degrees F. V8 stated the washing cycle should reach at least 150 degrees F, and sanitation cycle should reach at least 180 degrees. V8 stated the water cools down if the machine is run continuously, and asked staff to wait a little bit before running each cycle to let the water heat up. V8 tested the machine three times and each time the testing strips remained white. V8 stated the dishwasher was recently serviced and the yellow testing strips are new, and she did not know why they did not turn black. V8 stated if the strips don't turn black, it means the right temperatures were not reached during the wash/sanitize cycle, and the dishes are not being washed and sanitized properly. V8 stated this can cause cross contamination which can lead to residents getting food borne illnesses. V8 stated the dishwasher is a high temperature machine and the wash cycle water temperature should be above 150 degrees F, and the rinse cycle above 180 degrees F. On [DATE], at 2:32 PM V15(Dishwasher Repair Services/Vendor) stated the company has been having a lot of problems with the yellow dish washer testing strips he gave to the facility to test the dishwasher two weeks ago. The facility called him today ([DATE]) to let him know the dishwasher temperatures are not reaching the recommended temperature. V15 stated he has just checked the dishwasher sprays and they had food particles clogging the sprays and that could have contributed to the water not getting hot, therefore, V16 has cleaned the spays and turned up the dishwasher temperatures and now its washing at over 200 degrees F. On [DATE], during tour of the kitchen, with V8, observed in the freezer, an open big plastic bag of peas and carrots without a date indicating when opened or expiration date. V8 stated all opened food should be labeled with date it was opened and use by date so that it can be used before the food expires to prevent expired foods being cooked for the resident which can make residents sick. Policy titled Mechanical Cleaning and Sanitizing dated 2010 documents: Dish machines using hot water for sanitizing may be used if temperature of washing water is no less than that specified by the manufacturer, which may vary from 150 degrees F to 165 degrees F, depending on the type of machine, and if the final rinse temperature is no less than 180 degrees F. Policy titled Manual Sanitizing dated 2010 documents: -Chlorine-50 -100 PPM minimum 10 second contact time. -A test kit or other device that accurately measures the parts per million concentrations of solution will be available and used. Precision Chlorine Test Paper documented: Use dry finders to remove strip of paper from vial, dip strip into solution to be tested , without agitation and compare immediately with color chart on label. This color indicates approximate strength of the solution in parts per million (p.p.m) available chlorine. Policy titled hair restrains/Jewelry dated 2010 documents: -To reduce the spread of microorganism, employees shall use effective hair restraints. -Hair nets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated if necessary. -If taken out of original container, food will be tightly wrapped and labelled with the name of the item and date of delivery. Dish washer Operational Manual titled Getting started- introduction to CMA-180 documents: -Operation of the CMA-180 is automatic. The water tank heater will maintain the water temperature at 155 degrees F. The booster heater will produce a minimum of 180 degrees F final rinse water each cycle providing the in coming water supply is 120 degrees F.

Based on interview and record review the facility failed to ensure the designated Infection Prevention nurse completed specialized training in infection prevention and control in nursing homes. This failure has the potential to affect 104 residents residing in the facility. Findings include: During the survey period, the facility was not able to provide valid documentation/certification for V3 (Infection Preventionist / Licensed Practical Nurse) of the completion of the required training program to implement programs and activities to prevent and control infections in nursing homes. 2/4/25, the facility was asked to provide completion of Infection Prevention program certification, including total hours for accumulated for V3 (Infection Preventionist / Licensed Practical Nurse). 2/6/25, V3 provided a CDC (Centers for Disease Control and Prevention) Certificate of Training, Completion for Nursing Home Infection Preventionist Training Course, dated 2/5/2025. 2/06/25, at 9:13 AM, V3 (Infection Preventionist / Licensed Practical Nurse) stated V3 has been the IP nurse since January 2024. V3 does the antibiotic surveillance, immunizations, outbreaks of Covid, flu, C. diff (Clostridium difficile), etc., all infections, immunizations for residents and staff. V3 makes sure infection protocols are maintained throughout the building. V3 stated the infection prevention program requires completing the training modules and then taking and passing a cumulative/completion test. The test shows completion of the required hours and competency for the IP role. 2/6/25, at 4:05 PM, V2 (Director of Nursing) stated it is important to have a certified IP (Infection Preventionist) because it keeps us up to date with CDC (Centers for Disease Control and Prevention) recommendations. That person is updated with the latest bacteria and germs, isolation requirements and protecting the staff and residents. Facility policy Infection Prevention Program, no date, documents in part: The Infection Preventionist serves as a resource for all staff and all departments relating to prevention of infections. The Infection Preventionist has knowledge, competence, and interest in infection prevention.

Based on review of records and interviews the facility failed to ensure a Pre-Admission Screening and Residential Review (PASSAR) were done for 5 out of 5 residents (R9, R15, R16, R37, R54) prior to admission. These failures have the potential to affect 5 residents (R9, R15, R16, R37, R54) in a total sample of 21. Findings include: On 02/05/2025, at 10:25 AM, V16 (Social Service Director) submitted for R9, R16, and R37's print out document that reads PASRR Level 1 currently queued for review. V16 stated that she just submitted the request on 02/04/2025. V16 stated that PASRR is important to determine proper placement of resident. It should be done before the actual admission in the facility. R9 is [AGE] years old with diagnosis that includes psychosis, schizophrenia, schizoaffective disorder, and major depression. Per R9's PASSR report it documents the following: Notice Date: February 5, 2025: PASRR Level 1 review date February 5, 2025, determination of Level 1 is to refer to Level 11 onsite with suspected or confirmed PASRR condition of Mental Health Disability (MH). PASRR Outcome Explanation of Notice of PASSR Level 11 Onsite Evaluation Required. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASSR) Level 1 screen for you. This screen shows that you need a face-to-face Level 11 evaluation. PASSR Level1 screens and Level 11 evaluations are required by Federal law. You need this evaluation because you may have serious mental illness or intellectual/developmental disability. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. R9's diagnosis includes Schizophrenia, Schizoaffective disorder, Major Depression. R37 is [AGE] years old with severely cognitive impairment BIMS (Brief Interview for Mental Status) dated 01/02/2025, scored 99 because R37 unable to complete interview. R37 medical diagnosis includes dementia, anxiety disorder, major depression disorder, psychotic disorder. Per R37's PASSR report it documents the following: Notice Date: February 5, 2025: PASRR Level 1 review date February 5, 2025, determination of Level 1 is to refer to Level 11 onsite with suspected or confirmed PASRR condition of Mental Health Disability (MH). PASRR Outcome Explanation of Notice of PASSR Level 11 Onsite Evaluation Required. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASSR) Level 1 screen for you. This screen shows that you need a face-to-face Level 11 evaluation. PASSR Level1 screens and Level 11 evaluations are required by Federal law. You need this evaluation because you may have serious mental illness or intellectual/developmental disability. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. R37 Diagnosis includes Major Depression, Psychotic/Delusional disorder, anxiety disorder, other mental health diagnosis, insomnia. R16 is [AGE] years old with diagnosis that includes major depression and psychosis. Per R16's PASRR level 1 dated 02/05/2025, reads that level 11 is not required. Facility policy on Pre-Admission Screening and Residential Review (PASRR) dated 11/2024, reads: To comply with State and appointed screening agency. Request full and complete Pre-Admission Screening (PAS) documents to help assess and determine what type of problems, needs and issues need to be addressed to help resident function at his/her maximum level of well-being. 45000 R15s' Facesheet documents that R15 was admitted to the facility on [DATE], with diagnoses not limited to: Other psychotic disorder not due to a substance or known physiological condition. R15s' Level I PASARR/Preadmission Screening and Resident Review screening dated 11/13/2024, documents that R15 does not require a Level II PASARR because R15 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. R33s' Facesheet documents that R33 was admitted to the facility on [DATE], with diagnoses not limited to: Bipolar disorder and unspecified psychosis not due to a substance or known physiological condition. R33s' Level I PASARR/Preadmission Screening and Resident Review screening dated 09/02/2023, documents that R33 does not require a Level II PASARR because R33 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. On 02/06/2025, at 11:04 AM, V16 (Social Services Director) states she is responsible for inputting residents' PASARR information into the screening agency website. V16 states a PASARR/Preadmission Screening and Resident Review is a screening that needs to be done prior to a resident being admitted to the facility. V16 states the facility checks to see if a resident has a PASARR screening upon admission. V16 states usually, the hospital completes a residents' PASARR prior to the facility admitting the resident to the facility. V16 states the facility is responsible for ensuring that residents' PASARR information is accurate prior to admitting the resident to the facility. V16 states she is aware that the PASARR screenings are indicative of determining if a resident is appropriate for the nursing home setting or not. V16 states a PASARR Level II is needed for a resident if it is determined that the resident has a severe mental illness/SMI. V16 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V16 states R15 and R33s' current Level I PASARR screening are inaccurate, and they both require a new Level I PASARR screening to be completed. V16 states a new Level I PASARR screening has to be completed and submitted before R15 and R33 can receive a Level II PASARR screening. V16 states now that she is aware of this information, she will follow up to ensure that R15 and R33 have new PASARR screenings completed. Facility policy dated 11/2024 titled Preadmission Screening and Residential Review (PASRR) documents in part, Policy: 1. To comply with Illinois and the appointed screening agency. Procedure: 2. The screening material must be reviewed as a component of the assessment process and treatment, suggestions and recommendations should be identified and appropriately addressed. 6. All residents with possible serious mental disorders, intellectual disability or newly diagnosis with a mental disorder will be referred for Level II screening. 45111 R54 is a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. medical diagnosis includes but not limited to: schizoaffective disorder, bipolar type dated-6/19/2023, major depressive disorder, recurrent, mild dated -9/20/2023. R54's MDS (minimum Data Set) dated 12/07/2024, documents R54's Brief Interview for Mental Status (BIMS) as 14/15. Indicating R54 has intact cognitive abilities. On 02/05/2025, at 1:45 PM, V17 (Social Services Director) provided R54's Preadmission Screening and Resident Review (PASRR) 1 & 11 referral form dated 02/05/2025. On 02/05/2025, at 3:00 PM, V17 stated residents need to have their PASRR 1 completed before the resident comes to the facility, and the admissions office usually looks at the resident's referral packet from the hospital to see if there is a PASRR 1. V17 stated if the PASRR 1 is not in the packet, the admissions office should call the hospital to ask for it to be completed before the resident is discharged to the facility. V17 stated a PASRR 1 is completed to determine if a resident is a candidate for a nursing facility. V17 stated if the resident is coming from the community, or supportive living program, the facility must complete a PASRR 1 within 48 hours of the resident arriving to the facility. V17 stated R54 was first admitted to the facility on [DATE], from a community hospital and should have had a PASRR 1 completed from the hospital and should have been part of R54's medical records received from the hospital. V17 stated if R54 did not have a PASRR 1 upon admission, the admission director should have gone to PASRR screening agency's website and searched R54 under his social security number and put him on the queue so that the screening agency can come to the facility and complete R54's PASRR 1 screening assessment. V17 further said the facility should have referred R54 for a PASRR 11 screening because R54 has serious mental health diagnosis of schizophrenia, mood disorder, and major depressive disorder since 2023. V17 stated a PASRR 11 evacuation lets facility know what specialized treatment R54 needs to stay the facility for treatment and monitoring. V17 stated a PASRR 11 determines if a resident is approved for short term stay or long term stay for specialized services at the facility, and because R54 has not been assessed for PASRR level 11, he is not receiving the specialized treatment he requires. R54's PASRR 1 & 11 referral is dated 02/05/2025. PASRR Outcome Explanation -Notice of PASRR 11 Onsite Evaluation Required documents: -Your health care professional and outside screening vendor completed a Preadmission Screen Review (PASRR) Level 1 Screen for you. PASRR 1 screens and Level 11 evaluations are required by Federal law. -You need this evaluation because you have serious mental illness or an intellectual/developmental disability. -The purpose of this evaluation is to decide whether a nursing home facility is able to meet your needs. Policy titled Pre-Admission Screening and Residential Review (PASRR) documents: -The admissions director and/or social service director will request the complete screening from the referral source. -All residents with possible serious mental health disorders, intellectual disability or newly diagnosed with a mental disorder will be referred for level 11 screening.

Based on observation, interview, and record review, the facility failed to a.) administer residents' prescribed medications in a timely manner according to the physician orders and b.) keep an accurate count of all narcotic medications for four (R3, R24, R30, R31) residents reviewed for medications in a total sample of 21 residents. Findings include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility performing a controlled substance count and record review. Surveyor observes the following: A medication bingo card labeled R31s' name, Tramadol 50mg, surveyor observes there were 22 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 23 pills. A medication bingo card labeled R31s' name, Pregabalin 25mg, surveyor observes there were 13 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 14 pills. A medication bingo card labeled R31s' name, Diazepam 5mg, surveyor observes there were 19 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 20 pills. 8 liquid medication bottles labeled R24s' name, Methadone 10mg/ml R24s' controlled drug receipt record documents a count of 9 liquid medication bottles. V4 (RN) states she administered the medications to R24 and R31 this morning and forgot to document that she administered them. On 02/05/2025, at 8:37 AM, surveyor observes that the following medication was not given to R3 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN): Gemtesa 75mg. V17 states R3s' Gemtesa medication is not available in the facility, and she has to reorder it from the pharmacy. V17 observed deploying R3s' electronic medication administration record (eMAR) and reordering R3s' Gemtesa medication from the pharmacy via computer. R3 has diagnoses not limited to: Type 2 Diabetes without complications, Hemiplegia and Hemiparesis Following Cerebrovascular disease, and overactive bladder. R3s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Gemtesa 75mg- Give 75mg by mouth one time a day scheduled at 9:00 AM. R3s' eMAR documents that R3s' Gemtesa medication was not administered on 02/05/2025 and 02/06/2025 at 9:00 AM. Facility document dated 02/06/2025, titled Inventory Replenishment Report documents that R3s' Gemtesa medication is not available stored inside of the automated medication dispenser/AMD. On 02/06/2025, at 10:20 AM, surveyor located at the medication cart with V17 (LPN) and observes that R3s' Gemtesa is not located inside of the medication cart. V17 states she did not notify R3s' physician that R3s' Gemtesa medication was not administered on 02/05/2025 and 02/06/2025. On 02/05/2025, at 9:07 AM, surveyor observes that the following medication was not given to R30 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN): Mupirocin External Ointment 2%. V17 states R30s' Mupirocin medication is not available in the facility, and she has to reorder it from the pharmacy. V17 observed deploying R30s' electronic medication administration record (eMAR) and reordering R30s' Mupirocin medication from the pharmacy via computer. R30s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Mupirocin External Ointment 2%- Apply to bilateral thighs topically one time a day scheduled at 9:00 AM. R30s' eMAR documents that R30s' Mupirocin medication was not administered on 02/05/2025, at 9:00AM. R30s' eMAR documents that R30s' Mupirocin medication was administered on 02/06/2025 at 9:00 AM. On 02/06/2025, at 10:20 AM, surveyor located at the medication cart with V17 (LPN) and observes that R30s' Mupirocin medication is not located inside of the medication cart and V17 is unable to locate R30s' Mupirocin medication. V17 states she did not administer R30s' Mupirocin medication today on 02/06/2025. V17 states she documented that she administered R30s' medication in error because she wasn't paying attention when she was clicking the computer mouse to sign for medications. V17 states she did not notify R30s' physician that R30s' Mupirocin medication was not administered on 02/05/2025 and 02/06/2025. Facility document dated 02/06/2025 titled Inventory Replenishment Report documents that R30s' Mupirocin medication is not available stored inside of the automated medication dispenser/AMD. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 2. Medications shall be given within one (1) hour of the specified time, by the same nurse that prepared the dose. 11. Narcotics and all class II drugs must be recorded when given on the individual sheet 19. Narcotics must be signed out in the HER/electronic health record and the narcotic sheet.

Based on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in three of six medication carts, b.) remove and discard expired enteral feedings located in one of three medication storage rooms, and c.) properly label medications that had been open for resident use. These failures have the potential to affect 68 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility at the medication cart performing a controlled substance count and record review. Surveyor observes the following: 1 open liquid medication bottle labeled R32s' name, Morphine Sulfate 20mg/ml inside of the medication cart. R32s' liquid Morphine medication observed with an expiration date labeled 05/17/2024. V4 states that R32s' liquid Morphine medication should not be stored in the medication cart and should have been discarded once it expired on 05/17/2024. V4 states R32 could experience adverse reactions if she is given expired medications. On 02/04/2025, at 10:01 AM, surveyor and V6 (Licensed Practical Nurse/LPN) located on the third floor of the facility at the medication cart. Surveyor observes the following: 1 open house stock bottle medication labeled Bisacodyl Enteric Coated 5mg with an expiration date labeled 12/2024. 1 vial of Lispro insulin inside a clear plastic zip lock bag without a pharmacy label. V6 states the Lispro insulin belongs to R71. V6 states the Bisacodyl medication should not be stored in the medication cart and should have been discarded once it expired on 12/2024. V6 states R71s' Lispro insulin should have a proper pharmacy label identifying R71s' name, medication, and dosage on the insulin package. On 02/04/2025, at 10:05 AM, surveyor located inside of the third-floor medication storage room with V6 (LPN). Surveyor observes the following: 2 house stock enteral feeding containers labeled Nepro 1.8 CAL 33.8 ounces with an expiration date labeled 11/2024. Surveyor also observes milk curdles at the bottom of both enteral feeding containers. V6 states the enteral feeding containers should not be stored in the medication storage room for resident use and should have been discarded once it expired on 11/2024. V6 states residents could potentially get sick if expired enteral feedings are administered to them. On 02/04/2025, at 10:22 AM, surveyor and V22 (Licensed Practical Nurse/LPN) located on the fourth floor of the facility at the medication cart. Surveyor observes the following: 1 open house stock bottle medication labeled Bisacodyl Enteric Coated 5mg with an expiration date labeled 09/2023. 1 open house stock bottle medication labeled Vitamin C 500mg with an expiration date labeled 11/2024. 1 open house stock bottle medication labeled Vitamin D 250mcg with an expiration date labeled 10/2024. V22 states the Bisacodyl, Vitamin C, and Vitamin D medications should not be stored in the medication cart for resident use and should have been discarded once they expired. On 02/05/2025, at 9:07 AM, during a medication administration pass with V17 (Licensed Practical Nurse/LPN), surveyor observes V17 with a nasal medication labeled Fluticasone Propionate 50mcg. Fluticasone medication does not have a pharmacy label with R30s' name, medication, and dosage on the packaging. V17 states R30s' Fluticasone medication should have a proper pharmacy label identifying R30s' name, medication, and dosage on the package. V17 states she cannot be sure if the Fluticasone medication is prescribed to R30 since it does not have a proper pharmacy label. Facility census dated 02/04/2025, documents a total of 43 residents resides on the third floor of the facility and 21 residents reside on the fourth floor of the facility. Facility document titled G-tube Residents lists a total of 6 residents residing in the facility who have gastrostomy tubes for enteral feedings. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 7. A nurse may not write the name and/or strength of the medication on the label. Should the pharmacy fail to label it properly, the drug must be returned to the pharmacy for proper labeling. 8. House stocked medications should not be administered after expiration date located on the manufacture's bottle. 16. Never use medicine from an unmarked container. Return containers bearing illegal, unclear or stained labels to pharmacy for re-labeling.

Based on interview and record review the facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and Covid-19 for six residents (R27, R62, R73, R207, R257, R307). Findings include: According to R27 progress note, 8/29/2024, R27 was offered and refused the influenza (flu) vaccination in 8/2024. The facility is not able to provide documentation that R27 was offered the influenza vaccination subsequently or provide a refusal of the influenza vaccination by R27 for the current flu season. According to electronic record, immunizations sections for R62, R73 and R307, they were not provided immunization education prior to vaccine administration or refusal. Review of R207 Authorization and Release for Influenza Vaccine, 2/4/25, does not indicate if R207 consented or refused the influenza vaccine. Also, according to V3 (Infection Preventionist / Licensed Practical Nurse), V3 signed the form for R207 and there is no witness signature. Review of R257 Authorization and Release for Influenza Vaccine, no date, indicates R257 consented to receive the influenza vaccination. R257 has not received the influenza vaccine to date. Review of R257 Authorization and Release for Vaccinations, 1/28/25, indicates R257 consented to the administration of the Covid-19 vaccine. R257 has not received the Covid-19 vaccine to date. 2/6/25, at 9:13 AM, V3 (Infection Preventionist / Licensed Practical Nurse) stated V3 has been IP nurse since January 2024. V3 does the antibiotic surveillance, immunizations, outbreaks of Covid, flu, C. diff (Clostridium difficile), etc., all infections, immunizations for residents and staff. V3 makes sure infection protocols are maintained throughout the building. Influenza season starts in September and ends in March. During the season I offer to residents and staff the influenza immunization. If they refuse, I continue to offer throughout the season and encourage and educate of the benefits and risks of receiving the vaccine for added protection. If they want it, then I place an order for the vaccine or schedule a clinic. I started offering it on 9/2024 for flu season 2024/2025. If it is a new admission resident, within 72 hours I offer any and all immunizations/vaccines. I take historical information. I document and offer education. If they refuse, I document and offer education and tell them I'll come back to reoffer. I continue to document that I offer. I educate and encourage each time. I document under immunizations or progress notes in the electronic record. I offered R27 the influenza vaccine in January, but I did not document it. R27 has not received the flu vaccine. R27 received RSV (Respiratory Syncytial Virus). There was an issue with R27's insurance not paying. R27 was hospitalized for pneumonia. I don't have a refusal for this flu season for R27. Education is provided so the residents know the risks and benefits of the vaccine. If education is not given the resident is not informed. R62, R73 and R307 education is not documented. R207 did not want to sign the consent. R207 wanted me to sign. The ADON (Assistant Director of Nursing) was a witness but did not sign the consent as a witness. Consent was given 1/27/25 for R257 to receive the influenza and pneumo (Pneumococcal pneumonia) vaccines but the influenza has not been given at this time. I had given R257 the pneumo vaccine. R257 did not get the influenza because I was spacing it from the pneumo vaccine. I wanted to space the vaccines out. I talked to the NP (Nurse Practitioner) who consulted with the doctor. It is not documented that I received an order to space out the vaccines. I received consent for R257 for Covid-19 on 1/28/25. R257 has not been given Covid-19 vaccine. It was refused by pharmacy due to no insurance. I have not checked with our pharmacy. I have not ordered the Covid-19 vaccine yet for R257. 2/6/25, at 4:05 PM, V2 (Director of Nursing) stated immunizations are important because of a lot of different populations in the facility, immunosuppressed residents. We have to safeguard the population by making sure of no outbreaks, keeping residents healthy, and keeping them vaccinated from viruses and diseases. Facility policy Immunizations, no date, documents in part: In order to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia, it is the policy of this facility to offer influenza and pneumococcal vaccination to all residents. Each resident or the resident's representative will receive education regarding the benefits and potential side effects of influenza immunization. Each resident will be offered the influenza vaccination between October 1 and November 30 or as soon as possible if vaccine is not available by November 1, unless the immunization is medically contraindicated or the resident has already been immunized during this time period. Residents admitted after November 30 and until March 31 shall as medically appropriate receive an influenza vaccination prior to or upon admission or as soon as possible if vaccine is limited. The residents medical record will indicate: a. That the resident or residents legal representative was provided education regarding the benefits and the potential side effects of influenza immunization; and b. That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

Based on observations, interviews, and review of records the facility failed to maintain resident rights pertaining to dignity for 3 out of 3 residents (R 18, R37, R69) for a total sample of 21 residents reviewed for resident rights. Facility failures are as follows: failed to provide feeding assistant with dignity for one resident (R37); failed to protect/promote the right to confidentiality of medical information for two residents (R18 and R69). These failures have the potential to affect 3 residents (R18, R37, R69) in their right to maintain dignity. Finding includes: On 02/04/2025, at 1:09 PM, in the dining room, V21 (Certified Nursing Assistant) brought R37 who was sitting on a Geri-chair near table to be fed. V21 while standing took a spoon, and fed R37 the whole meal. V21 kept on inserting food to R37's mouth while R37 was still chewing. The food inside R37's mouth was hard to see. V21 kept on calling R37 by the first name. R37 does respond with words and was making moaning sounds when addressed by name. By 1:17 PM, all of R37's food was done except green peas. During feeding of R37 by V21, R37 had a hard time keeping up with the food V21 was giving. V21 stated that during feeding residents, it should be on eye level to resident's mouth. But since R37 head was tilting up she stood while feeding. V21 stated I was having a hard time seeing if R37 still had food in her mouth. V21 insisted to go back to R37 to check her prior position (standing). V21 then went to R37 and pulled up a chair. After V21 sat on the chair and on eye level position to R37's mouth, V21 was asked if it was better position compared to standing because she sat on the chair. V21 did not answer. On 02/05/2025, at 11:03 AM, V2 (Director of Nursing) stated that V21 should sit and feed the resident on eye level position to make sure that V21 can see that R37 was able to take the food while feeding. By doing so, it helps prevent aspiration. On 02/06/2025, at 12:45 PM, V14 (Director of Rehabilitation) stated that when feeding a resident that needs assistance reposition up to 90 degrees, take smaller bites and alternate solid with liquid. Check if the resident's mouth has food in it. Staff and the resident need to be at same level position. This way staff can see a little bit better, because when standing you cannot see the mouth of resident. V14 said, For me it is a dignity thing when you are standing and feeding at the same time. R37 is [AGE] years old with severely cognitive impairment BIMS (Brief Interview for Mental Status) dated 01/02/2025 scored 99 because R37 unable to complete interview. R37 medical diagnosis includes dementia, anxiety disorder, major depression disorder, psychotic disorder. Per nutrition care plan of R37, resident needs one on one assist during meals. Resident Rights policy dated 08/2022 reads: The right to live in an environment that promotes and support each other's dignity with consideration and respect. 49666 On 02/04/25, 10:43 AM, R18 was lying down in bed, wearing a hospital gown, wearing glasses, and in no apparent distress. Fall mats noted on the floor on both sides of R18's bed. R18's bed with lock on. A hot pink or fuchsia color sign at R18's head of the bed's wall documents in part R18's name, diet puree visible. On 02/04/25,12:47 PM, R69 in his room sitting on his wheelchair, dressed in his own clothes, and in no apparent distress. A yellow sign visible at R69's head of the bed's wall documents in part R69's name, dated 12/4/24, diet: regular solids, liquid: thin liquids. R69 states that he does receive occasional visitors. On 2/6/25, 12:39 PM, V14 (Director of Rehab) states that when speech therapy (ST) has recommendations for a resident, they will usually leave a swallow precaution sign with a list of instructions of what ST recommend. V14 states it is typically a hot pink sign and it is usually posted above the resident's bed or beside countertop. V14 continues to state that the swallow precaution sign will include information such as how the patient should be eating, and cues to remind patients if they are feeders. We give proper recommendations on how to properly feed the residents. V14 reports that the form will also notate if the resident requires 1:1 feeding assistance. V14 states that the rationale for posting the form is for speech department to make sure the staff are following precautions, so patients won't get aspiration pneumonia. V14 states that he does believe all the information on a swallow precaution form is a resident's medical record and it is their personal information because not everyone is on a special diet so not everyone should be aware of their medical records such as the type of diet they are on. V14 states if visitors are coming in to visit the resident or the resident's roommate, they can visibly see this information. R18's current face sheet documents R18 is a [AGE] year-old individual with diagnoses not limited to: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, other sequelae of other nontraumatic intracranial hemorrhage, dysphagia following cerebral infarction, aphasia. R18's MDS/Minimum Data Set Section C dated 12/13/2024, documents that R18 was unable to complete the interview for BIMS/Brief Interview for Mental Status. R18's current physician order set documents in part regular diet puree texture, nectar consistency. R69's current face sheet documents R69 is a [AGE] year-old individual with diagnoses not limited to: encephalopathy, unspecified, malignant neoplasm of overlapping sites of lip, oral cavity and pharynx, unspecified visual loss. R69's Minimum Data Set (MDS), dated [DATE], documents R69 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R69 is cognitively intact. R69's current physician order set documents in part diet regular texture, thin liquids consistency. Facility document dated 8/22 titled Resident's Rights documents in part no resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this Community, nor shall a resident forfeit any of the following rights: the right to confidentiality of the resident's medical, financial, or other records.

Based on observation, interview, and record review, the facility failed to assess/monitor one of three residents (R30) for self-administration of medication out of a total sample of 21 residents reviewed. Findings include: On 02/05/2025, at 9:07 AM, during a medication administration pass with V17 (Licensed Practical Nurse/LPN), surveyor observes V17 with a nasal medication labeled Fluticasone Propionate 50mcg. V17 gives the Fluticasone medication to R30. R30 asks V17 how many sprays, 2 right? V17 replies Yes. R30 then observed self-administering the Fluticasone medication to herself, administering 2 sprays into both of her nostrils. V17 states she gave R30s' Fluticasone medication to R30 to self-administer because R30 is able to self-administer her medication and does not trust the facility staff nurses to administer it to her correctly. Review of R30s' Physician order sheet/POS, medication administration record/MAR, and electronic health record/EHR documents that R30 does not have a physician order and has not been assessed to self-administer her own medications. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 13. Self-administration of medications by residents is permitted only when resident has been assessed and is capable of self-administration and a physician order has been written for self-administration.

Based on observations, interviews, and review of records the facility failed the following related to [NAME] Program: facility failed to display [NAME] information in a public and accessible location, a department provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition. Failure includes 12 out of 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) included in the sample list for December 2024 and January 2025 of residents that can be a part of the [NAME] program. This failure has the potential to affect 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) in their right to exercise community transition given proper information. Findings include: On 02/04/2025, at 2:35 PM, after checking all floors to verify the [NAME] program posting, there was none seen posted. V16 (Social Service Director) was asked about poster for the [NAME] program. V16 replied that she is not sure if there are any posting in the facility. V16 said that best area for resident to see any posting is the main dining room on the 1st floor. During that time, the bingo activity was going on. Upon checking all areas on the main dining room there was no poster found. V16 agreed to go to all floors to check for posting. Using the elevator, the 2nd floor was checked. The 3rd floor was checked as well. All floors were seen without posting for the [NAME] program. V16 stated that she will make sure poster will be posted for residents to have information and be able to see contact information when wanting to be a part of the [NAME] program. On 02/05/2025, at 10:28 AM, V16 stated educational materials and information to all residents was not given until yesterday after checking facility. There was no poster in the building. On 02/06/2025, at 12:15 PM, V16 stated that [NAME] program is important because it provides access to residents to see if they are ready to be in community setting. Community settings are less restrictive than skilled settings. There are residents that are self-sufficient that can live in the community. On 02/07/2025, at 8:21 AM, V16 provided list of possible candidates for [NAME] program for the month of December 2024 and January 2025. Included in the list are (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) that could be a part of the [NAME] program if proper information, assessments, and education were provided.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff and also failed to appropriately identify incident(s) of abuse. This failure affected one resident (R2) whose wrists were tied to their bed side rails using pillowcases by a facility nurse as an attempt to confine R2 in bed for the nurse's convenience. As a result, R2 experienced feelings of humiliation and despair as evidenced by being tearful as well as physical pain and discomfort in both wrists. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 RN (Registered Nurse) tied R2 with pillowcase to the bed side rails. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17 pm. The immediate jeopardy was removed on 11/28/24 at 3:36 pm. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: R2 is a [AGE] year-old, cognitively impaired resident with diagnosis that includes but not limited to restlessness and agitation, tracheostomy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, muscle wasting and atrophy and repeated falls. On 11/14/24 at 2:43 pm, V6 RN (Registered Nurse) stated that the shortage (referring to facility staffing) started at the beginning of the shift (referring to CNA shift 3:00 pm to 11:00 pm). V6 stated normally the second-floor staffing is to have three CNAs (Certified Nurse's Aide) but only two were working. V6 stated because R2 is known for climbing out of bed and falling and the RN (V6) was busy passing medication, V6 decided to tie R2's wrists to the bedrail with a pillowcase. V6 stated R2 had become agitated when the family member who came to visit R2 left. V6 stated that they (V6) knew what they did was wrong, but it was done so R2 would not fall when there was not enough staff (referring to CNAs). V6 stated that there was no other staff involved in tying R2 down. When the surveyor asked if R2 was willing to be tied down V6 stated that R2 was not cooperative with the tying down, but V6 was busy and could not stay with R2 and supervise them. V6 acknowledge that there was no physician order in R2s chart to restraint R2 with a pillowcase or any other restraint. When asked if that is a form of abuse V6 stated Yes, it can be abuse. The surveyor asked V6 if R2 is able to easily remove a pillowcase tied to their wrist and V6 stated No, because both hands were tied. On 11/14/25 at 2:51 pm, V20 CNA (Certified Nurse's Aide) stated On 10/12/24 I (V20) was not in the building, but V21 (CNA) called me at home very upset and told me how she found R2 tied down like a dog with a pillowcase in the bed. So, I called V2 (Director of Nursing). On 11/14/24 at 2:58 pm, V21 (CNA) stated that she witnessed R2's wrists tied to the bed side rails by use of pillowcases on 10/12/24. V21 stated she called V8 (Registered Nurse) working on the floor to see what was going on. V21 then stated that tying a resident to the bedrail with a pillowcase was a form of abuse. V21 confirmed that when she found R2, they were tearful, showing gestures for help and when she released R2's wrists from the pillowcase, R2 began rubbing their wrists and gesturing to pain and discomfort by use of mouth gestures. V21 also stated that R2 was grateful for V21's help and began blowing kisses and mouthing thank you. V21 acknowledged that a reasonable person would not want to be tied down like R2 was. V21 said, I could not believe what I saw so I walked out and called the other nurse V8 (RN) and V25 (CNA). I also called a union representative because this traumatized me, and I was not allowed to go home because we (facility) were short of working CNAs. I had to go off the floor for a short period in the staffing lounge. V21 confirmed that she called V20 at home to talk about what happened and at that time, V20 called V2 (Director of Nursing) to report what had happened. On 11/14/24 at 3:28 pm, V1 (Administrator) stated that the incident was marked as abuse but it was not founded to be abuse an applying the pillowcase was for safety of R2 and no injury was discovered. V1 attributed V6's action to V6 being busy with another resident and did not have other staff available to assist them (V6) in making sure R2 was supervised. Present during the interview with V1 was V22 (Nurse Consultant) who stated, it is a form of abuse, and it should absolutely be reported to IDPH (Illinois Department of Public Health). On 11/18/24 at 10:42 am, V19 (Restorative Director) stated that it is not appropriate to use a pillowcase as a restraint device because it can cause psychological and emotional anguish. V19 stated, This can cause the resident to be sad and feel isolated .a pillowcase can block flow of blood circulation due to it not being designed for use as a restraint device. The surveyor asked V19 that in his own professional opinion can this be a form of abuse and V19 stated Yes, it can be a form of abuse that should be reported. On 11/18/24 the facility staffing schedule dated 10/12/24, showed documentation that V21 was pulled from the 3rd floor to work on the 2nd floor because there was only one CNA present with two nurses at 3:00 pm. On 11/25/24 at 2:04 pm, V1 stated that V6's action did not constitute a form of abuse because it was not unreasonable confinement. V2 (DON) who was present at the time of V1 interview stated that it was a form of abuse because the effect can be psychological/ mental anguish. Record review of R2's medical record showed that the only way R2 can communicate with facility staff is by using R2's hands, either by writing or using hand gestures. R2's MDS (Minimum Data Set) dated 10/18/2024 section C-cognitive patterns did not score R2's BIMS (Brief Interview for Mental Status) indicating that R2 was unable to complete the interview. R2's medical record did not show any Plan of Care stating R2 was susceptible to abuse. On 11/18/24 at 1:30 pm, R2 was observed in the room sitting in a recliner chair using the right hand to wipe saliva from the mouth. R2's left hand was noted with weakness; R2 was using their right hand to lift their left hand onto their lap. When asked about the incident on 10/12/24, R2 answered with thumbs down while shaking their head back and forth in a No gesture. The surveyor asked R2 whether R2 wanted to be tied down R2 shook the head back and forth in a No gesture and mouthed NO. When asked if R2 experienced pain, R2 shook their head Yes. On 11/18/24 at 3:21 pm, V23 (Physician) stated that he has never heard of staff tying down a resident and will never give an order to do so. V23 stated How can anyone do that? In [AGE] years of being in medicine, I know that it is not professional, and it is not right. On 11/18/24 at 3:46 pm, V24 (Psychiatrist) stated, I will never give such order. The nurse (V6) acted on their own. V24 stated Use of mitten may be used, not a use of pillowcase. It is not good, and it should not be done, and no physician should give that kind of order. That kind of abuse it is unheard of. When asked about what can happen to a resident who is inappropriately restrained, V24 stated that it can compromise their breathing. On the 11/25/24 facility census report for 10/12/24 presented for the 2nd floor showed that 41-residents were residing on the 2nd floor and 110 total residents residing in the facility. On 12/04/24 at 10:14 am, V29 (PRSD/Psychiatrist Rehabilitation Services Director) stated that she is new to the facility and was not sure what happened for the nurse to tie down R2. When the surveyor asked about the 10/12/24 incident in which V6 restrained R2 with a pillowcase when the facility was short-staffed and if that can be a form of abuse, V29 stated In my own professional opinion, yes, it will be considered abuse, and it should have been reported. On 12/05/24 at 1:12 pm V6's time sheet presented showed that on 10 /12/24 V6 clocked in at 7:11 am and clocked out at 7:26 pm, showing that V6 worked the whole shift. The facility Abuse Prevention Program policy presented with revised date 04 January 2018 documented that definition of abuse includes but not limited to willful infliction of injury, unreasonable confinement, pain and mental anguish. Willful as used in the definition of abuse means the individual must have deliberately, or that the individual must have intended to inflict injury or harm. The policy under external reporting documented that initial reporting of allegations documented that when an allegation of abuse occurred the department of Public Health's regional office shall be informed by telephone or fax. The facility policy presented titled Abuse Prevention Program Facility Policy and Procedure with revised date January 4, 2018, documented that abuse is defined as the willful infliction of injury that includes but not limited to unreasonable confinement, or punishment that is resulting in pain or mental anguish. The policy documented that Willful as used in this definition of abuse, means the individual must acted deliberately not that the individual must have intended to inflict injury or harm. The surveyor confirmed on 12/04/24 and 12/05/24 through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: the facility completed all measures on the abatement plan. Therefore, the abatement plan could be approved on 11/18/24. 1. R2 screened, reassessed for risk for abuse with care plan interventions. 2. All staff in-serviced training completed on 11/26/24 by V1, V2 and V29. 3. Documentation showed that all residents were re-educated on abuse with completion date of 11/26/24. 4. R2, R14, R15, R16, R17, R18, R19 and R20 were screened for potential abuse with care plan reviewed and initiated. 5. All staff will be responsible for monitoring residents for behavior that can make them vulnerable for abuse. 6. All residents determined to be vulnerable or those that will be affected by this deficiency citation R2, R14, R15, R16, R17, R18, R19 and R20 were identified, and plan of care initiated, with ongoing, on admission, quarterly and annually. 7. Review Quality Assurance audit tool started on 11/27/24 weekly ongoing to ensure compliance.

Based on interview and record review, the facility failed to assure that residents are free of unnecessary physical restraint(s), failed to identify the specific medical symptoms warranting the use of physical restraint(s) and failed to obtain physician orders with medical justification for physical restraint(s). This failure affected R2 whose wrists were tied to the bed side by a pillowcase by a nurse with no physician order, no consent or resident permission, and no medical justification. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 (Registered Nurse) tied R2 to their bedside rails with a pillowcase. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17pm. The immediate jeopardy was removed on 12/3/24 at 3:29 pm. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: R2's medical record Admission Record showed documented that R2 was admitted originally to the facility on [DATE] with latest admission on 11/14/24. Listed diagnosis includes but not limited to Tracheotomy status, restlessness and agitation, hematemesis, Type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, acute and chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and repeated falls. R2's MDS (Minimum Data Set) dated 10/18/2024 section C-cognitive patterns did not score R2's BIMS (Brief Interview for Mental Status) indicating that R2 was unable to complete the interview. R2's medical record did not show any documentation of medical symptoms or behavior that would justify the use of restraint, no physician order for restraint usage, no restraint assessment, no consent, and no plan of care for restraint usage. On 11/14/24 at 2:43pm, V6 (Registered Nurse) stated that there was staffing shortage for CNAs that started at the beginning of the shift (referring to 3:00pm to 11:00pm shift on 10/12/24). V6 stated that normally the second-floor staffing is to have three CNAs, but only two were working. V6 stated Because R2 is known for climbing out of bed and falling and I (V6) was busy passing medication and taking care of other residents that were screaming and yelling, I (V6) decided to tie R2's hands with a pillowcase to prevent R2 from falling. I know what I've done is wrong, but it was done so R2 will not fall when there was not enough staff . When asked about the daily staffing for 2nd floor, V6 stated there should be two nurses and three CNAs (3pm to 11pm shift). When the surveyor asked for any medical justification like R2 trying to remove the tracheostomy tube or the oxygen, V6 stated that R2 was not trying to remove the tracheostomy tube or the oxygen, but was just trying to climb out of bed. V6 stated, R2 became restless and agitated because the family (V41) came to visit R2, and V41 (family member) had just left. V6 confirmed that R2 did not have any physician order(s) for restraint and that R2 was tied at the beginning of the shift. V6 also confirmed that before V6 could return to check on R2, V21 (CNA) discovered that R2 has been tied down. When the surveyor asked whether R2 was willing to be tied down V6 stated that R2 was not cooperative with the tying down, but V6 was busy and could not stay and supervise R2. V6 stated, I know that is not a restraint device but tying R2 down is a form of restraint that was not ordered. V6 stated, I did not want R2 to fall. The surveyor then asked whether restraints is a part facility intervention for falls and can R2 free self from the restraints without injury. V6 stated I should not have tied R2 down, and it is not part of intervention for fall prevention. On 11/14/24 at 3:28pm, when this was brought to V1 (Administrator) attention, V1 stated that applying the pillowcase was for safety of R2 and no injury was founded. V1 attributed V6's action to V6 being busy with another resident and did not have other staff available to assist him (V6) in making sure R2 is stabilized not fall. On 11/25/24 at 2:26 pm, V2 DON (Director Of Nursing) stated that the nurse (V6) should not have used a restraint on R2 and if this was left to her she would have terminated V6 but V1 (Administrator) prefers for this situation to go through them first. V2 confirmed that the situation with R2 was an unnecessary use of restraint. R2's medical record showed no recorded documentation that R2 had prior to 10/12/24, or after, any physical restraint assessment performed by the facility. There also was not any consent obtained from R2 or a resident representative, either written or verbal for the use of physical restraints. There was also no medical justification for physical restraints documented in R2's medical record. R2's care plan for communication initiated 07/15/2024 and revised on 08/05/2024 showed that R2 is non-verbal and can only communicate with staff using a writing pad and pen as well as using hand or mouth gestures. When the surveyor asked R2 about how R2 feels about being tied with pillowcase. R2 responded with hand gestures showing a thumbs down and shaking the head to gesture No. R2's medical record, Risk for Falls assessment dated [DATE] showed that R2 scored 18 and under category deemed to be at a moderate risk for falls. Facility in-house investigation report on 10/12/24 documents in part: Staff witnessed R2 tied up to the bed side rails with a pillowcase by V6 (Registered Nurse). As a result, R2 experienced psychosocial impact that was described as crying for help and tearful. V6 stated R2 was agitated and restless and because there was not enough staff working at the time of the incident he tied R2 with the pillowcase. V6 stated that he was busy with other residents and could not supervise R2. V42 (Director of Rehabilitation services) statement dated 10/16/24 with no date of incident and interview. V42 wrote I (V42) was not present at the time of incident but R2 was in therapy due to having multiple falls out of bed. V42 documented in part in the statement that whenever R2 is trying to get out of bed he can usually redirect R2 and that R2 can usually tell of the needs through on-verbal communication. V42 further stated that R2 likes to have a towel to clean up saliva the mouth/trach (Tracheostomy) and R2 can become anxious if (R2) does not have one. V8's statement documentation dated 10/12/24 documented that on 10/12/24 at 6:10 pm when (V21 CNA) called her (V8 RN) to R2's room the room was dark and when the light was turned on, she (V8) observed R2's left, and right wrist tied with pillowcase. On 11/18/24 at 10:40 am, V19 (Restorative Director) stated that the facility is a restraint free facility therefore no physical restraint should be used on any of the resident and if there is justification for emergency usage for the restraint there must be a physician order immediately after or within eight hours of use. V19 stated that the resident must be placed on 1:1 staff supervision for safety reasons and it is not appropriate to use a pillowcase as a restraint devise because it can cause psychological/ psychological emotional anguish. V19 stated that this can cause the resident to be sad and isolated. And a pillowcase can cause flow of blood circulation due to it not designed to be used as a restraint device. R2's medical record did not show any documentation of medical symptoms or behavior that justify use of restraint, no physician order for restraint usage, no restraint assessment, no consent, and no plan of care for restraint usage. R2's medical record review showed that the only way of R2 communicating with facility staff is by using writing or using mouth and hand gestures. R2's medical record showed no recorded documentation that R2 before 10/12/24 and after had any physical restraint assessment done. There was no consent obtained either written or verbal. R2 was not informed. No physician order, no psych-evaluation and no medical justification for the use of restraints. On 11/18/24 at 1:30 pm, R2 was observed in the room sitting in a recliner chair using the right hand to wipe saliva from the mouth. R2's left hand was noted with weakness while R2 was using the right hand to lift the left hand unto the lap. When asked about the incident on (10/12/24). R2 answered with thumbs down and shaking the head that it was bad. The surveyor asked R2 whether R2 wanted to be tied down R2 shook the head and with lip movement to gesture NO. R2 indicate with yes that it was painful. R2's medical record risk for Falls assessment dated [DATE] record that R2 scored 18 and under category deemed to be at a moderate risk for falls. On 11/18/24 at 3:21 pm, V23 (Physician) stated that he has never heard of staff tying down a resident with a pillowcase and will never give an order to do so. On 11/18/24 at 3:46 pm, V24 (Psychiatrist) stated, I will never give such order, V6 acted on their own. V24 stated that use of mitten may be used in a hospital but not a use of pillowcase. V23 stated it is not good and it should not be done, and no physician should give that kind of order, it is a kind of abuse it is un-heard off. When asked about what can happen to the resident. V24 stated that it can compromise R2's breathing. V24 stated, No, I did not give that order because there is no such thing in physician book for a staff to tie up a resident with a pillowcase. On 12/04/24 at 10:36 am, interview conducted with V8 (Registered Nurse) regarding the incident of 10/12/24 where R2 was tied down to the bedside rails with pillowcase. The surveyor asked if R2 was able to remove the pillowcase if R2 wanted to and if it was easily removable. V8 stated No, R2 would not be able to remove the pillowcase. I reported it to V2 (Director of Nursing). Surveyor asked why did V8 report the incident, V8 said that they did because it was wrong and it was abuse. Surveyor asked if V8 ever tied any of the resident up like that, V8 said No, that will be abusive. With any restraint use, we must get a doctor's order and monitor the resident. The restraint is not necessary and the purpose of pillowcases is to be used for pillows, it should not be used as a restraint. The incident happened around 5:30 pm and R2 was happy to be released. This is restraint free facility. When asked what was R2's reaction to what happened. V8 stated that R2 was using hand gestures to thank us. V8 also said that a reasonable person would not have liked to be tied down and it is wrong to do that and no one would like to be tied down. On 12/04/24 at 1:00pm, V19 (Restorative Director) stated that I V19 returned to work 12/02/24 and is still auditing the residents records. V19 stated that the facility is a restraint free facility and that safety belt, medical recliners, side rails and mittens are forms of restraint devices, but the facility does not use restraints. V19 stated that medical recliners are used for positioning and comfort for poor trunk control All those things listed that V6 (RN) did not follow with R2. On 12/04/24 at 2:06 pm, V25 CNA (Certified Nurse Aide) stated that she worked 3pm to 11pm on 10/12/24. V25 stated, at the beginning of the shift when making rounds, R2 kept trying to get out of bed and the V6 (Registered Nurse) came in R2's room and stated he will stay in the room with R2. V25 stated, I (V25) was doing my rounds. Dinner trays came and the other CNA (V21) was passing the dinner trays when she saw R2's arm restrained to the bed rails. V21 told me to come and look and I saw R2's hands tied with pillowcases to the bed rails. R2 was just lying there on the bed. When V25 was asked about what a reasonable person would like and if would R2 liked to be tied down to the bed rails, V25 stated No. On 12/05/24 at 1:12 pm V6 time sheet presented showed that on 10 /12/24 V6 clocked in at 7:11 am and clocked out at 7:26 pm, showing that V6 worked the whole shift. The facility procedure for the use of Physical Restraint:Exception for emergency Situations documented that after less restrictive interventions to prevent the resident from serious harm have proven ineffective, determined the need for an emergency physical restrain. This determination may be made by the nurse. Under emergency authorization documentation documented that approval for the use of emergency physical restraints must be made by attending physician , the medical director or a supervisory nurse.if approval is given by a nurse , a physician's order must be received within eight (8) hours, validating the supervisory nurse's decision. Physician orders regarding emergency physical restraint placement may be taken by telephone or fax machine. The facility Fall Prevention policy presented with revised date 12/20/22 documented that based on the result of the falls assessment, the Inter disciplinary team will determine the best approach to implement for fall prevention, adjust the care plan, inform the family and resident and implement comprehensive fall prevention management approach. The facility titled Restraints Policy presented with revised date 9/17 documented under policy statement that in accordance with federal and state laws has a stringent policy regarding the use of physical and chemical restraints on resident. Our philosophy (Facility) of providing residents with the highest possible quality of care and life is reflective of our belief that is essential for our residents to maintain their dignity and independence by being permitted to take the normal risks of everyday life. For these reasons and in accordance with federal and state laws, restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident. Listed procedures includes but not limited to with a physician order, with consent of the resident (or legal representative); when the benefits of the restraint outweigh the identified risks. If the restraint use is deemed necessary, the goal will be to use the least restrictive type of restraint for the shortest period possible. On 12/04/24 and 12 /05/24, the surveyor made observations, conducted interviews, and received documentation to confirm the following removal plan was initiated. 1. All staff were trained on what constitute proper training, unnecessary use of restraint, with ongoing training scheduled Quarterly by V29 and completed on 11/28/24. 2. All residents have been assessed to ensure that none are restrained improperly or unnecessarily by V19. 3. Assessment will be ongoing and conducted at admission, quarterly and annually 4. Outside consultant and V2 and V29 conducted in-service training on behavior management. On 11/27/24 and 12/05/24. 5. Documentation showed all the facility residents were in-service on abuse and restraints by V29. 6. R2, R14, R15, R16, R17, R18, R19 and R20 were care planned/interventions with potential for abuse and proper restraints related to their diagnoses. 7. A system put in place for audit to be done weekly to ensure compliance with unnecessary use of restraint to be monitored by V1, V2 and V29.

Based on interview and record review, the facility failed to provide wound treatments for 2 (R1,R4) of 3 residents who were reviewed for wounds. The facility failed to : 1. Provide wound treatment for R1's surgical site. 2. Develop skin care plan interventions for R1. 3. Ensure wound skin assessment and Braden scale assessment completed on weekly basis for R1. 4 Provide wound treatment as ordered by physician for R4. These failures resulted in R1 being admitted to the hospital on 9/4/24 for dehiscence of the wound to groin area and R4's wound dressing not being changed daily. The findings include: R1's admission record documented admitted on 8/20/24 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 diabetes mellitus, Other obesity due to excess calories, Essential (primary) hypertension, Hyperlipidemia, Angina pectoris, Other specified anemia, Atherosclerotic heart disease of native coronary artery, Peripheral vascular disease, Encounter for other specified surgical aftercare, Depression, Other abnormalities of gait and mobility, Other lack of coordination. R4's admission record documented admitted on 3/14/23 with diagnoses not limited to Central Cord syndrome at C5 level of cervical spina cord, Chronic Obstructive Pulmonary Disease, Retention Of Urine, Mild Protein-Calorie Malnutrition, Pressure Ulcer Of Right Hip Stage 4, Pressure Ulcer Of Right Heel Stage 3, Pressure Ulcer Of Other Site Stage 4, Non-Pressure Chronic Ulcer Of Skin Of Other Sites With Unspecified Severity, Anemia Due To Enzyme Disorder, Peripheral Vascular Disease, Acquired Absence Of Left Leg Above Knee, Atherosclerosis Of Native Arteries Of Left Leg With Ulceration Of Other Part Of Foot, Non-pressure Chronic Ulcer Of Other Part Of Left Foot With Fat Layer Exposed. R1's progress notes dated 9/4/2024 documented in part: Resident went out on appointment with escort. Resident was being admitted for dehiscence of the wound to groin area. MDS (Minimum Data Set) dated 8/27/24 showed R1's cognition was moderately impaired. She needed set up or clean up assistance with upper body dressing; Supervision or touching assistance with toileting and personal hygiene, shower / bathe self; Partial / moderate assistance with lower body dressing, chair / bed, and toilet transfer. MDS showed R1 had surgical wound. R1's wound / skin assessment dated [DATE] documented in part: Lt Inner Thigh measuring 4.5 x 1.5 x 0.1cm with light serosanguinous drainage. R1's Admission History and Physical notes dated 8/21/24 documented in part: Patient underwent Left femoral above to the knee popliteal bypass with Graft. ENCOUNTER FOR OTHER SPECIFIED SURGICAL AFTERCARE - Monitor and change surgical site as per facility protocol. On 10/06/24 at 10:11am Interview with V3 (Wound care nurse, Licensed Practical Nurse / LPN) stated she started working in the facility in July 2024. She said resident's skin condition is checked upon admission and if there is skin alteration such as pressure, non-pressure or surgical wounds, assessment and documentation should be done weekly as it would give information about the wound that include drainage, measurement, treatment, and status of the wound. Any skin alteration, need to have a treatment in place. Treatment will make the wound healed and prevent infection. If there is no wound treatment, could lead to infection, necrosis, worsening of wound. Braden scale assessment is to identify if the resident is at risk for skin breakdown. It is done upon admission / readmission x 4 weeks then quarterly and significant change. Reviewed R1's electronic health record (EHR) with V3 and stated R1 was admitted with surgical site to her left inner thigh related to poor circulation. R1 had stent placement - Left femoral popliteal bypass. She said assessment was done on 8/21/24, showed surgical site on left inner thigh with sutures in place with moderate serosanguinous drainage. She said Treatment: Border gauze dry dressing every Monday, Wednesday, Friday and as needed. Upper part of the left groin area site was closed. She said surgical sutures are dissolvable. Stated standard of practice, treatment order should be in the POS (physician order sheet) and reflected in the TAR (treatment administration record), should be signed after each treatment. If not documented, treatment was not done or provided. R1 went out for a doctor's appointment and was directly admitted to the hospital. Diagnosis: Worsening / Dehisce of the wound on the left groin area. V3 said, she was not aware that wound on left groin area re opened. It was a closed wound that re open. Reviewed R1's POS and TAR with V3 and said did not see treatment order for left groin and left inner thigh surgical wound. Weekly skin wound assessment completed on 8/21/24. She said there should have another documentation on 8/28/24 but was not completed. On 9/4/24, R1 went to the hospital so weekly skin wound assessment was not completed. She said surgical wound should have a care plan that would include interventions to provide guidance for the staff on how to care for the resident. Reviewed R1's skin care plan with V3, no intervention found. Braden scale was completed upon admission on 8/20/24. None for 8/27/24 and 9/3/24. At 12:19am Interview with V2 (DON) stated if resident has a surgical wound, assessment and documentation should be done weekly, it is a reference regarding the status of the wound. Care plan should include interventions and goals to help staff how to care for resident. There should be a treatment order for every wound and can be found in POS (Physician Order Sheet), TAR (Treatment Administration Record), or MAR (Medication Administration Record). After treatment was provided TAR should be signed or documented. Nursing standard practice, if it was not documented then it was not done. If treatment is not done or provided could possibly lead to wound deterioration / worsening / decline in the status / wound infection. She said on 9/4/24, R1 went out for doctor's appointment and was directly admitted to the hospital due to wound on groin area. She said there was an odor in the room. Not sure where the odor was coming from. Did not see R1's wound. She said the wound nurse saw R1 and odor was not from the wound. Stated R1 has a sister working as a CNA (V18) in the facility. On 10/7/24 at 9:07am Interview with V18 (CNA/Certified Nursing Assistant) stated she has been working in the facility for over a year. She said R1 is her sister who had a surgery, stent was placed on her left leg. It was inserted to the groin down to the leg. R1 has 2 surgical sites, on left groin and left inner leg. She said R1's surgical wound was not properly taking care of. She escorted R1 on 9/4/24 for Doctor's appointment and she could smell the odor. She said the doctor checked the surgical sites on left groin area and it got infected. The doctor said that R1 needed to go back to the hospital to clean up the infection. She said from appointment, R1 was directly admitted to the hospital. She said R1 was placed in ICU (Intensive Care Unit), tracheostomy tube and G-tube were inserted. R1 is still admitted in the hospital. At 9:33am Interview with V17 (Nurse Practitioner / NP) stated he was not able to fully recall R1 and reviewed R1's EHR and stated patient underwent Left femoral above to the knee popliteal bypass with Graft. V17 stated he did not see the surgical sites. He assumes that there would be a surgical incision on left groin area where stent was inserted and should be monitored. Wound care should notify the wound specialist for any changes. Treatment care would depend on the assessment of would care. He said any surgical site, nursing should make sure that a daily skin check is done. He said surgical site is a vulnerable area - it would not expect any dehiscing process. Never seen dehisce surgical wound before from stent placement. V17 stated he does not know the events that happened why the surgical wound had dehisced. No wound assessment found for Left groin surgical incision in R1's EHR. No weekly skin assessment found on 8/28/24 and 9/4/24 for R1's left inner thigh surgical site. R1's POS, MAR and TAR for August and September 2024 reviewed, no treatment order for left inner thigh / left groin surgical site. R1's care plan dated 8/21/24 documented in part: The resident has potential / actual impairment to skin integrity. No interventions documented / found. R1's Braden assessment dated [DATE] and 9/4/24 with lock date on 9/8/24 and 9/9/24 respectively showed low risk for skin breakdown. No Braden assessment found on 8/27/24 and 9/3/24. On 10/6/24 at 11:54am R4 was observed lying in bed, alert, and oriented x 3, verbally responsive, no odor. Air mattress in placed. R4 stated his wound dressings should be changed daily, but they are not being done. He said wound treatment is done thoroughly every Wednesday when the wound doctor is here in the facility. R4's TAR: Right hip and buttock: Cleanse with Dakins then pack wound loosely with dakins wet to dry, cover with border gauze one time a day and as needed. Treatment was not signed as provided on 8/16/24, 9/24/24 and 9/25/24. MDS dated [DATE] showed R4 was cognitively Intact. Dependent with ADLs. MDS showed 2 Stage IV pressure ulcers, 2 venous and arterial ulcers present. R4 Care plan Update Review on 9/11/24 showed: Treatment to wounds as directed. Facility's surgical wound care policy dated 4/2023 documented in part: To establish clear guidelines for the care, management, and monitoring of surgical wounds to minimize the risk of infection, promote optimal healing and ensure patient safety. All surgical wounds must be assessed and documented upon admission, after surgery and during each dressing change. Comprehensive wound documentation must be completed after each assessment and dressing change. In patients with co-morbidities such as diabetes, obesity or immune-compromised states, more frequent wound assessment and specialized care may be required. R4's TAR: Right hip and buttock: Cleanse with Dakins then pack wound loosely with dakins wet to dry, cover with border gauze one time a day and as needed. Treatment was not signed as provided on 8/16/24, 9/24/24 and 9/25/24. MDS dated [DATE] showed R4 was cognitively Intact. Dependent with ADLs. MDS showed 2 Stage IV pressure ulcers, 2 venous and arterial ulcers present. R4 Care plan Update Review on 9/11/24 showed: Treatment to wounds as directed. Facility's surgical wound care policy dated 4/2023 documented in part: To establish clear guidelines for the care, management, and monitoring of surgical wounds to minimize the risk of infection, promote optimal healing and ensure patient safety. All surgical wounds must be assessed and documented upon admission, after surgery and during each dressing change. Comprehensive wound documentation must be completed after each assessment and dressing change. In patients with co-morbidities such as diabetes, obesity or immune-compromised states, more frequent wound assessment and specialized care may be required. Facility wound treatment procedure (undated) documented in part: Apply treatment as ordered. Document. Facility's skin inspection and reporting policy dated September 2024 documented in part: All changes in resident's skin must be documented in the EHR (electronic health record) care will be updated.

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse. This failure affected R5 who was physically pushed by R1, causing R5 to fall and sustained a left hip fracture required emergency transfer to the hospital with surgical repair of the left hip fracture and affected R7 who was physically punched in the face by R1 causing a periorbital contusion when reviewed for resident to resident, physical assault, in the sample of 4 residents (R1, R3, R5 and R7). Findings include: 1. On 2/22/24 at 1:23 pm, R5 observed lying in bed with a left arm mold cast wrapped with bandage. R5 stated R5 just got back from hospital. R5 stated R5 had surgery on left hip and elbow due to being hurt real bad while showing surveyor R5's left hip surgical bandage. When asked how R5 injured left hip and elbow, R5 stated, Someone (R1) punched me on the elevator, and I fell down. When asked the name of the someone, R5 said R5 didn't know the name, but it was another resident with a physical description matched by R1. When this surveyor stated R1's first name, R1 stated, Yes, it was (R1). R5 stated this occurred days ago. R5's Admission Record, documents, in part, diagnoses of chronic obstructive pulmonary disease, anemia, pain, hyperlipidemia, vitamin D deficiency, major depressive disorder, dementia, cognitive communication deficit, and hypertension. R5's emergency ambulance records, dated 2/19/24, V35 (Emergency Medical Services, EMS/Fire Department Paramedic) documents, in part, upon EMS staffs' arrival at the facility, R5 was found laying supine in the elevator complaining of left leg pain with R5 alert and oriented x 4. Trauma assessment found obvious deformity of the high left femur, shortening of the left leg and rotation outwards of the left leg. Nursing home staff stated, (R5) stated, (R5) was pushed by another resident (R1) and that's how (R5) fell . V35 documented R5's cause of injury was assault. R5's emergency hospital records, document, in part, R5 was brought in by ambulance after being pushed to the ground by another resident (R1) at the facility. R5's hospital radiology report for left hip X-ray (2-3 views), dated 2/17/24, documents, in part, the results of acute, complete obliquely oriented fracture involving the left proximal femoral diaphysis. In R5's hospital operative report, dated 2/18/24, V36 (Orthopedic Surgeon) documents, in part, in discussion with R5 prior to surgery, R5 was able to tell (V36) (R5) is admitted for (R5's) hip fracture after being pushed at the nursing home. V36 documented, in part, V36 performed R5's surgery of a left hip cephalomedullary nail for intertrochanteric hip fracture. On 2/27/24 at 12:21 pm, V12 (Front Desk Receptionist) stated V12 was working on 2/17/24 from 3:00 pm to 11:00 pm. V12 stated V12 was seated at the facility's front lobby receptionist's desk shortly after 3:00 pm. V12 heard R1 yelling, Hurry up or I am going to push you. V12 stated, I (V12) don't think a second went by and I heard the fall. V12 stated despite a door separating the front lobby receptionist's desk from the 1st floor elevator area, which is very close in proximity, R1 yelled loud enough for me to hear it. V12 stated when V12 immediately got up to see what happened, V12 saw R5 on the elevator floor. R5 was screaming, Oh, my leg, my leg. V12 stated R1 standing outside the elevator looking at R5. V12 stated nursing staff responded from the dining room which is located on the east side of the elevators. V12 ran back to the receptionist desk to call an emergency overpage code for further staff assistance. When asked how V12 recognized it was R1's voice yelling, Hurry up or I am going to push you!, V12 stated V12 definitely knew R1's voice and recognized it right away. V12 stated R5's fall sound in the elevator was a loud thud. V12 stated V12 reported this information about R1 pushing R5 to V3 (Assistant Administrator) on 2/17/24. Facility document titled Statement, dated 2/18/24, V12 documents, in part, I (V12) heard (R1) screaming and saying, 'Hurry up or I'll push you.' Then I heard a loud noise. I got up and saw (R1) standing in front of the elevator and (R5) screaming on the elevator floor. On 2/28/24 12:46 pm, V20 (Escort) stated on 2/17/24, V20 was working as activities staff in the 1st floor dining room. V20 stated R1 and R5, amongst other residents, were in the 1st floor dining room on 2/17/24 afternoon. V20 heard residents saying R5 was on the floor in the elevator. V20 stated V20 immediately responded to see R5 was laying on R5's back, somewhat on left side with R5's walker on its side on the elevator floor next to R5. V20 stated R1 was standing directly outside the elevator. R1's Admission Record, documents, in part, diagnoses of paranoid schizophrenia, psychosis, restlessness and agitation, hypertension, gastro-esophageal reflux disease, vitamin D deficiency, depression, and cocaine abuse with intoxication. R1's MDS, dated [DATE], documents, in part, a BIMS score of 13 which indicates R1 is cognitively intact. R1 no longer resides in the facility and was unable to be interviewed. On 2/22/24 at 3:17 pm, V3 (Assistant Administrator) stated V3 was informed by V12 that R5 had fallen in the elevator and V12 heard R1 yelling if you don't hurry, I will push you with a few seconds later hearing a noise like a fall. On 2/28/24 at 11:35 am, V3 stated V3 interviewed R5 on 2/22/24 and R5 stated another resident pushed R5 in the elevator. V3 stated R5 provided a physical description matched R1 with a first name very similar to R1. When asked for the conclusion of R1/R5's allegation of physical abuse on 2/17/24, V3 stated, (R1) pushed (R5), and R1 didn't think R1 wanted to get on the elevator with R5. When asked with the allegation of physical abuse of R1 towards R5 on 2/17/24, was this allegation substantiated, V3 stated, Yes. (R1) did push (R5) on purpose. On 2/28/24 at 11:49 am, V1 (Administrator) stated V1 is the abuse coordinator for the facility and has a duty to protect all the residents in the facility. V1 stated after conducting the investigation with V3 about R1/R5's incident on 2/17/24, V1 can see R5 was very sharp. V1 concluded R5 provided a clear description of what occurred with R1. When asked if physical abuse is substantiated, V1 stated, That's really hard. I (V1) can substantiate the incident occurred. V1 stated V1 knows abuse is the intent to cause harm. 2. On 2/27/24 at 3:05 pm, R7 observed sitting at a table in the 1st floor dining room with other residents present at other tables. R7 stated R7 was agreeable with an interview. This surveyor observed R7's speech very slow and pronounced. R7 stated R7 doesn't remember what happened when asked about a physical incident involving R1 where R7 was hit in face in November 2023. R7's Admission Record, documents, in part, diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, epilepsy, anemia, hypertension, hyperlipidemia, osteoporosis, thyrotoxicosis, schizoaffective disorder, dementia, chronic atrial fibrillation, mild cognitive impairment, dysphagia, tachycardia, and mood disorder. R7's MDS, dated [DATE], documents, in part, a BIMS score of 9 which indicates R7's cognition is moderately intact. On 2/28/24 at 1:04 pm, V21 (Activities Aide) stated on 11/18/23 around 9:30 am, during activities program in the 1st floor dining room, V21 observed R1 walking into the dining room, talking to V21. V21 stated R7 was sitting at a table for the activities. V21 stated R1 was walking past R7 when R1 swung and hit (R7) in the eye with a closed fist. V21 stated V21 immediately intervened and separated R1 from R7. On 2/27/24 at 11:01 am, V10 (PRSA, Psychiatry Rehabilitation Services Assistant) stated on 11/18/23, V10 was walking with R1 from the 1st floor dining room. R1 heard R7's voice from a conversation with another resident, and R1 turned, going back to R7 (who was in a seated position) and punched R7 in the side of the head. When asked what did R7 do, V10 stated R7 sat there and didn't say anything. V10 stated an emergency code was paged overhead for staff assistance. On 2/27/24 at 1:21 pm, V15 (LPN) stated V15 responded to the emergency code in the 1st floor dining room on 11/18/23 due to R1 hitting R7 with a closed fist. V15 stated V15 brought R7 upstairs, performed assessment with R7 having redness to right side of face. V15 notified V37 (Attending Physician) who ordered for monitoring R7. V15 stated on 11/20/23, R7 continued to have redness on R7's right side of face with no complaints of pain from R7. V15 stated on 11/21/23, V15 noted R7's right side of face with increased redness. V15 notified V37 who ordered for R7 to be transferred to the hospital for further evaluation. R7's hospital discharge instructions, dated 11/21/23, document, in part diagnoses from R7's hospital visit as periorbital contusion, eye injury, and contusions are the result of a blunt injury to tissues and muscle fibers under the skin. Facility policy dated January 2023 and titled Abuse Policy, documents, in part, Each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including, but not limited to . other residents . 'Abuse means the willful infliction of injury . 3. 'Physical Abuse' includes, but not limited to hitting. Facility policy dated August 2022 and titled Resident's Rights, documents, in part, Purpose: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this Community, nor shall the resident forfeit any of the following rights: . 14. The right to be free of abuse.

Based on observations, interviews, and record reviews, the facility failed to keep R6 free from abuse. This failure resulted in R6 being sprayed in the face with a chemical agent by a staff member (V26). R6 experienced eye irritation and pain which required irrigation at the emergency department. The facility further failed to keep V26 away from R6 after the incident by allowing V26 to continue to work with R6 and allowed V26 to remain on the same unit. This situation was identified as an immediate jeopardy. The Administrator, Assistant Administrator-in-training, and the Director of Nursing were presented with the immediate jeopardy template on 1/5/2024 at 9:55 AM. The immediate jeopardy began on 11/15/2023 and removed on 1/12/2024. The facility presented an acceptable removal plan on 1/12/2024. 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: R6's face sheet documents in part medical diagnoses of psychosis, restlessness, and agitation. R6's comprehensive care plan does not contain a focus for R6's risk for abuse. Facility's final reportable to the Illinois Department of Public Health reads: an incident occurred between R6 and V26 (former Restorative Aide) on 11/15/2023. It documents in part: Based on the known fact's resident appeared aggressive towards staff. Staff was fearful of resident and sprayed pepper spray at the resident and not on the resident. Surveyor reviewed the written witness statements and interviewed staff regarding the incident. During interview regarding 11/15/2023 incident on 1/2/2024 at 12:19 PM, V18 (Nurse) stated, There was something in the air when I got to the floor. I started coughing because it was something in the air. It was clear. Not cloudy or hazy or smoky but it made my eyes burn and caused me to cough that I had to turn right around. I couldn't respond properly to the code. V18's written witness statement dated 11/15/2023 documents in part that V18 could not properly respond to the code because V18 started coughing bad and eyes were burning. On 1/2/2024 at 1:46 PM, V20 (Certified Nurse Aide) stated around 7:20 AM on 11/15/23, R6 was at the desk asking V39 (Nurse) about coffee and breakfast. V39 told R6 that breakfast will be up shortly and directed R6 back to the bedroom. The elevator opened and V26 (former Restorative Aide) was there. V26 told R6 to go to the bedroom. R6 stated [R6] did not want to go back to the bedroom and started yelling. V20 stated, [R6] started coming towards [V26] a little aggressive so [V26] sprayed [R6] with something towards [R6's] face. R6 grabbed R6's head with R6's hands and put R6's head down. V20 stated V26 later took R6 to the bedroom. On 1/3/2024 at 2:13 PM, V35 (Nurse) stated, I got off the elevator that day and it was something in the air that caused my eyes and nose running. I had to go someplace to get some air. I was coughing and had a headache for two days. I never experienced it before. I didn't know what it was. I had to drink cold water to get me through that day. I had to flush my eyes out and I wear glasses. Never felt that way while at work. V35 written witness statement dated 11/15/2023 documents in part: When I came off the floor, something was in the air. My eyes were running. I started coughing and throwing up. V13's (Nurse) written witness statement dated 11/15/2023 documents in part: Elevator opened smell of pepper spray. I couldn't get off the elevator because the smell was so strong. On 1/3/2024 at 2:27 PM, V24 (Psychiatric Rehabilitative Services Director) stated, If a resident is agitated and aggressive towards someone, you try to separate them. Try to get them to calm them down by talking to them calmly. Ask what's going on and see what brought them to that level of agitation. We have to see what we can do to help them. When asked about R6's incident, V24 stated they should have calmed [R6] down and talked to [R6] calmly and not be aggressive with it. You don't spray. No spraying. If it was that bad, you always call for help. Call for more assistance. If [R6] was escalating bad and showing more agitation, I'd call for help and step back and see what they can do. You're not supposed to have something on you in here to spray. I will walk away and get more assistance and let them know how [R6] is reacting. Find my exit and let them know this is what's going on so we can get more people to help. On 1/4/2024 at 8:46 AM, V34 (Certified Nurse Aide) stated, Me and [V18], the nurse, came out the stairwell and before I even reached the nurses' station, I had to turn around. I probably only got half-way through the hallway because the smell was so strong. It smelled like pepper spray. I had to turn around. It was affecting my eyes and getting into my nose. I just remember [R6] standing there by the nurses' station rubbing [R6's] eyes. V34's written witness statement dated 11/15/2023 documents in part that when V34 arrived on scene, it smelled like bear spray. V34 had to turn around because V34's eyes were burning. During interviews on 1/4/2024 at 9:22 AM and 11:35 AM, V26 stated R6 came towards V26 aggressively but [V26] did not spray anything at R6. V26 stated someone was spraying an air freshener in the hall. V26 stated afterwards that V26 brought R6 coffee and breakfast. V26 stated [V26] did not leave the facility until around 9:30 AM on 11/15/23. V26 acknowledged the facility provided an in-service about how to handle residents with behaviors at the beginning of the year but felt it wasn't specific to psychiatric behaviors or offered frequently enough throughout the year. On 1/4/2024 at 11:58 AM, V37 (Director of Nursing at the time of the incident) stated staff are not to carry pepper spray or anything that is caustic or that's an eye irritant while working with residents. V37 stated if a resident is displaying aggressive behaviors, the first line is to separate the individuals and try to talk and see what's going on or find root cause. On 1/5/2024 at 12:08 PM, V42 (R6's Physician) stated, Staff should not be using pepper spray in the facility. They shouldn't be carrying it. The purpose of pepper spray is to keep a person away from you. If it is sprayed and it goes into your eyes, it will have irritating effects because it is a chemical. You have to wash out your eyes. On 1/9/2024 at 9:24 AM, V1 (Administrator/Vice President of Quality Assurance) stated a substance got into R6's eyes and the resident was sent to the emergency room for evaluation. V1 stated when facility reviewed the surveillance video of the incident, it was not an air freshener. V1 stated it was clear what the employee had on hand in the video. On 1/9/2024 at 11:57 AM, V47 (Manager on Duty at time of incident) stated when [V47] arrived at the unit, R6 was frustrated, loud and upset. V47 stated, I saw orange on him like orange pepper spray. V47 stated R6's face and eyes were red. On 1/9/2024 at 10:02 AM, surveyor reviewed facility's surveillance footage of the incident with V3 (Director of Nursing), V25 (Assistant Administrator-in training), and V45 (Human Resources). No audio was with the footage. First review was of the fourth floor nurses' station camera angle which showed, on 11/15/2023 at 7:26:52 AM, V20 (Certified Nurse Aide) and V39 (Day Nurse) were at the nurses' station. Elevators are in front of the nurses' station. R6 came out of the bedroom and pressed the elevator button at 7:27:02 AM. R6 remained standing in front of the elevator door with R6's back turned to V20 and V39 waiting. No observation of physical aggression from R6 observed. At 7:30:50 AM, V7 (Wound Tech) emerged from the big elevator and went to grab the wound cart. There is a hand seen out of the elevator stopping R6 from getting on. At 7:31:04 AM, V7 brought the wound cart into the big elevator and V26 (former Restorative Aide) stepped left out of the elevator. At 7:31:10 AM, V26 is west of the elevator (if facing the elevator, V26 is on the right side) motioning in front of R6 and pointing towards east hallway - R6's room. R6 is facing V26. During video footage review surveyor does not observe R6 to be puffing chest, running, or swinging arms. At 7:31:11 AM, V26 holds a small, black, cylindrical item with a silver split key ring with right hand. At 7:31:15 AM, V26 raises up the black cylindrical item with right hand as the left hand starts messing with it. V26 steps out of frame. At 7:31:29 AM, R6 remains facing west where V26 exited the frame. V5 (Anonymous Staff) is facing R6 standing to R6's right front. V39 came out of the nurses' station and grabbed gloves from the top of one of the medications carts. V20 is standing behind V39. V20 and V39 are facing R6. R6 takes a step, and a dark orange/almost brown substance shoots linear into frame and hits directly at R6's face. R6 raises left hand up over face. R6 stumbles back towards the nurses' station and hits the medication carts with right side at 7:31:34 AM. Staff start to disperse away from the scene. V20 (Certified Nurse Aide) has a hand over nose and mouth. V46 (Maintenance) uses blue shirt to cover nose and mouth. V39 (Nurse) is covering mouth. R6 remains by the medication carts holding head. At 7:32:20 AM, V5 (Anonymous Staff) is waving a white item to swat the air. At 7:32:40 AM, V26 (former Restorative Aide) passes R6 and heads to the dining room which is behind the nurses' station. At 7:33:40 AM, R6 remains near the medication carts. No staff has approached R6. R6 is bent over with head down. R6 grabs [R6's] face with the left hand. At 7:34:00 AM, multiple staff come out of the big elevator including V7 (Wound Tech), V21 (Certified Nurse Aide), V27 (Nurse), and V35 (Nurse). V27 can be seen bending at the hip, leaning forward, and coughing. At 7:34:18 AM, V26 is walking around R6 who remains near medication carts. V26 gets on the elevator at 7:34:22 AM. R6 remains in place while switching from standing to bending at the hip and leaning forward. At 7:36:23 AM, as R6 is hunched over, two large, liquid/fluid drops come from R6's face which appears to be saliva/spit. At 7:37:15 AM, V26 emerges from the elevator and returns to the unit. At 7:37:36 AM, R6 leaves the nurses' station unassisted to return to the bedroom. During video footage review surveyor does not observe any staff come near R6 to assess or assist R6 in rinsing eyes or face out. At 7:38:15 AM, V47 (Manager on Duty) is seen standing by R6's room talking to someone (person can't be seen from camera angle). V26 remains on the unit and is seen at the nurses' station at 7:38:50 AM. At 7:41:09 AM, V26 has a white spray bottle and sprays repeatedly in the air. V26 does this multiple times throughout the unit including a few times in front of R6's room. At 7:46:38 AM, V26 went into R6's room. At 7:47:02 AM, V26 leaves R6's room, then went back in at 7:47:06 AM, and back out at 7:47:15 AM. At 7:47:35 AM, staff bring out coffee and breakfast carts from the big elevator. V26 grabbed a mug and pours a liquid into it. At 7:47:54 AM, V26 went into R6's room with white spray bottle in left hand and mug in right hand. At 7:48:09 AM, V26 leaves R6's room with the white spray bottle in right hand. V26 continues to walk around and spray the hall with the white spray bottle. At 7:51:24 AM, V26 went inside R6's room and leaves room at 7:51:38 AM. At 7:52:04 AM, V26 gets into the elevator. At 8:00:50 AM, V26 (former Restorative Aide) emerges from the elevator and returns to the unit. Paramedics arrive on scene at 8:09:56 AM. R6 went onto their stretcher at 8:10:59 AM and R6 is in the elevator at 8:12:46 AM. V26 remained on the unit with other residents. On 1/5/2024 at 11:22 AM, surveyor reviewed the Fourth Floor [NAME] Hall camera angle surveillance footage with V3 (Director of Nursing), V25 (Assistant Administrator-in-training), and V45 (Human Resources). V26 is at the top of the frame. Housekeeping cart is behind V26. View of the left side of hall near nurses' station is blocked by an open door. At 7:31:29 AM, V26 is standing near the elevators. V26 then starts moving left with right hand up. V45 stated, Yeah, I see [V26] go forward and bring that right hand up. On 1/5/2024 at 11:30 AM, surveyor reviewed the Fourth Floor East Hall camera angle surveillance footage with V3, V25, and V45. At 7:31:29 AM, V26 brings up the right arm as V26 moves left. V45 stated, [V26] brought [V26's] right hand up after [R6] stepped forward. V26's Employee Report documents in part: Investigation Review that something was sprayed, and several staff were coughing. Witness statement indicate that employee did spray pepper spray at resident. R6's 11/15/2023 ambulance records (page 2 of 6) document in part: [Patient] is complaining of eye pain from being maced. [Patient] appears to have been maced. [Patient] is coughing and [patient's] eyes are irritated. Scene smells like [NAME] was discharged . R6's 11/15/2023 hospital records document in part: Patient was pepper sprayed. When I reevaluated the patient, patient reports persistent pain in [R6's] left eye after irrigation (page 3 of 16). [Patient] was reportedly maced by [Nursing Home] staff. [Patient] arrives with red, irritated face and eyes. [Positive] tearing. [Positive] pain (Page 6 of 16). V26 signed Receipt and Acknowledgement Employee Handbook - Local No. 4 (11/99) on 11/16/2011. V26 signed Certificate of Receipt of Employee Handbook on 3/8/2013. V26 signed additional Code of Conduct Attestation Statement on 4/5/2013. Facility's Employee Handbook dated 6/11/2021 documents in part: The Facility will not tolerate any physical, verbal or mental abuse, bullying, or intimidation 'Workplace Violence' whether of residents, patients, employees, visitors, vendors, and/or volunteers. We do not tolerate fighting (physical or verbal) or disorderly conduct on the job. In addition, we prohibit the possession of firearms, knives, or any other weapon on company property or while conducting business on behalf of the Company (page 14). V26's signed Compliance/False Claims Act/Ethics Program and Code of Conduct Employee Understanding Agreement dated 11/15/2013 documents in part: Don't mistreat a resident in any way. V26 signed facility's educational in-service for Managing Difficult Behaviors on 02/07/2023. Slide 23 titled 10 Tips for Communication documents in part: Set a positive mood for interaction. Watch your body language and verbal tone. When the going gets tough, distract and redirect. Slide 24 titled Specific Strategies-Agitation document in part: Distract the persons with an activity or snack. Confronting a confused person increases anxiety. Allow the person to do as much for themselves as possible. Support independence. Facility's Abuse Prevention Program last revised 03/08/2016 documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Abuse is any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect, mistreatment or misappropriation of resident property will be removed from the resident contact immediately until the results of the investigation have been reviewed by the administrator. The Immediate Jeopardy that began on 11/15/2023 was removed on 1/12/2024 when the facility took the following actions to remove the immediacy: The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance that will be or has been achieved by the stated date of completion. Submission of this Plan of Abatement does not constitute in any way an admission of any facts and/or conclusions of law reflected in the alleged deficiencies, nor does it constitute a waiver of the Facility's right to contest the deficiencies and/or any remedies imposed because of this or future surveys. On 11/15/2023, The restorative aide V26 was accused of spraying pepper spray towards resident R6. Employee was suspended pending investigation. The incident occurred at 7:30am. V38 was informed immediately and was in route to the facility with an arrival at 8:15am. The employee punched out at 9:35am (see timecard). Preliminary incident investigation was sent to IDPH. Investigation was initiated, based on witness statements and review of video camera, employee was terminated. The final abuse investigation report was sent to IDPH on 11/21/2023. I. 1. All residents will always be free from abuse. 2. R6 is no longer in the facility after being sent to the hospital the day of the incident he left AMA. 3. V26 was relieved of her duties immediately and was subsequently terminated in accordance with the facility policy. She then filed a grievance, the facility responded and maintained that the termination was justified. 4. Abuse In-service was conducted on 11/28/23 after the incident occurred. The Inservice included: individual including a caretaker of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Review physical abuse, sexual abuse, verbal abuse, mental abuse, and misappropriation of resident property, involuntary seclusion, and neglect. Review that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately or to an immediate supervisor who must then immediately report it to an administrator. Reviewed that employee accused of allegations of abuse will be suspended pending investigation. II. 1. A review of the requirement that all residents be always free from physical abuse. 2. A review of the alleged deficiency. 3. All staff will be re- in serviced on the facility abuse policy and procedures. The Inservice will include: individual including a caretaker of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Review physical abuse, sexual abuse, verbal abuse, mental abuse, and misappropriation of resident property, involuntary seclusion, and neglect. Review that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately or to an immediate supervisor who must then immediately report it to an administrator. Reviewed that employee accused of allegations of abuse will be suspended pending investigation. The facility employee list will be used to ensure all staff are in service in each department to be completed by 1/10/24 conducted by V1, RN, LNHA and V24, ASST ADMINISTRATOR. Any staff not available at the time of these in services will be retrained upon arriving at work. All new nursing staff will be trained in these policies at the time of hire. All agency staff who have not worked at the facility before will be required to arrive one hour before their shift to be trained on the facility abuse policy. V3, DON, RN will conduct Inservice. 4. Any staff on vacation will be trained upon returning to work. V3, DON, RN will conduct Inservice. All staff will be Inservice on facility policy on calling code grey when resident is observed with increased behavior and/or agitation. Inservice will be conducted by V25, ASST ADMINISTRATOR completed by 1/16/24. 5. All staff will be in serviced on their responsibilities for the care and the safety of all residents in a crisis. Inservice will be conducted by V25, ASST ADMINISTRATOR will be complete by 1/16/24. 6. All staff will be in serviced on the facility code of conduct policy which include the facility prohibit the possession of firearms, knives, or any other weapon on company property or while conducting business on behalf of the company, this also includes pepper spray or any other caustic agent that could harm a resident, this Inservice will be conducted by V1, RN, LNHA and V25, ASST ADMINISTRATOR to be completed by 1/16/24. 7. Social service consultants V66 LCSW will conduct an Inservice on De-escalation and conflict resolution to be completed by 1/18 /24. 8. Social Service consultant V65, LCSW will be conduction ongoing CPI training by 01/24/24. All allegations of abuse will be reviewed immediately as the event occur to assure the timeliness of reporting and the removal of staff immediately. Each event will be discussed daily during morning meeting and reported monthly to the QA. The Asst. Administrator V25 will conduct a QA audit via random direct questions during daily rounds to determine staff retention of abuse policy. A QA audit will be conducted monthly x 3 months quarterly thereafter and upon hire to ensure continued compliance. The results of the QA audit will be submitted to the QAPI committee for review and follow up. The QAPI committee will ensure that the systems are in place and are effective. This will be done monthly x 3 months the quarterly thereafter unless additional meetings are deemed appropriate to prevent reoccurrence. The facility presented a plan to remove the immediacy on 1/5/2024. The survey team reviewed the abetment plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised plan on 1/8/2024, 1/11/2024, and 1/12/2024. The survey team accepted the plan on 1/12/2024. On 1/16/2024 and 1/18/2024 the surveyor, via observation, interview and record, confirmed the implementation of facility's removal plan. On 1/16/2024 at 9:15 AM, V46 (Maintenance) stated V46 did not receive recent abuse or code of conduct in-services. On 1/16/2024 at 9:37 AM, V10 (Certified Nurse Aide) stated attending the in-services for abuse and de-escalation techniques; however, did not receive code of conduct in-service. On 1/16/2024 at 9:42 AM, V5 (Anonymous Staff) stated attending abuse in-service but did not receive one for de-escalation, code greys, or code of conduct. On 1/16/2024 at 9:47 AM, V6 (Nurse) stated attending the in-services on abuse and de-escalation techniques but did not receive the ones for code grey or the code of conduct. On 1/16/2024 at 9:49 AM, V20 (Certified Nurse Aide) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 9:55 AM, V13 (Nurse) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 9:59 AM, V17 (Nurse) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 10:05 AM, V48 (Activities) stated attending the abuse in-service but did not receive the ones for code grey or the code of conduct. On 1/16/2024 at 10:08 AM, V50 (Dietary Manager) stated attending all the in-services. On 1/16/2024 at 10:16 AM, V49 (Receptionist) stated attending the abuse in-service but did not receive the ones for code grey or the code of conduct. Discussed the above interviews with V1 (Administrator) and V25 (Assistant Administrator in-training) on 1/16/2024 at 10:45 AM. Facility did not complete the target goals on 1/16/2024. Surveyor returned 1/18/2024 to confirm the implementation of facility's removal plan. On 1/18/2024 at 9:43 AM, V1 and V25 stated they re-in-serviced all the required topics with the staff. Facility also has ongoing de-escalation in-services and will have CPI (Crisis Prevention Intervention) training in the coming weeks. During interviews on 1/18/2024 from 9:49 AM to 10:48 AM, V9 (Restorative Aide), V44 (Certified Nurse Aide), V53 (Dietary), V54 (Dietary), V48 (Activities), V46 (Maintenance), V56 (Housekeeping), V57 (Social Services), V59 (Certified Nurse Aide), V60 (Nurse), V61 (Certified Nurse Aide), V62 (Housekeeping), and V49 (Receptionist) stated they received in-services on abuse, de-escalation techniques, code grey, and code of conduct. On 1/16/2024 and 1/18/2024, did not observe any staff carrying weapons or caustic agents. Reviewed facility's in-service summary sheets, in-service materials, and sign-in sheets.

Based on interviews and record reviews, the facility failed to have a nurse assess a resident (R1) immediately after a fall and notify the physician. This resulted in a delay of care for R1 who sustained a displaced fracture of the greater trochanter of the right femur (right hip fracture) from the fall. R1 required surgical intervention. This affected one of six residents reviewed for falls. Findings include: R1's face sheet documents in part medical diagnoses of displaced fracture of greater trochanter of right femur and history of falling. On 1/2/2024 at 11:29 AM, R7 stated R1 fell while staff were trying to help R1 get into the shower. R7 stated R1 kept backing up, slipped, and fell between the footboard and the wall. During a follow-up interview on 1/3/2024 at 10:02 AM, R7 stated, [R1] was trying to get away from those ladies that wanted to give [R1] a shower. [R1] slipped some sort of way and hurt [R1's] back. R7 stated, [R1] was hurting on [R1's] side down to [R1's] feet. [R1] was shaking and hollering. R7 stated the facility did not send the resident out until later in the day. On 1/2/2024 at 11:51 AM, V9 (Restorative Aide) stated staff tried to assist R1 with incontinence care because R1 had soiled pants. V9 stated R1 got up and walked around the bed and when R1 came around the bed, R1 slipped to the wall and slid onto the floor. V9 stated R1 complained of hip pain but didn't say which hip. V9 called for help and staff got R1 up. During a follow-up interview on 1/3/2024 at 9:22 AM, V9 stated, When [R1] slid down, [R1] laid flat on the floor then [R1] was like 'oh I broke my hip.' [R1] slid all the way to the floor and was hollering that [R1's] hip was broke. V9 stated staff used a draw sheet to get R1 off the floor. V9 stated R1 complained of pain at the time of transfer from floor to bed. On 1/3/2024 at 11:11 AM, V29 (Certified Nurse Aide) stated staff were trying to give R1 a shower around 1:00 PM on 12/15/23. R1 declined so V29 removed gloves and began to exit the room. When V29 turned back around, R1 was sitting on the floor. V29 did not witness how R1 got to the floor but stated R1 stumbled between the footboard and wall. V29 got additional help and assisted R1 back in bed. V29 stated R1 complained of leg pain. Surveyor interviewed V32 (R1's Day Nurse during time of incident) on 1/3/2024 at 2:45 PM. V32 stated staff did not inform [V32] that R1 fell . V32 stated, I don't know about a fall. Nobody called me for anything. I don't know anything about a fall. Reviewed facility's nursing schedule for 12/15/2023 showed V32 was the only nurse listed for the unit. R1's day shift (7:00 AM - 7:00 PM) progress notes for 12/15/2023 show no documentation of R1's fall, which V29 stated occurred around 1:00 PM. No documentation of staff's assessments immediately post fall. On 1/3/2024 at 11:26 AM, V20 (Certified Nurse Aide) stated [V20] took over R1's care for the evening shift (3:00 PM to 11:30 PM). V20 stated staff did not inform [V20] that R1 fell . On 1/3/2024 at 11:48 AM, V33 (Night Nurse) stated [V33] took over R1's care at 7:00 PM. V33 did not receive shift-to-shift nurse report that R1 fell . At around 9:00 PM, R1 complained of pain and stated [R1] fell when it was still daylight. V33's progress note dated 12/15/2023 9:29 PM documents in part: upon medication administration resident verbalized [R1] is experiencing pain to bilateral hips and [R1] is unable to move them. Resident was asked if [R1] fell and per resident [R1] believe [R1] fell earlier in the day when it was day light. On 1/4/2024 at 1:21 PM, V40 (Facility's onsite Nurse Practitioner) stated staff did not notify (V40) of R1's fall. On 1/5/2024 at 12:47 PM, V43 (Physician) stated staff should have sent R1 to the hospital when [R1] fell and complained of pain. If they would have notified me, I would have sent [R1] out. On 1/4/2024 at 10:06 AM, V36 (Fall/Restorative Nurse) stated if an aide witnesses a fall, the aide must first get the nurse before getting the resident up. The nurse assesses the resident and their pain. The nurse looks for redness, warmth, shortening, or rotation. V36 stated, They don't lift the resident until assessment is completed by the nurse because what if they had a fracture or dislocation and you lift the resident then you might make it worst. Depending on the nurse's assessment, the nurse will either call the doctor or send the resident out to hospital right away. On 1/9/2024 at 12:08 PM, V3 (Director of Nursing) stated if a resident is on the floor and complains of pain, [V3] would assess the resident and call 911. V3 would not transfer or move the resident for safety purposes. R1's 12/16/23 hospital records documents in part, when R1 arrived in the emergency department, R1 had right hip deformity with right lower extremity shortened and externally rotated (page 25 of 99). The x-ray of the hip revealed an acute comminuted intertrochanteric fracture of the right proximal femur. Mild displacement of the fracture fragments. Mild valgus angulation (page 26 of 99). Orthopedic consultation documents in part right hip fracture requiring Open Reduction Internal Fixation (ORIF) surgery on 12/16/2023 (pages 4-5 of 99). R1's comprehensive care plan contains a focus last revised on 11/27/2023 which documents in part: [R1] is High Risk for falls [related to] Gait/balance problems, poor safety awareness due to impaired cognition, use of psychotropic medication, poor safety awareness. Interventions initiated 6/21/2021 documents in part: Follow facility fall protocol. Facility's Fall Prevention Policy last revised 12/20/2022 documents in part: If a resident experiences a fall, nurses will complete an incident report and document the fall in the resident record, as well as the 24-hour report. The policy does not have procedures or protocols on how to care for a resident immediately post fall. Physician Notification Policy last revised 2020 documents in part: Physician will be informed of any significant changes in the resident's condition and or any abnormal labs/x-ray results. Staff will document in the resident's record when a physician is notified including who was notified, date, time, and physician response/plan of care. Unsuccessful attempts to notify a physician will also be documented with any further actions that are taken by the nursing staff.

Based on interviews and record review, the facility failed to develop and implement appropriate measures to ensure adequate supervision for 2 residents (R1 and R2) out of 3 residents reviewed for supervision and use of illicit substances. As a result, R1 overdosed twice and R2 overdosed once. Findings include: R1's face sheet shows R1 was admitted on [DATE] with diagnosis that includes but not limited to major depressive disorder, recurrent, severe with psychotic symptoms; cocaine dependence; opioid dependence; insomnia; nicotine dependence, cigarettes ; suicidal ideations ; respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia. On 11/22/23 at 10:44 am R1 stated, I used heroin in the past. I haven't been out in the community yet. You have to be okayed by the doctor and the nurses to go out to the community. I don't remember who gave me the drug here, but it was another resident. I don't know if the person is still here. I don't remember what happened. I know they took me to the hospital. I snorted it. I don't have any with me. On 11/22/23 at 11:48 am V2 (Director of Nursing/DON) said social services work with residents who are drug users by referring them to the drug treatment program. V2 said some people use methadone to prevent the craving for the drugs and some people use the suboxone depending on the order. V2 stated, It helps with the craves and withdrawal. On 11/22/23 at 2:00 pm, V1 (Administrator- ADM) said, We contacted the police to see if they can bring a sniffer dog, but they said they can't. They said they can do rounds in this area, but not inside the facility. We can't randomly ask to search the rooms. We can't just look in the residents' room. We have to ask their permission. Most residents have a history of drugs. We try to keep them out of the rooms as much as possible, but sometimes they use drugs. They go to the methadone clinic. When this happens, we call the doctor and he tells us to observe if the residents allow it. If we become suspicious, we will search them, but if they refuse, we cannot. We restrict their pass. On 11/22/23 at 12:09 PM, V3 (SOCIAL SERVICE DIRECTOR- SSD) stated, If we have suspicion, we do the drug test on them. If they are showing signs, not normal, leaning over, talking slurred speech, like they are going fall over, they normally do not respond well and not comprehend nothing you are saying. I did not see (R1) because I was not here. If they refuse, we get in touch with the doctor, depends on what the doctor says. We have to follow what the doctor said. The nurses are the one who do the drug tests and document it. We have the program who came in using drugs, we would refer them to the program. They talk to them about how to deal with drugs. (R1) used to go out to the community, but we stopped it. She does not have the privilege. That's what we're trying to find out, how she (R1) got the drug. She can go to the patio to smoke; the patio is locked, and the staff is there with her. Residents have to sign in and out when they go to the community. It could be someone bringing it in. We don't check on them when they come back. Will they allow us to do this? I don't know. We don't know who's coming back with drugs. (R1) is not allowed to go to the community, not right now. After the incident she will be on restriction for 14 days, and then when she gets off, we will evaluate again and then lift the restriction. (R1) will be going out to the community with supervision. I will be evaluating her and lifting the restriction. I don't think is safe for her to go out to the community, not in this area. We will make sure she will go to this program, and if she wants to go somewhere, such to the store, one of the staff will walk with her, or myself, if I have to do, yes, I will walk with her. On 11/22/23 at 02:18 pm V4 (Social Services) stated, With R1 I tell her about the open room policy, meaning she can come to talk to me anytime, so she won't be defensive. I just try to keep my eyes on her, trying to make her comfortable so she will confide in me. Let me know how she is doing. See if she needs anything. If she would talk to me instead of going to drugs. R1 is safe to go out to the community with supervision. It can be a family member, but they have to leave their information here in the front desk, ID, phone number, address. Regarding on how R1 got the drug, she won't tell me anything, or she will acting confused and denies it. I tried a couple times to have her tested for drugs, but she would say, It's my right, I can refuse it, no. On 11/22/23 at 02:41 pm V2 (Director of Nursing-DON) said two residents went out for overdosing on 11/15/23 (R1 and R2). V2 stated, Neither one gives any information. They won't tell us. We just trying to figure out by talking to them, communicate with them, trying to find out how did they get the drugs. I talked to Social Services, but we never found out how the drugs were brought over here. It was a regular day. I saw nothing suspicious on the camera, nothing outside of the normal. We are monitoring our visits, if we see there is someone that is not family, we will ask who they are. We have the Guardian Angels. They are managers who come up on the floor, and they act like extra pair of eyes. They go to the floor and inside rooms that they are assigned to. The administrator assigns them. They will report to the administrator if they find anything out of the normal. I think it was the nurse who found out the residents who overdosed. On 11/28/23 at 11:42 am V5 (Licensed Practical Nurse-LPN) stated, R1 was sent to the bedside for breakfast. The only person with her was her roommate, but she is bedbound. I did my rounds and R1 was in the bathroom. Upon me passing the medication, she was sitting on the side of the bed eating breakfast. I'm not sure if she was using drugs when she was in the bathroom because I didn't see her. When I knocked on the door, she answered quickly. I said, 'are you there', and she said yes. I want to say, maybe it was an hour, an hour and a half after that, to the point where I saw her lethargic. I gave her the medication; she took the it and I didn't notice any changes. I noticed her breakfast tray was still there and she was leaning over the side table. It was then that I noticed that she was lethargic and when I called her name, she was slow to respond. I went to get Narcan, did one nostril first, she didn't respond and then did the second nostril and she was back to baseline. I don't know how many residents are at risk of overdose on my floor. If they arrive with a diagnosis of drug use, we just monitor them to see if there is any change, for example, I knew R1's baseline . She is oriented and stable person, so I knew she was not in her baseline, so I intervened. I didn't ask where she got the drugs. Before this incident she was normal, at first, communicating well. I watched her take her medication. For monitoring, we just do our usual rounds to check them. Making rounds and making sure they are at baseline. The Certified Nursing Assistant (CNA) usually does rounds for one hour and nurses for the next hour. After the R1 overdose, I personally went to her room to see if she could see anything, but I didn't. I didn't go through her personal belongings because we cannot do without the presence of the SS. I did an environment check and didn't see anything. In the episode on 10/21/23, when the CNA went to check on her, the CNA said that R1 was in the bathroom. I became suspecting because of the last incident. So, I went to the other side of the bathroom because on her side the door was locked. I saw something, but she flicked it in the toilet. I asked what it was, she said it was nothing. I asked what she was doing, and she said nothing, but I noticed she was about to use the drug. I don't know what kind of drugs. I notified the doctor, there was no new order, just to continue monitoring. I notified the SS and they came to talk to her. I informed the administrator and the DON of the situation. I didn't see anyone in her room, but she walks around, so she can get it from someone who doesn't necessarily go to her room. On 11/28/23 at 01:50 pm V1 stated, We asked the Chicago Police Department (CPD) to bring a search dog into the facility, but they said they cannot, only to the area, unless we have a suspicious individual. R1 does not receive external visitors but has friends within the facilities. We don't know who is bringing drugs into the facility. We're trying to see who she's friends with. We are keeping her out of her room as much as possible, leaving her in the activity room with the staff and in an open area so we can see her. R1's progress note dated 09/10/23 reads: Upon medications administration writer noted resident to be lethargic. Resident normal baseline is A/o/x3. Resident received scheduled medications; medications tolerated well. Resident became more lethargic than usual; Resident began to lean forward before knocking breakfast off bedside table. Resident was alert but slow to respond. Writer then administered Narcan once. No change in condition. Writer then gave Narcan to resident 1 more time, before returning back to normal baseline. MD made aware, orders to send resident out to hospital for further evaluation. All appropriate parties made aware. Resident is responsible for self. Resident waiting for ambulance transportation. R1's progress note dated 10/21/23 reads: describe Behavior/Mood: : Resident noted to indulged in illegal substance in room bathroom. What was the resident doing prior to or at the time of behavior/mood: Resident was ambulating the facility. Interventions attempted: Writer educated resident on the importance of follow facility protocol and only taking prescribed medications via current pcp (procedure). Resident encouraged to not interfere in healing process. MD and SS made aware of situation. Resident is responsible for self. Effectiveness of the interventions: MD gave orders to monitor resident for any change and conditions. R1's progress note dated 11/15/23 reads: Writer contacted hospital at this time to obtain a status update of resident's condition. ER Nurse informed writer that resident was still waiting to be medically cleared d/t heroin overdose. Once cleared resident will be returning back to the facility. R1's hospital record shows a drug screen was performed on 11/16/23 and the result came up as positive for cocaine and opiate. R1's care plan was reviewed on 9/10/23; 10/21/23 and 11/15/23, but there are no monitoring interventions described. R2's face sheet shows R2 was admitted on [DATE] with diagnosis that includes but not limited to asthma, opioid abuse with intoxication, uncomplicated heroine dependence anxiety disorder, unspecified ; tobacco use ; other bipolar disorder. R2's Progress note dated 10/5/2 reads: Writer was notified by staff of resident's behavior. Resident was leaning forward in chair, nodding in and out. Resident admitted to taking illicit drugs. Resident was reminded of restriction for 14 days. Resident was referred to psychologist. Resident was remorseful and receptive to information. R2's progress note dated 10/2/23 reads: resident has returned from methadone clinic and came back with 3 bottles. Call placed to MD to have resident community access pass restricted for 72 hours. R2's progress note dated11/15/23 reads: Upon rounds resident was observed sitting in her wheelchair slouched over extremely drowsy. During resident was noted with decreased respirations. Resident was issued naloxone (2) MG via nasal route. 911 was called immediately to transport resident to the nearest ER for medical clearance. Nursing supervisor informed. Resident's primary care physician informed at this time. resident's niece notified of incident at this time. R2's hospital record document R2's diagnosis dated 11/15/23 was opiate overdose and opioid withdrawal. Facility Policy on Resident Drug Use and Trafficking reads: The use of any alcohol and/or opiates (narcotics), other substances used for the purpose of obtaining a high (spray paint fumes, glue, etc.) prescription or non-prescription (over-the-counter medications, Nyquil, Cough Syrup, etc.) medication without a doctor's order is expressly prohibited within this healthcare facility. This policy includes and extends to day/home passes. Residents are expected to only use prescribed medication and only alcohol with the permission of the attending physician.

Based upon record review and interview the facility failed to follow the abuse prevention policy, failed to implement mood/behavior interventions, and failed to ensure that two of four residents (R4, R5) reviewed for abuse remained free from abuse. These failures resulted in R4 being struck by R5 thereby sustaining right forehead raised area, bruise, abrasion, and skin tear which required first aid. Findings include: R4's diagnoses include major depressive disorder, human immunodeficiency virus and encounter for palliative care. R4's (7/17/23) progress notes state resident was hit by another resident, causing a skin tear to her forehead. The other resident was passing by and just proceed to hit her in the head. There was no conversation exchanged between the two residents. The area was cleaned with normal saline solution, pat dry, and covered with an island border gauze. The (7/17/23) preliminary incident investigation report states (R5) made physical contact with (R4). Body assessment completed with bruise noted to (R4) forehead. The (7/17/23) final abuse investigation report states when (R4) got off the elevator (R5) was in resident's face and hit (R4). (R4) was noted with a raised area with an abrasion to her right forehead. R4's (7/22/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). On 8/22/23 at 11:09am, R4 was lying in bed and verbally unresponsive likely due to dying process. A small linear scar was observed above R4's right eyebrow, V18 (Family) affirmed R4's scar resulted from injury sustained during (7/17/23) incident. R5's diagnoses include dementia, schizoaffective disorder and violent behavior. R5's care plan includes (2/4/23) Resident has a mood problem related to irritability, anger, and delusional disorder. Interventions: administer medications as ordered. Provide resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise and physical activity. (4/10/23) Resident sometimes have behaviors which include bumping into others, hitting during care, kicking, shouting and spitting. Interventions: help me to avoid situations or people that are upsetting to me. Attempt interventions before my behaviors begin. Refer me to my psychologist/psychiatrist as needed. R5's (5/9/23) BIMS (Brief Interview Mental Status) determined a score of 5 (severely impaired). On 8/14/23 at 1:14pm, R5 refused to respond during interview. On 8/22/23 at 10:13am, V1 (Administrator) stated, I got a call stating that (R5) hit (R4) abruptly when walking by. She (R4) had an abrasion to the head and refused to go to the hospital. He (R5) was sent out for a psychological evaluation, and they changed his meds. He's (R5) a 1:1 now. V1 stated, Everyone's saying he (R5) had no reason, and he (R5) don't remember what happened. He (R5) has a diagnosis of dementia, nothing triggered him or anything. The (10/2022) abuse prevention policy states in part this facility desires to prevent abuse and mistreatment by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: On the comprehensive care plan, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or history of trauma, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.

Based on interviews and record reviews, the facility failed to follow policy and procedures for Fall Prevention by not completing a fall risk assessment to determine fall risk factors and target approaches to reduce risks, on a quarterly basis, for 1 (R37) of 1 resident reviewed for falls out of a total sample of 26 residents. As a result of this failure, R37 fell on the ground on 12/7/22 while wheeling herself independently on a wheelchair and sustained a left clavicle fracture. Findings Include: On 4/4/23 at 1:09 PM, R37 was eating lunch in R37's room. R37 complained of left shoulder pain radiating to R37's left arm and hand. R37 stated that R37 broke R37's clavicle sometime last year due to a fall. R37 stated, I was wheeling myself in the wheelchair from my smoking break. My wheelchair got stuck in a dirt. It tipped over and I landed on my left side on the ground. R37's progress notes dated 12/8/22 at 2:00 PM documented by V22 (Registered Nurse) documents that R37 came to V22 and stated that R37 fell on [DATE] outside during smoke break while wheeling herself (R37) back into the building. R37's wheelchair got stuck in the dirt and fell out of the wheelchair. R37 complained of left arm pain and an X-ray was ordered. R37's X-ray of the left shoulder dated 12/8/22 findings show Acute distal clavicle fracture. R37's clinical records show R37 has diagnoses not limited to Multiple Sclerosis, Trigeminal Neuralgia, and Left Clavicle Fracture. R37's Minimum Data Set (MDS) dated [DATE] shows R37 is cognitively intact. R37's comprehensive care plan shows R37 has impaired visual function, impaired decision making, and requires supervision and monitoring during smoking break. There was no Fall Risk Assessment found in R37's electronic health record from the last annual MDS assessment dated [DATE] until R37's fall on 12/7/22. On 4/6/23 at 9:14 AM, V17 (Restorative Nurse) stated that a resident's Fall Risk Assessment should be completed at the time of admission and should have a re-assessment done quarterly, annually, and with significant changes. V17 stated that the Fall Risk Assessment can only be found under the assessment tab in the resident's electronic health record. V17 stated that the purpose of the Fall Risk Assessment is to determine the potential risks of falling for the residents and has the components that will determine the risk score of the resident. V17 stated that staff implement fall preventative interventions based on the fall risk score of the resident. V17 stated that if the Fall Risk Assessment is not completed for the resident, the resident can potentially fall because staff would not know what type of interventions and assistance to provide the resident to prevent them from falling. At around 9:20 AM, surveyor checked R37's electronic health record with V17, and there were no Fall Risk Assessments completed within the one-year lookback period prior to R37's fall on 12/7/22. The facility's policy titled; Fall Prevention Policy with no date reads in part: Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. Procedure: Within three days of admission, the resident will be assessed for risk of falls. Either nursing staff or therapy staff may complete the falls assessments. Based on the results of the falls assessment, the interdisciplinary team will determine the best approach to implement for fall prevention, adjust the care plan, inform the family and resident and implement comprehensive fall prevention management approach.

Based on interviews and records review, the facility failed to follow their fall prevention policy by failing to provide adequate monitoring and fall prevention for 1 resident(R2) of 4 residents reviewed. This failure resulted in R2 sustaining head injury. Findings include: R2 is a [AGE] year-old individua with multiple admissions to the facility, and last admission is documented as 12/2/2022. R2's MDS (Minimum Data Set) Section C (Cognitive Patterns) dated 3/2/ 2023, document R2 has a BIMS (Brief Interview for Mental Status) score of 9/15, indicating R2 has some cognitive deficits. R2's MDS section G, ADL (Activities of Daily Living- Assistance), dated 3/2/2023, documents R2 needs extensive assistance, two persons plus assistance with Bed mobility, transfer, and toilet use. R2 needs extensive assistance with one person assist with locomotion on and off unit, dressing, eating and personal hygiene. For balance during transitions and walking, R2 is documented as not steady moving from seated to standing position, not steady, able to stabilize with staff assistance for surface-to-surface transfer (Transfer between bed and chair or wheelchair). Walking is documented as Activity did not occur. Functional Limitation in Range of Motion; Impairment on one side, lower extremity (hip, knee, ankle, foot)-impairment on one side. Mobility Devices, R2 uses manual wheelchair. On 3/11/2023 at 10:07am, R1 was observed in bed with bed in low position and fall mattresses in place. R2's call light was near R2, and his room is near the nurse's station. R2 answered questions with yes and no answers. On 3/11/2023 at 11:34am, V2(Director of Nursing) said on 2/18/2023, V3(Registered Nurse -RN) reported to V2 that R2 was in the hallway sitting in his wheelchair and V3 said when she turned her back away from R2 that R2 fell in the hallway and was found in facing up position, R2 had a small open area on right eyebrow. V2 said V3 applied pressure and ice to the area, and the bleeding stopped. R2 was sent to the local hospital for further evaluation. V2 said all residents are fall risks and must be monitored. V2 said, at that time, R2's room was not close to the nursing station when R2 fell . V2 said high fall risk residents like R2, should be near the nursing station when in wheelchair so that if resident slides or turns to the side, the nurse can see and reposition the resident before the resident falls. V2 said R2 should have been always monitored to prevent falls, because R2 has had many falls in the past. On 3/11/2023 at 12:36AM, V3(Registered Nurse) said that on 2/18/2023 in the morning about 10:30am, V4(Certified Nurses' Assistant-CNA) came running to V3 saying that R2 was on the floor in the hallway after falling and was bleeding on the face. V3 said V4 was in a resident room performing her daily duties and when she come out a resident room, V4 found R2 in the hallway on the floor, face up and bleeding from the face. V3 said she run to R2 to assess R2 and provide care, and V3 found R2 on the floor and he(R2) was bleeding to the right brow and had moderate bleeding to oral cavity. V3 said V3 applied pressure to R2's bleeding right brow and the bleeding subsided. V3 said she assessed R2 and R2 was not in pain, and R2 did not lose consciousness. V3 said V3 got an order to send R2 out to the hospital for further evaluation especially because R3 was on blood thinner medications. V3 said high risk fall residents are supposed to be always monitored. they are supposed to be in the day room with staff, or in activities room on the first floor or at nursing station where they can be monitored by nurses if the CNAs are busy taking care of other residents. V3 said monitoring the residents always helps maintain safety. V3 said high risk residents have star/leaf on the door to alert staff that a resident is a fall risk. V3 said R2 is a high fall risk because he is a stoke patient and has right Hemiplegia(paralysis). V3 said staff are supposed to always monitor R2 because he a high fall risk and has a history of falls before this fall. On 3/11/2023 at 1:22pm, V4(Certified Nurse's Assistant -CNA) said she was in a resident room doing patient care and as she was coming out of the other resident room, V4 saw R2 lying on his right side by his room, just outside the room. V4 said she went and got the nurse(V3) who come and assessed R2. V4 said R2 is a high falls risk resident. V4 said fall risk residents are not supposed to be left alone because anything can happen. They might try to get up and fall. V4 said to prevent R2 from falling, staff should have taken R2 to activities room on the first-floor main dining room where he could have been monitored, or in the day room with staff, or put him(R2) by the nursing station so that R2 could have been always monitored. V4 said fall risk residents who are fall risk have a leaf on their doors to alert staff of their fall risks, and R2 is one of the high-risk residents. R2's hospital records with encounter date of 2/19/2023 document: -Date of Admission: 2/19/2023 -Primary diagnosis: ICH (Intracerebral hemorrhage) -History of Present Illness (HPI) documents: R2 has a fall from wheelchair on 2/18/2023 at the nursing home where R2 resides, was taken to (ED)emergency room and was admitted to trauma service, CTH (Computed Tomography Head) and at that time per report, was found to demonstrate L(Left) frontal traumatic: ICH (Intracerebral hemorrhage). Hospital notes further document: R2 admitted to NSICU (Neuroscience Intensive Care Unit) on 2/19. R2 transferred to another hospital for further work up of suspected aneurysm in setting of expanded L(Left frontal ICH (Intracerebral hemorrhage) with SAH(subarachnoid hemorrhage) S/P(Status Post) fall at nursing home. R2's care plan with initiated date of 10/6/2021, Revised 11/10/2022 documents R2 has had multiple falls on: 10/5/2021, 3/9/2022, 3/17/2022, 3/25/2022, 411/2022, 12/0/2022, 12/15, 2022, 2/18/2023. Facility Policy titled: Fall Prevention Policy, no date documents: -it is the policy of [NAME] to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk for falls and possible injuries. -Direct Care Providers will be instructed regarding approaches and goals for the management of the resident falls risk -Any resident experiencing a pattern of falls (two or more during a 30-day period) or an injury from a fall will be referred for a falls assessment to be completed by the nurse or therapist. R2's Fall Risk assessment dated [DATE] documents -R2 is a falls risk related to having fallen before, has more than one diagnosis on the chart, has an impaired gait, overestimates, or forgets limits. For ambulatory aids, R2 is documented as: None/bedrest/wheelchair/nurse assist.

Based on interview and record review the facility failed to provide services necessary to avoid physical harm to 1 (R2) of 3 (R3, R4) residents reviewed for falls. This failure resulted in R2 sustaining injuries of unknown origin including acute displaced multipart fractures involving the mid to distal tibial and fibular diaphysis, tibial fracture appearing to be a spiral fracture, additional displaced fractures of the distal tibia and fibular diaphysis with likely extension of the malleoli, a posterior malleolus fracture and diffuse soft tissue swelling. Findings Include: R2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 MDS (Minimum Data Set) Section-C Cognitive Pattern has a BIMS (Brief Interview for Mental Status) score of 06 indicating severe impairment. Facility's Reportable dated 07/29/22 document in part at approximately 8 am CNA (Certified Nurse Assistant) on duty noticed R2 wasn't at her baseline. Nurse assessed R2 and left leg was warm to the touch and resident was lethargic. R2 was sent out to the hospital for evaluation. R2 was admitted with AMS (Altered Mental Status) and a fracture of R2 left tibia. Analysis/Conclusions: Family member stated that the doctor at the hospital stated with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The conclusion is that this fracture was caused by a pathological fracture from R2 diagnosis. On 08/16/22 at 01:15 V13 (Certified Nurse Assistant) stated R2 is a 2 person assist with the Mechanical Lift. On 08/16/22 at 02:16 PM V15 (Licensed Practical Nurse) stated R2 is alert and oriented x2, need assistance and is a 2 person assist for transfers. R2 was able to pivot and R2 had no complaints of pain prior to going out to the hospital on 07/29/22. On 08/16/22 at 02:24 PM during the interview, R2 was unable to verbalize events that occurred on or around the time of her (R2) injuries. On 08/16/22 at 02:26 PM V16 (Licensed Practical Nurse) stated R2 is alert and oriented x 1-2 and a 2 person assist. R2 did not have any complaints of pain prior to her (R2) injury. On 08/17/22 at 12:17 PM V26 (Restorative Director) stated I am familiar with R2. We do Range of motion and toileting. I don't know how often the aide perform R2 range of motion. On 08/17/22 at 01:02 PM V27 (Certified Nurse Assistant/Restorative Aide) stated I took care of R2 and observe if any changes, physical swelling or if there is anything I need to let the nurse know. I do range of motion and bed exercises. Prior to R2 injury R2 had a splint on right leg. R2 now has a boot on the left leg and a splint on the right leg. R2 is transferred with a 2 person assist with a mechanical lift. I am not sure how they transfer her during the PM shift. The CNA's (Certified Nurse Assistants) transfer R2. Prior to the injury there was no swelling or redness to R2 legs. I see R2 every day to do range of motion and help feed her (R2). R2 never complained of pain to me. On 08/17/22 at 01:48 PM V28 (Certified Nurse Assistant) stated R2 is a total 2 person assist, was alert and oriented x2. When transferring R2 we use 2 people with the Mechanical lift or 2 people stand pivot with the gait belt. I transferred R2 on 07/27/22 and R2 went out to the hospital on 07/29/22. On 07/27/22 I transferred R2 and put R2 in the wheelchair. I moved the wheelchair by the bed, made sure it was locked, sat R2 up in a sitting position on the bed, put the gait belt around R2 waist, stood R2 up with the 2 people assist, pivoted, and sat R2 in the wheelchair. The Restorative Director helped me transfer R2. R2 was able to bear a little weight on the left lower extremity and the right lower extremity is contracted. R2 had on the right leg splint, the little leg thingy. R2 had no complaints of pain when transferred. There was no swelling or redness to R2 left of right lower extremity. On 07/29/22 I asked where was R2 and R2 was in the hospital. On 08/17/22 at 02:08 PM V26 (Restorative Director) stated on 07/27/22, I think I was doing rounds and V28 (Certified Nurse Assistant) had R2 sitting on the bed with the gait belt. R2 really did not weight bear, R2 was a lift and R2 was heavy. I remember that 'see what I'm saying'. We lifted R2 with the gait belt with 2 persons. When R2 stood we pivoted R2 and sat R2 in the wheelchair. R2 did not complain of pain, and I did not see any swelling. R2 is totally dependent. How to transfer a resident depends on each resident. R2 would not have been able to bear her (R2) weight on her (R2) own and R2 required the gait belt with us bearing her (R2) weight. I only use the care planning and MDS (Minimum Data Set). As far as I am concerned R2 is a 2-person transfer. Mechanical lifts are used with 2 people. From restorative standpoint R2 is a 2 person assist. I did not know about this mechanical lift, I thought R2 was just a 2 person assist. We did not totally lift R2. We told R2 to turn her (R2) hips to pivot. There is a potential for anyone to be injured when being transferred. On 08/17/22 at 02:30 PM V29 (Certified Nurse Assistant) stated One morning I went in R2 room to give R2 her (R2) tray and it was hard for R2 to respond. R2 was just staring. I told the nurse R2 did not look good. The nurse came in did an assessment and they said to send R2 out. As I was cleaning R2 I noticed the left leg was swollen. I asked R2 did her (R2) leg hurt and R2 nodded her (R2) head as if gesturing yes. R2 is transferred with the mechanical lift. I have never transferred R2 stand pivot with a gait belt. R2 has been a mechanical lift all the time, that is how they weight R2. R2 was heavy and solid. Everything about the residents' care can be seen when doing charting. It is on the index card. On 08/17/22 at 02:37 PM V2 (Director of Nursing) stated If residents are totally dependent, they use a mechanical lift for transfers. R2 has always been a 2 person assist with the mechanical lift for transfers. On 07/27/22 I am thinking that the mechanical lift was not available, and the staff did a 2 person assist with the gait belt, pivot to transfer R2 to the wheelchair. It is possible for an injury to occur if a resident is not transferred with the correct device. R2 does not have the ability to bear weight. R2 should not have been transferred with the gait belt, they should have used the mechanical lift. I am aware of the R2 tibular and ankle fracture. On 08/17/22 at 03:02 PM V2 (Director of Nursing) stated the CNA (Certified Nurse Assistant) said R2 could bear weight on the left leg when they transferred R2. R2 was able to pivot with the gait belt. On 08/17/22 at 03:09 PM V32 (Certified Nurse Assistant) stated I worked on 07/29/22 when R2 was being sent out. I never saw R2 leg, swelling or redness. R2 is a 2 person assist using the gait belt. How R2 was transferred depended on how R2 is feeling or what type of day R2 was having. If R2 say she (R2) was not feeling well, I would use the mechanical lift. If R2 felt okay, R2 would pivot for us. We can see how to transfer the resident in their chart, and we will be able to see it when we chart on them every day. The IDT (Intra Disciplinary Team) alert us of the resident transfer status. V32 showed the surveyor using her (V32) phone a Document Response dated 08/17/22 and stated R2 was a 2 person assist prior to the injury. Mechanical lift 2 person. On 08/18/22 at 09:29 AM R2 was observed in bed and just stared when asked questions. On 08/18/22 at 11:02 AM Per telephone interview, V30 (Primary Physician) stated on 07/29/22 the Nurse Practitioner was covering for me. The fracture to R2 tibia and ankle could be from several things. R2 could have laid in a position that is not appropriate and pathological fractures can be seen in people that are bed bound. R2 is Demented and doesn't know what she (R2) is doing. Another possibility is a spontaneous fracture. It is hard to say what caused the fracture, but these are the possibilities. R2 is a 2 person assist and I was not notified of any falls. R2 was sent to the hospital with pain and swelling and they found R2 with the fracture at the hospital. I believe they gave R2 an immobilizer and sent R2 back to the facility. R2 was not a candidate for surgery because of R2 comorbidities of Dementia, Diabetes and being bed bound. They recommended conservative management. R2 was bed bound, has [CONDITION(S)] and osteopenia. A spiral fracture can be from trauma or fast turning. If R2 was transferred using the gait belt and pivoting to transfer to the wheelchair it is possible that the spiral fracture could have happen from a twist. If a twist happens there is sheer stress force from one side to the other that can lead to fractures. On 08/18/22 at 11:40 AM V2 (Director of Nursing) stated the 2 persons transfer with the mechanical lift was in R2 medical record prior to R2 injury. Based on the 2 persons transfer with a mechanical lift, staff transferred R2 incorrectly by doing the stand and pivot transfer. On 08/18/22 at 11:53 AM Per telephone interview, V33 (Nurse Practitioner) stated she (V33) was informed of R2 fracture to the Left Lower Extremity. Surveyor asked V33 in her professional opinion what could have caused the fracture. V33 responded in my thinking it could be related to a trauma or a possible fall. R2 was a 2 person assist with the mechanical lift prior to R2 injury. Surveyor informed V33 that on 07/27/22 R2 was transferred using a gait belt, stand and pivot. V33 responded oh my goodness, there is a possibility that a spiral fracture could be caused with a pivot. I was looking for a Dexa scan and have not seen any bone scan. I referred R2 to Ortho. Diffused soft tissue swelling can be due to the fracture or third spacing from a stagnant extremity. On 08/18/22 12:16 PM pre telephone interview V36 (Agency Licensed Practical Nurse) stated during the period I worked there R2 was fine when I did my rounds. R2 had no complaints of pain to the lower extremity. I did not see R2 leg, but the CNA did not report anything to me. On 08/18/22 at 12:23 PM V2 (Director of Nursing) stated the former restorative nurse never updated R2 care plan, and it does not reflect the sling lift, full lift. The care plan should have been updated 07/19/21. Progress note dated 07/23/22 at 10:35 document in part: Nurses Note: resident noted up in chair. Progress note dated 07/27/22 at 18:59 document in part: Nurses Note: resident noted up in chair. Progress note dated 07/28/22 at 13:18 document in part: Nurses Note: resident noted up in chair. Progress note dated 07/29/22 at 08:00 document in part: Nurses Note: CNA notified writer that resident was not at normal baseline & seems lethargic. Writer assessed resident & observed resident slow to response & lethargic. LLE (Left Lower Extremity) warm swollen & pain to touch. Progress note dated 07/29/22 at 16:13 document in part: Health Status Note: Resident admitted to hospital with Dx (Diagnosis) of [CONDITION(S)] (Urinary Tract Infection) and Fx (Fracture) of Lt (Left) Tibia. Progress note dated 08/2/22 at 08:40 document in part communication - with Family/POA (Power of Attorney) Note Text: The POA for the resident came to the facility to discuss the incident from the weekend. She stated she was with R2 for 4 hours and she received a couple different versions of what possibly occurred. She said what R2 finally told her was R2 didn't fall but a couple family members had come by last week and she isn't sure who and took R2 out of bed without staff assistance. The doctor at the hospital stated with R2 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated 08/10/22 at 12:07 document in part: Health Status Note: # acute trimalleolar fracture: acute displaced multipart fractures of the mid-distal tibia and fibular diaphysis orthopedics were consulted, R2 to be managed non-operatively as recommended. Care Plan document in part: R2 is at risk for decrease or loss in functional abilities and requires AROM (Active Range of Motion). Date Initiated: 10/21/19 Revision on: 02/09/21. nursing rehab/restorative: active ROM Program - R2 will perform 3 sets of 10 reps of flexion, extension, adduction, and abduction exercises to all upper/lower extremities for at least 15 minutes daily. Date Initiated: 10/21/19 Revision on: 11/01/20 - R/L (Right/Left) Hip flexion/extension - R/L Hip abduction/adduction - R/L Knee flexion/extension - R/L Ankle flexion/extension. R2 requires limited assist with bed mobility as evidenced by generalized muscle weakness, immobility, and lack of coordination. Date Initiated: 11/06/19. Assist in turning and repositioning every 2 hours as appropriate, use draw sheet if necessary. Date Initiated: 11/06/19. R2 is at risk for falls. Date Initiated: 02/08/22. R2 has an ADL self-care performance deficit r/t (Related/to) muscle weakness. Date Initiated: 11/01/20 Revision on: 04/26/21. Bed Mobility: Extensive assistance Two+ persons physical assist Transfer: total assistance Two+ persons' physical assist. R2 has impaired cognitive function/dementia or impaired thought processes r/t Impaired decision making, impaired memory. Date Initiated: 02/09/21. R2 is at risk for falls r/t Incontinence, DM type 2, [CONDITION(S)], and medication regimen. Date Initiated: 07/23/19 Revision on:11/06/19. R2 has had an actual fall with no injury 10/30/21 Date Initiated: 11/01/21. Mobility & Lift Status review dated 07/19/21 document in part: C. Mobility and Balance: Mobility and Balance: Ability to roll from side to side: Poor. Ability to sit up unassisted: Poor. Ability to maintain sitting balance: Moderate. Ability to stand: Poor. Ability to maintain standing balance: Poor. D. Transition Movements: Surface-to-Surface transfer: Not steady, only able to stabilize with staff assistance. E. Weight Bear: 1. Can the resident bear weight: No. Type of Transfer: 15c. Sling lift (full lifter). Electronic Medical Record Form dated 07/28/22 document in part: ADL: Transferring. Instructions: Hoyer 2-person. Hospital Record dated 07/29/22 document in part: patient here with AMS (Altered Mental Status), noted to be more somnolent, slow to respond. LLE (Left Lower Extremity) swelling, redness and [CONDITION(S)] noted. Reason for Consultation: Left tibia shaft and left ankle fracture. Physical Exam: LLE has some swelling about mid tibia, tenderness to palpitation, compartments soft. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Fracture of tibial shaft left, closed. Imaging reviewed: Left tibial shaft fracture, left trimalleolar ankle fracture, unknown mechanism of injury. Patient has been non ambulatory for the past 2 years. Xray ankle 2 views left: Impression: 1. Acute trimalleolar fracture. 2. Acute displaced multipart fractures of the mid-distal tibia and fibular diaphysis. 3. Diffuse soft tissue swelling. Xray Tibia/Fibular Left: Impression: 1. Acute trimalleolar fracture. 2. Acute displaced multipart fractures of the mid-distal tibia and fibular diaphysis. Findings: There are acute displaced multipart fractures involving the mid to distal tibial and fibular diaphysis. The tibial fracture appears to be a spiral fracture. Additional displaced fractures of the distal tibia and fibular diaphysis with likely extension of the malleoli There is a posterior malleolus fracture. Diffuse soft tissue swelling. Left leg with long leg mold immobilizer placed in ED (Emergency Department) and wrapped with TED hose. After review of thirty pages of R3 hospital records dated 07/29/22, there was no mention of [CONDITION(S)], osteopenia, or brittle bones as a contributing factor for R2 fractures and there was no DEXA scan (Bone Densitometry Screening) performed. There was no care plan of how to properly transfer R2 and the method of transferring R2 was conflicting during staff interviews. Policy: Titled Abuse, Neglect & Misappropriation revised 05/21 document in part: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 7. 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. 6. Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to the following possible indicators: c. Physical injury of a resident, of unknown source. Titled Lift, Total Mechanical Lift (Hoyer) revised 09/16/22 document in part: To enable two employees to lift and move a resident safely. Equipment: 1. Total Mechanical Lift.

Based on interviews and record reviews, the facility failed to provide (R3) 1 of 3 residents reviewed for falls with injuries access to immediate medical attention, failed to follow the established policy and procedures for monitoring a resident after an unwitnessed fall, failed to notify the physician or do continued monitoring of neurological checks, of a fall for a resident on an anticoagulant. This failure resulted in R3 being transported to the emergency room via ambulance 3 days after the unwitnessed fall and diagnosed with Traumatic Subarachnoid Hemorrhage without loss of consciousness (Bleeding on the Brain). Findings Include: R3 is an [AGE] year-old with the following diagnoses, Dehydration (3/3/2022), Traumatic Subarachnoid Hemorrhage (3/3/2022), Peripheral Autonomic [CONDITION(S)], Long Term (Current use of Anticoagulants), Spinal Stenosis, [CONDITION(S)], Dementia without behavioral disturbances. History of a healed fracture and [CONDITION(S)] (stage 3). R3's medications include [MEDICATION(S)] therapy, putting R3 at a greater risk for bleeding. Review of R3's progress note dated 2/27/2022 by V4 (Nurse) at 2:51 pm, writer was doing rounds when resident was observed laying on the floor. Resident informed writer that she wanted to go to bed. Writer was performing patient care on another resident, writer informed resident that she will assist her back to bed once care for other resident was completed. R3's MDS (Minimum Data Set) dated 12/22/2021 scored R3 for self- performance at a 3 indicating R3 requires extensive assist from staff for weight bearing. R3 was scored as a 2 for support indicating R3 needs one-person physical assist to perform for all Activities of Daily Living (ADLs). During a face- face interview on 03/15/2022 at 2:40 pm with V1 (Administrator), surveyor asked V1 for the reportable incident of R3 's fall on 02/27/2022. V1 stated we didn't report it because she didn't go out to the hospital until a couple days later. Surveyor asked V1 if he notified IDPH of R3's injury of a brain bleed due to a fall and delayed medical treatment. He stated honestly, I did not report it to IDPH. V1 (Administrator) was asked for an internal investigation of the incident, V1 said he didn't do an investigation. V1 was asked if he was aware that V4 (Nurse) left R3 on the floor in her room crying and told R3 that she needs to stay on the floor and wait until she completes care with another resident. V1 said yes, I am aware of that progress note where V4 told R3 she would be back after she took care of another resident. V1 said V4 was told to change the documentation. There were two progress notes dated approximately 3 minutes apart by V4. Both progress notes by V4 noted V4 told R3 she would get her off the floor and back to bed after she finishes giving care to another resident. During a phone interview with V4 (Nurse) on 3/17/2022 at 5:07 pm, V4 was asked about the fall incident with R3 on 2/27/2022. V4 said she was told that R3 does a lot of screaming and crying but this was the first time it happened on her shift. V4 said she was doing [CONDITION(S)] care on another resident across the hall when she heard a lot of yelling and screaming coming from R5 (roommate) across the hall. R5 was screaming that R3 had thrown herself onto the floor. V4 stated she stopped and went to see what was going on. V4 said she observed R3 laying on the floor with her arm under her head. V4 stated R3 didn't appear to be hurt, she was crying and wanted to go back to bed. V4 said she told R3 she would have to wait until she finished taking care of another resident. When I finished doing [CONDITION(S)] care on the resident, I came to see about R3. I had to wait to get help to put R3 back into the bed. V11 (Nurse) came and helped me put R3 back to bed. Review of physician note dated 02/27/2022 at 11:32 pm by V10 (Advance Practice Nurse - APN), 83 y/o Caucasian female resident with h/o CKD, DM-2, obesity, depression, [CONDITION(S)], HLD, anxiety, Covid-19, low back pain, spinal stenosis- lumbar region and dementia seen and examined earlier today as per NOD request. NOD reported resident found lying on the floor and her roommate told she did on purpose. Resident is alert and verbal, now back to bed, resting, forgetful in baseline, denies any pain and discomfort at present. ASSESSMENT/PLAN: # S/p Fall- found lying on the floor: - Monitor vitals, neuro- notify if any deviation from baseline - Offer pain medication - Fall precautions/prevention - call light in reach - explained resident to give call light and wait for assistance - Maintain hydration, nutrition, ADLS - Keep skin dry and clean - Continue all other Tx - Discussed about covid precautions Plan of care discussed with PCP, nursing staff, and patient, Time of the note does not necessarily correlate to the time or date the patient was seen. Time Spent: Total Time Spent with Patient including assessment, medication review, education, POC, 25 min. On 3/16/22 , at 11:42 am, V1(Administrator) was asked for a contact number to speak with V10(Advanced Practice Nurse) . V1 said V10 is out of the country and will be gone at least a month. Surveyor was not able to interview V10 about her order for monitoring vitals and neurological checks. During interview on 3/16/2022 at 10:50 am with V2 (Director of Nursing), V2 was asked to provide the neurological assessments on R3 and the flow sheets for vitals. V2 stated I only have the assessment completed on 02/27/2022 by V4 (Nurse) after they got R3 back to bed. Surveyor asked V2 for the Fall policy and the Neurological Assessment Policy. Surveyor asked V2 is there anyway to get the other neuro assessments. V2 stated we don't have any other assessments, I have checked. Surveyor asked how often are the neuro checks documented, V2 stated several times within the first few hours and then over a period of time. During a phone interview on 03/17/2022 at 1:32 pm with V12 (Physician), V12 was asked if he received a call from V4 (Nurse) on 2/27/22 about R3 being found on the floor. V12 said no he answers and returns all his calls. Surveyor asked if he knew R3 was found on the floor with no apparent injuries and receiving [MEDICATION(S)] as an anticoagulant what orders would be given to the nurse. V12 stated he would order neuro checks regularly and monitor for change in condition. Surveyor asked the doctor was he aware that the resident was complaining of pain to the head and was observed with bruising to the right temple on 3/2/2022. (V12) stated obviously R3 hit her head, this is why neurological checks are done. They waited too long to contact me, I would have ordered R3 out to the hospital for a CT scan. During a phone interview with V9 (Nurse) on 3/17/22 at 1:50 pm, V9 stated R3 was complaining of a headache. On 3/2/22 pain medication was given. V9 stated she spoke with V12 (physician) about a bruise to R3's left temple, I was given an new order to send R3 out to the local hospital for CT scan. Review of hospital note by V13 (Nurse) on 3/2/2022 at 7:43 pm - V13 spoke with nurse at the hospital, R3 is being XXX under care of Dr. YYY. Spoke with MD and made him aware, DON aware, and brother aware. Progress Note dated 3/4/2021 at 10:00 pm by V11 (Nurse), F/U readmit R3, Received in bed. A&O x2 breathing easy & unlabored no SOB. Good appetite. Incontinent of B&B kept clean & dry. Meds taken as ordered. VSS. Able to make needs known. At dinner time resident was noted crying. When asked what was wrong, she stated that my table is too far from me. Writer educated resident that she could pull her table closer to her herself. Writer moved table closer to resident & resident was ok. Call light within reach. Staff will continue to monitor. Care Plan Revision: Date 2/27/2022 - review of R3's care plan noted no information pertaining to R3 being sent out for a hospital stay related to the fall on 2/27/22 with an injury of Brain Bleed and returning back to the facility on [DATE]. Fall Policy/Prevention: Revised 05/2021: #5. Upon arrival of the nurse, a quick head to toe scan will be performed without unnecessary movement, palpating, and examining all areas for break in the skin and or other abnormal findings. #6. Obtain vitals #7. Obtain neurological checks per policy for unwitnessed fall or any fall with evidence of injury to head. #10. The nurse will complete an incident report. #12. Resident fall will be evaluated for 72 hours post fall, including vital signs every shift. #13. The Director of Nursing (DON) will be notified immediately for falls resulting in injury and or transfer. The DON will notify State Agency per state specific requirements. Facilities Policies: Neurological Assessments: dated 5/2021: Neurological assessments are performed to evaluate a resident's nervous system including brain function. Early detection of an injury or underlying condition provides the best chance of decreasing long term complications. Resident/patient with conditions resulting in changes, or potential changes, in their neurological status will be assessed for transfer to the acute care setting. Neurological assessments Policy: Neurological assessments will be completed by a licensed nurse: 1. To assess central nervous system status of a resident/patient. 2. To assess level of consciousness for a traumatic or potentially traumatic injury to the head, after any loss of consciousness or change in condition that may have resulted from stroke or adverse event 3. To assess neurological status after an un-witnessed fall. 4. Neurological assessments will be completed as follows: a. Every 15 minutes x first hour b. Every 30 minutes x 2 hours c. Every hour x 2 hours d. Every shift x 72 hours e. Then as primary healthcare provider orders PROCEDURE: 1. The licensed nurse will complete the Neurological Assessment Flowsheet for data collection. a. Identify resident/patient, explain procedure, and provide privacy, wash hands. 2. Complete data collection. 3. Immediately report changes or concerns to the primary healthcare provider and family.

Based on observations, interviews, and record reviews, the facility failed to (A) follow their wounds, prevention and management policy to ensure residents does not develop pressure sores, (B) ensure that residents received wound treatments, (C) place decreased mobility residents on a turn and repositioning schedule, (D) follow manufacture's instruction for proper settings on the low air mattress. These failures resulted in R1, R2, and R13 developing facility acquired pressure wounds; [R1] stage 4 (sacrum), stage 4 (left ear), unstageable (right back), [R2] stage 3(right proximal foot), stage 3(right foot), stage 3 (right distal medial foot), stage 4 (post-surgical abdomen wound), stage 2 (right buttock), stage 2 (left shin), [R13] stage 3(right hip), and stage 2 (left buttock). Findings include: 1/25/22 at 10:30 AM, R1's medical record read admitted on [DATE], medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's TAR [treatment administration record] R1 did not receive wound care treatments that was prescribed on the following dates; Sacrum-1/8/22, 1/9/22,1/15/22,1/16/22, 1/18/22, and 1/22/22. Right back-1/22/22. R1's weekly wound assessment dated [1/21/22] Site #2- Stage 4 sacrum measures 8x6x not measurable, Site #3 Stage 4 left ear measures 0.5x0.3x0.1cm, and Site#4- unstageable wound to the right back measures 6x8x not measurable cm all three areas classified as facility acquired pressure wounds. 1/25/22 at 11:10 AM surveyor observed R1 resting on a low air loss mattress (set at 140 pounds) lying supine position with bilateral heel boots in place. R1 was alert/oriented to person, time, place and situation. R1 stated, I have sores down on my feet and my back side, my bandages are not changed every day. I wait a while to get cleaned up sometimes. No one helps me turn from side to side. I lay on my back all day just like this. R1's current weight is 114.3 lbs.; air loss mattress was not set according to R1's weight. Progress note dated [1/19/22]- documents in part V26 [Wound Care Nurse]; R1 was assessed by wound team. R1 noted with skin condition to left ear due to oxygen tubing and shearing to upper Right Back. Treatment applied/initiated. Incontinence care provided with moisture Barrier to follow every shift. R1 pressure redistributing mattress. Heel Boots on while in bed. R1 is turned/repositioned q2 hours and Prn 1/25/22 at 11:50 PM R2's medical record read admitted [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plans documents in part; dated [ 11/16/21] R2 is unable to use the call light, and staff to make frequent rounds. R2 has an activity of daily living self-care performance deficit and requires 2-person assistance for mobility/transfers, one person assist for bathing, and personal hygiene. Due to contractures, provide skin care daily to keep clean and prevent skin breakdown. R2's TAR [treatment administration record] R2 did not receive wound care treatments that was prescribed on the following dates; right distal medial foot-1/15/22, 1/16/22, 1/17/22, 1/22/22, right foot- 1/15/22, 1/16/22, 1/17/22, 1/22/22, and right proximal foot-1/15/22, 1/16/22, 1/17/22, 1/22/22. Barrier cream on peri area after each incontinence episode- 12/1/21, 12/2/21, 12/7/21, 12/8/21, 12/11/21, 12/12/21, 12/14/21, 12/18/21, 12/19/21, 12/22/21, 12/25/21, 12/26/21, 12/27/21, 12/28/21, 12/30/21, 12/31/21,1/1/22, 1/2/22, 1/3/22, 1/4/22, 1/5/22, 1/7/22-1/11/22, 1/13/22, 1/15/22, 1/16/22, 1/17/22, 1/18/22, 1/20/22, 1/22/22, and 1/25/22. R2's weekly skin assessment dated [1/21/22] Stage 3 right proximal foot measures 2.5 x 2 x 0.1cm, stage 3 right foot measures 2.5 x 3.5 x 0.1 cm, stage 3 right distal medial foot measures 0.6 x 1.5 x 0.1cm, stage 4 post -surgical wound abdomen full thickness measures 1 x 1x 0.1cm, stage 2 right buttock measures 2 x 4x not measurable cm, and stage 2 left shin measures 5 x 1.5 x 0.1cm. 1/25/22 at 12:10 PM surveyor observed R2 resting on an air loss mattress bed (set at >350 pounds) lying in supine position [back] with gastric tube in place. Current weight 140.4lbs. The air loss mattress was not set according to R2's weight. 1/25/22 at 1:00 PM, 1:20 PM, 1:50 PM, 2:25 PM surveyor observed R2 resting in bed lying supine position, without repositioning. 1/27/22 at 9:46 AM surveyor observed R2 lying in supine position on a square cloth chuck with no sheet on the mattress. Progress Note dated [1/10/22] V26 [ Wound Care Nurse] documents in part; R2 was assessed by wound team. R2 noted with skin conditions to Right Dorsal foot, and Right Lateral ankle. Treatment applied/initiated. See assessments for measurements. R2 lower legs are contracted backwards where her feet are under her buttocks causing pressure and moisture to her feet and that leads to skin breakdowns.

Based on interviews, observations, and records reviewed the facility failed to follow their identified care plan interventions to prevent a fall. The facility failed to implement a care plan with interventions related to the contributing factors of a fall and failed to implement care plan interventions implemented after a fall. This failure resulted in R8 sustaining an acromioclavicular separation and scalp hematoma after falling from bed during care.This failure affected 3 of 4 (R8, R1, R2) residents reviewed for falls. Findings include: R8's [DIAGNOSES REDACTED]. During an interview on 8/12/20 at 8:50AM with V3, Unit Manager, she said an initial fall risk assessment is completed on admission and after every fall. V3 said the floor staff is notified of residents at risk for falls in report, during stand-up meetings, with the use falling star symbols, and oral reports given to CNAs daily. During an interview on 8/13/20 2:00PM, V2, Director of Nursing, said a Certified Nursing Assistant improperly rolled R8 on 7/12/20 and walked away and R8 rolled off the bed. V2 said R8 sustained a closed hematoma on her forehead and a right acromion process dislocation. During an interview on 8/13/20 at 2:17PM V16, Certified Nursing Assistant (CNA), said R8's care before the fall included staff to bathe her, 2 persons for transfers, and dependent on staff for incontinent cares. V16 said R2 requires 2 persons to reposition her. V16 said R8 now has a rail for her to grab and pull while in the bed. V16 said R8 did not always have the rail before the fall because it is removable. V16 said if R8 has a pillow or wedge she could be left on her side. V16 said R8 would not be safe left on her side without a device to support her. During an interview on 8/14/20 at 9:29AM with V26, Nurse Practitioner, she said she expects the facility to follow the resident plan of care, so if 2 persons are required for care then they should be using 2 persons. V26 said the fall on 7/12/20 was the cause of R8's shoulder dislocation. V26 said on her assessment prior to the fall R8 was able to move her arms without difficulty. When R8 was sent to the emergency room for evaluation following the fall they found she had the dislocation immediately on 7/12/20. During an interview on 8/14/20 at 11:52AM with V25, CNA, she said she was providing care to R8 on 7/12/20. R8 was in the bed and V25 left her to get more towels. V25 said she was providing care to R8 alone and no other staff was in the room. On 8/13/2020 at 3:06PM R8 observed awake and alert, in her bed eating a snack. Half side rails up, call light on her lap, name tag on her right wrist. No arm sling noted on either arm. There is a #2 posted on the wall above head of bed. R8's name appears as the first name on the list of residents outside of the room, but there is no star next to her name. During an interview on 8/14/20 at 9:25AM V29, Nurse, said R8 is cooperative with wearing her sling. V8 was a 2 person assist because she is heavy weight for one person to turn and reposition while in the bed. 8/14/20 Record review of R8's care plan for self-care performance deficient dated 2/22/20 intervention for bed mobility dated 2/22/19 states 2 staff to turn and reposition. Record review of R8's Fall Report on 8/14/20 dated 7/12/20 written by V24, Nurse, notes when asked what happened CNA reported that she attempted to roll resident to one side and went to go pick up materials, resident rolled out of bed. Evaluation noted to have a hematoma to forehead with swelling and bleeding. Record review of R8's care plan on 8/14/20 note date initiated 7/12/20 R8 had an actual fall with injury. CT scan performed positive for right acromion dislocation. Interventions dated 7/13/20 note CNA in service on how to do an Activity of Daily Living care regarding proper placement, repositioning and gathering material prior to attending to residents. Right arm sling to wear at all times except during ADL care. Review of Occupational Therapy Plan of Care dated 7/20/20 notes R8's Functional Deficits for Activity of Daily Living for hygiene required maximum assistance prior to the fall and her current level is dependent. R8's prior Functional Deficits for Activity of Daily Living for upper body dressing was moderate assistance and her current level of assistance is dependent. Record review of R8's physician orders [REDACTED]. [MEDICATION NAME] HCL tablet 50mg as needed for pain. Record review on 8/14/20 of R8's Emergency Department Chart Report dated 7/12/20 notes chief complaint fall. Diagnosis: [REDACTED]. 2). R1's [DIAGNOSES REDACTED]. R1's most recent admitted listed on the face sheet is 12/18/17. R1 is no longer in the facility. During an interview on 8/12/20 at 1:43PM V12, Nurse, said during her rounds on 4/13/20 she saw R1 sitting on the floor. R1 told her he did not know how he got to the floor. V12 said following a fall the department heads will discuss the fall the next day and discuss new interventions. V12 said prior to the fall she can not recall if R1 has any fall precautions in place. During an interview with V14, Nurse, on 8/12/20 at 3:15PM, he said Fall Risk Assessments should be done on admission. V14 said the purpose of a Fall Risk Assessment is plan interventions to prevent falls. During an interview on 8/13/20 at 9:17AM V2 said if she would have done the fall follow up for R1 she would have a care plan entry for each fall dated 4/13/20 and 4/15/20. Surveyor asked V2 for the care plan following R1's 4/13/20 fall and V2 said It's not there that is why I didn't bring it. During an interview on 8/13/20 at 11:30AM V20, CNA, said she didn't think R1 was a fall risk. V20 said if a resident is a fall risk, she is made aware by the resident's gait and walking ability and the nurses will tell you who is a fall risk. V20 said the nurses never said R1 was a fall risk. V20 said someone who falls twice within a couple of days should be a fall risk. During an interview on 8/13/20 at 2:31PM with V21, Nurse, she said on 4/15/20 during rounds she saw R1 was on the floor. V21 said she was not familiar with R1 because she is a float nurse. V21 said she received report from the prior shift's nurse on 4/15/20. V21 said she was not made aware during report that R1 had a fall on 4/13/20. Record review on 8/12/20 of R1's Fall reports include fall on 4/13/20 and a fall on 4/15/20. Record review on 8/13/20 of Fall Risk Assessments dated 4/13/20 and 4/15/20. No other Fall Risk Assessments are present in R1's electronic record for review. Record review on 8/13/20 of R1's care plan includes a fall focus dated 4/15/20. Interventions to monitor the resident and neurological checks are both dated 4/15/20. No other interventions are on the care plan. 3). R2's [DIAGNOSES REDACTED]. During an interview with R2 on 8/12/20 at 12:40PM he said he fell a few weeks ago. R2 said he fell trying to change his brief while in bed because no one had changed him and he was wet. During an interview on 8/13/20 at 11:50AM with V18, Nurse, said on 7/24/20 R2 told her he was sitting at the edge of the bed and he slid to the floor. V18 said all residents are at risk for falls. V18 said the care plan interventions added should be something that address the situation related to the resident's fall. V18 said R2's wheel chair was not involved in this fall. V18 said the nonskid pad intervention will help when the resident is in the wheel chair, but if the resident is not in the wheel chair it won't help. During an interview on 8/13/20 at 11:18AM V19, Director of Rehab, said we had added R2 to case load on 7/22/20, before he fell , for decline involving problems with transfers and bed mobility. We screened him and noticed he had changed. V19 said after the fall R2 had told her he was trying to get his balance while sitting on the bed and he said he lowered himself to the floor. V19 said R2 is alert, oriented, and credible. V19 said she discovered R2 was on the floor and the wheel chair was nowhere near him when she saw him on the floor. On 8/13/20 at 10:48AM During an observation of R2 with V27, CNA, present R2 stood up from his wheel chair with assistance of V27. While standing surveyor observed wheel chair cushion in wheel chair. No non-skid device was on top of the cushion. Surveyor asked V27 if the nonskid is present under the cushion. V27 lifted the cushion and said no nonskid is present under the cushion. V27 said she had gotten R2 ready and into his chair in the morning. Record review on 8/12/20 of R2's Fall report dated 7/24/20 written by V18, Nurse, reads resident statement I slid while sitting at the edge of my bed. On the same report mental status documented as oriented to person, place, and situation. Record review on 8/12/20 of R2's Progress Notes dated 7/24/20 written by V18 read when resident was asked what happened verbally told slid while sitting at the edge of my bed. Record review on 8/12/20 of R2's Care Plan date initiated 3/3/20 notes the resident had an actual fall with no injury. Intervention dated 7/24/20 reads continue interventions, nonskid pad to wheel chair cushion, and rehabilitation to evaluate and treat as orders post fall. (Rehab had already been initiated on 7/22/20.) R2's Order Summary Report includes an order dated 7/20/20 for Occupational therapy to evaluate and treat. an order for [REDACTED]. The 3 orders are prior to the date of the fall on 7/24/20. R2's assessment for Functional Status dated 7/30/20 stated R2 requires extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. assessment dated [DATE] for Balance During Transitions and Walking is assessed as activity did not occur. Record review on 8/14/20 of the facility's undated Incident / Accident Facility Responsibility List states fall care plan interventions updated with date. The facility's undated Fall Program Guidelines reviewed on 8/18/20 states: Purpose to define guidelines in implementing a falls program to promote resident safety and prevent or reduce falls. Enroll resident's in Falling Star Program and communicate interventions to staff. Resident's identified as a fall risk will have an individualized care plan to address the contributing factors that place them at risk, goals to prevent falls / injuries, and interventions / approaches to promote safety of the resident.

Based on interview and record review the facility failed to follow care plan interventions to ensure a consistent and safe transfer utilizing two person transfers with the gait belt and the mechanical lift for 1 of 3 residents (R1) reviewed for avoidable accidents. This failure resulted in R1 sustaining a left proximal non-displaced tibial fracture. Findings Include: R1's admitting [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents a brief interview for mental status (BIMS) score of 15. The BIMS is a brief screener that aids in detecting cognitive impairment. Scores from a conducted BIMS assessment suggest the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. R 1's progress note dated 4/6/18 at 8:02 AM, documents R 1 is Alert and oriented x3. Complaints of left leg pain 10/10. Doctor called for x-ray orders awaiting call back. R 1's Physician's progress note dated 4/6/18 at 10:22 AM documents R1 was observed in bed and complained of left calf pain that began last night and got worse. Pain 8/10 localized to calf only. R1 is alert and oriented x3. R'1 progress note dated 4/6/18 at 14:23PM documents contracted x-ray Company called for left leg x-ray and Doppler. R 1's facility contracted x-ray report dated 4/6/18 at 15:45 documents impression of suspected proximal tibial fracture, recommend dedicated Multiview imaging. R 1's progress note dated 4/6/18 at 22:32, documents R 1's x-ray results relied to V 15 (Physician) V15 gave orders to send R1 to local hospital and Ambulance Company called for transfer. Local hospital records documents arrival date 04/06/18 at 23:34 to emergency department. Under triage; documents R 1 has no mental status changes. R1 is alert and awake. Oriented to person, place and time. R1 states she had been dropped when they were putting me in bed on Wednesday night around 7 pm. Local Hospital Records under Clinician history dated 4/6/18 documents R1 reports she was being transferred to bed 2 days ago and had a pop in her left leg. Hospital consultant request/report dated 4/7/18 documents R1 is alert and Oriented x3 and presented to emergency room after being dropped during a transfer at nursing home on Wednesday 4/4/18. Hospital Consultation report dated 4/8/18, documents that while transferring with nursing home staff, fell on [DATE]. Generally this is an alert lady who is conversant and follows commands. Review of the facility's Final Investigation Report dated 4/12/18 for R 1 documents under brief description of incident at approximately 1000AM, writer was called to floor to further evaluate R1 who was complaining of pain after attempting to ambulate with assistance (Resident is one person assist) stated I heard a pop when I stood up, then there was pain in my left leg and they laid me back in bed, writer asked resident who is alert if she had fallen or hit anything and she stated no. On 4/20/18 approximately 11:10 AM, V5 (Certified Nursing Assistant, CNA) stated R1 is Alert and oriented. V5 said that on Thursday 4/5/18, R1 said that one girl was transferring me back to bed yesterday evening and then my leg started hurting. V5 said that on 4/5/18 he observed R1's left leg to be swollen and warm to the touch. V5 stated R1 gets up out of bed to her wheelchair on Mondays, Wednesdays, and Fridays. V 5 stated he informed V8 (Nurse). V5 said, R1 is a 2 person assist for transferring and that R1 would stand and bear weight to legs and then be able transfer to chair. On 4/20/18 11:41 AM, V8 (Nurse) stated R1 was alert and oriented x3. On Friday 4/6/18, a CNA informed her that R1 was complaining of pain, V8 stated R1 leg was swollen. R 1 stated her leg had started hurting on Wednesday after she went back to bed, and I called doctor for x-ray's and awaited a call back. MD was in building and ordered x-ray and Doppler. On 4/20/18 12:45PM, V 10 (Nurse) stated R1 is alert and oriented x3. V 10 overheard from another nurse saying R1 stated she heard a popped in her leg when being transferred and said that R1 had a fracture and was sent out to hospital later. A review of R 1's Minimum Data Set ((MDS) dated [DATE] under Section G documents; transfer 3/3 -extensive assistance, 2 person assist. R 1's Care plan initiated 4/16/16 documents, R1 is at risk for falls related to [MEDICAL CONDITION], need for staff for transfers and mobility. Care plan interventions dated 7/19/16 documents staff to assist x2 with gait belt and mechanical lift with all transfers. On 4/18/18 approximately 1230 PM V3 (CNA) stated R1 is alert and oriented. V3 stated she was assigned to take care of R1 at times but unable to recall specific date and time. V3 would get V4 (CNA) to assist with transferring R1 to high back wheelchair. V3 said R1 is 2 person assisted and had contractures in both of her legs. V3 said R1 would be lying in bed and one person would have the top portion and the other person would have her legs and they would lift her into the chair. V3 said they did not use a gait belt for transfer. V3 stated she assisted R1 with her legs and that she was complaining of pain in her legs prior to transfer but not specific to which one. R1 said she was waiting for MD. V3 informed V 8 (nurse) of pain. V3 unable to recall exact date/time of transfer. A review of the Electronic kiosk (daily charting system for certified nurse aide) documents Activities of daily living legend report documents on 4/4/18 and 4/6/18, V3 (CNA) documents assisting R1 with eating, dressing, and bathing. On 4/18/18 approximately 1250 PM, V4 (CNA) stated R1 is alert and oriented. V4 said she would sometimes assist other staff with transfer for R1. V4 said she assisted V3 with transferring R1. V4 said they used a gait belt to assist R1 out of bed to wheelchair. V4 said there would be one person on each side of the residents with the wheelchair in front of R1 and then use gait belt to transfer R1 to chair. On 4/20/18 12:50PM, V11 (Certified Nursing Assistant, CNA), said R 1 is alert and oriented x 3. R 1 is a 2 person assist with transfers. V 11 (CNA), said she uses a gait belt, with one person on each side of R1 and then lift R1 into the wheelchair. V11 stated R1 cannot stand and can't put weight on her leg. On 4/20/18 1:30PM, V 9 (Certified Nursing Assistant, CNA), said R1 is alert and oriented, R1 was complaining of pain Thursday 4/5/18 day shift. V9 said she was providing incontinence care and R 1 said her hips were hurting. V9 informed V8 (nurse) of R1's complaint of pain On 4/20/18 1:50 PM V12 (Certified Nursing Assistant, CNA), stated she heard R1 leg was swollen and possibly fractured on Friday (4/6/18). I was not assigned to R1. A review of the Electronic kiosk (daily charting system for certified nurse aide) documents Activities of daily living legend report documents on 4/4/18 V3 (CNA) and V12 (CNA) provided care to R1. On 4/4/18 at 19:16 V 12 assisted R1 with transferring. At 19:17, V12 (CNA) assisted R1 with bed mobility. A review of the Electronic kiosk Activities of daily living log documents on 4/5/18 at 11:20 V9 (CNA) assisted R1 with toilet use. On 4/20/18 2:54PM, V9 (CNA) reviewed electronic documentation and confirmed that R 1 complained to her of leg pain on Thursday 4/5/18 and V 9 said that she notified V8 (LPN) of R1's complaint of leg pain. On 4/20/18 3:10 PM V3 (CNA), stated she did not put R1 back to bed prior to leaving her shift on 4/4/18. At 3:00 PM. A review of local hospital records radiology report dated 4/7/2018 documents R1 was assessed with [REDACTED]. A review of Facility's education/meeting attendance record titled Resident Transfer, The Safe Way was presented to staff on 4/8/18. According to the American Academy of Orthopaedic surgeons documents that a proximal tibia fracture causes are mostly from the result of trauma. Older persons with poorer quality bone often require only low-energy injury (fall from a standing position) to create these fractures.

Based on interview and record review the facility failed to conduct a comprehensive pain assessment and address escalating complaints of leg pain for one of three resident ( R1) reviewed for comprehensive pain assessment. This failure resulted in R1 complaining of pain to staff for at least (2) days, and R1 subsequently being sent to the local hospital and evaluated and treated for [REDACTED]. Findings Include: On 4/20/18 1:30PM, V 9 (Certified Nursing Assistant, CNA), said R1 is alert and oriented, R1 was complaining of pain Thursday (4/5) day shift. V9 said she was providing incontinence care and R 1 said her hips were hurting. V9 informed V8 (LPN) of R1's complaints of pain. A review of the Electronic kiosk (daily charting system for certified nurse aide) documents Activities of daily living legend report documents on 4/5/18 at 1120, V9 (CNA) assisted R1 with toilet use. Reviewed R 1's progress notes and no documentation of any pain assessment done on 4/5/18. No documentation noted for R1 on 4/5/18. Reviewed R 1's Physician's progress note dated 4/6/18 at 10:22 AM documents R1 was observed in bed and complained of left calf pain that began last night and got worse. Pain 8/10 localized to calf only, only Tylenol with no relief. R1 is alert and oriented x3, Tylenol for pain management. Reviewed R 1's progress note dated 4/6/18 at 8:02 AM, R 1 is Alert and oriented x3. Complaints of left leg pain 10/10. Reviewed R 1's facility contracted x-ray report dated 4/6/18 at 15:45 documents impression of suspected proximal tibial fracture. Reviewed facility's initial incident report form dated 4/7/18 documents that R1's incident was immediately reported to nurse. Immediate action taken body assessment done, pain medication given, area immobilized. Reviewed R 1's Medication Administration Record [REDACTED]. No record of any pain medication being administered to R1. Reviewed local hospital records documents arrival date 04/06/18 at 23:34 to emergency department. Under triage documents R 1 has no mental status changes. R1 is alert, awake oriented to person, place and time. R1 has some swelling to left lower leg; complains of pain 8/10. On 4/20/18 11:41 AM, V8 (nurse) said R1 was alert and oriented x3. On Friday 4/6/18, a CNA informed her that R1 was complaining of pain, V8 said R1's leg was swollen. V8 explained R1 said her leg had started hurting on Wednesday after she went back to bed. V8 cannot recall if any pain medication was given. V8 explained R1 said as long as she was able to stay still in bed, she did not have any pain and may have refused any pain medication. V8 unable to find completed pain assessment in R1's medical chart. On 4/20/18 at 4:00pm via telephone V15 (Physician) said that he was told by nursing staff at the facility that R1 was not involved in a fall. V15 said he didn't ask R1 what happened when he assessed her on 4/6/218. V15 said he didn't know what type of fracture R1 sustained and said he would have to review R1's clinical record and further discuss R1's occurence. Several attempts were made to speak with V15 again before the exit of 4/27/218 with no response. On 4/25/18 approximately 9:55 AM, V2 (Director of Nursing, DON) said if a resident complains of pain 8-10 is considered moderate pain, the nurse assigned to the resident should administer and document pain medication. a comprehensive pain assessment should be completed and a call placed to the doctor. The nurse is expected to reassess pain after medication given. If Medication Administration Record [REDACTED]. Facility's Pain Management policy dated 4/2017 documents that pain will be monitored daily and effectiveness of intervention will be documented in the medical record. An intensity scale will be utilized to record pain levels prior to and after responses when necessary. Pain will be assessed and documented when warranted by changes in the resident's condition. Subjective pain scale with ratings from 1 to 10 provided documents 0 to 3 minor pain able to adapt to pain, 4 to 7 moderate pain that interferes with many activities, and 8 to 10 severe pain that patient is disabled and unable to function independently. A pain rated 8 documents utterly horrible comparable to child birth or a real bad migraine headache. A pain rated 9 documents excruciating unbearable, pain so intense you cannot tolerate it and demand pain killers. A pain rated 10 documents unimaginable unspeakable pain that is so intense you will go unconscious shortly.

Based on interview and record review the facility failed to provide a policy on reordering medication and failed to administer [MEDICATION NAME] for 1 of 3 R5 residents reviewed for administration and availability of pain medication. This failure resulted in R5 being without opiate pain medication for 2 days resulting in R5 being transferred to the local hospital and being admitted and treated for [REDACTED]. Findings include: A review of R5's clinical record physician order [REDACTED]. According to the controlled drug receipt/disposition form documents R5 had an order for [REDACTED]. According to the disposition form and the Medication Administration Record [REDACTED]. On 11/27/17 at 4:30pm E2 (Director of Nursing) said that her expectation and facility practice is to re-order medication prior to running out of the said medication. During this interview E2 said that the nursing staff should reorder medication 3 to 4 days prior to the medication runs out. According to the facility policy documents the facility should notify the pharmacy by when reordering is necessary. According to the clinical record progress note dated 11/11/2017 8:03pm R5 experienced a change in condition consisting of vomiting and coffee ground emesis and was sent to the local hospital for evaluation. According to the local hospital record dated 11/11/2017 R5 presented to the emergency room with chronic wide spread pain and nausea vomiting, and a history of opioid addiction. According to record R5 was admitted to the local hospital and treated for [REDACTED]. According to [MEDICATION NAME] insert [MEDICATION NAME] is defined as an opioid/narcotic pain medication. [MEDICATION NAME]-release tablets are a strong prescription pain medicine used to treat moderate to severe pain that requires around-the-clock, long-term treatment. When the patient no longer requires therapy with [MEDICATION NAME], use a gradual downward titration of the dose to prevent signs and symptoms of withdrawal in the physically-dependent patient. Do not abruptly discontinue MS Contin.

Based on interview and record review the facility failed to develop a plan of care to prevent a potential tripping hazard of an extended length oxygen tubing for 1 of 3 residents R1 reviewed for fall risk and fall prevention interventions. This failure resulted in R1 getting out of bed walking to the bathroom with her nasal cannula and oxygen tubing connected, falling to the floor sustaining a large hematoma and laceration to the head requiring a repair with staples. Findings include: According to R1's clinical record 9-13-17 3:45am E5 (Certified nurse aide) noticed the call light was on and upon entering R1's room R1 was on the floor and called out for the nurse. The note documents that R1 was face down on the floor, and that R1 was unable to state what happened and denies pain or loss of consciousness, R1 attempted to get up but was encouraged to lay still. On 11/27/17 at 9:30am E17 (nurse) said that on 9-13-17 around 3:30am she heard E5 (Certified nurse aide) call out from R1's room. E17 said she ran to the room and observed R1 lying face down on the floor near the bathroom with a moderate amount of blood on the floor. E17 said because R1 is a dialysis patient she checked the fistula site first. E17 said that she noticed that R1 had matted blood on the side of her head and blood coming from the head. E17 said that she applied ice and pressure, and had asked E4 (nurse) to call 911. E17 said that R1 was slow to respond but eventually did respond and was noted to be alert and oriented. E17 said that she noticed that R1's oxygen tubing was alongside of R1. E17 said that R1 was not tangled in the tubing but it was right alongside of her. E17 said that the tubing was very long so that R1 could go from her bed to the bathroom. On 11/27/17 at 10:00am E5 (Certified Nurse aide) said that on 9-13-17 around 3:15am she left R1 in the bed asleep, and made rounds to other residents rooms. E5 said that around 5 or 10 minutes later she noticed the call light on in R1's room. E5 said that when she went to answer the call light she observed R1 on the floor face down with blood on the floor. E5 said that she called out for help. E5 said that she assisted E17 with R1 who was observed to be alert. E5 said that R1 was unable to say what happened. E5 said that R1 was not tangled up in the oxygen tubing, however said that the oxygen tubing was lying right alongside of R1. E5 said that R1's oxygen tubing was very long, E5 said it allowed R1 to move around the room and go to the bathroom while leaving the oxygen tank at the bedside. E5 said that she can't recall if R1 was wearing the oxygen at the time of the fall, however E5 said that R1 has on the oxygen tubing most of the time. E5 said that R1 didn't pull the call light, but R1's roommate (R6) pulled the call light. On 11/27/17 at 10:20am E4 (Nurse) said on 9/13/17 around 3:30am E5 called out for help and she went into R1's room and observed R1 on the floor face down with blood on the floor. E4 said that E17 and E5 assisted R1. E4 said that R1 was observed to be alert. E4 said that R1 said she didn't know what happened. E4 said that R1 was not tangled in the oxygen tubing, but said that R1 was still wearing her oxygen tubing. E4 said that the nasal cannula was still in R1's nose. E4 said that R1 had very long oxygen tubing which allowed her to go to the bathroom while being able to keep the oxygen tank at the bedside. E4 said that R1 had a large liquid oxygen tank. According to the physical therapy evaluation dated 8/24/17, R1's functional deficits as balance while standing requires handhold support, unable to maintain balance while turning head/trunk. R1 is also documented as requiring contact guard assist for transfer from sitting to standing position, and from standing to seated position. The evaluation also includes noted fall precautions, low endurance, safety precautions, safety awareness; oxygen 2 liter per nasal cannula.R1 is also noted to be high risk for falls. On 11/14/17 at 11:30am E9 (Physical therapy) said that contact guard assist is defined as placing a hand on the back or shoulder to assist with balance while standing or ambulating. E9 also said that because R1 wore oxygen that R1 required someone behind pulling the oxygen tank so that the oxygen tubing doesn't become a tripping hazard. According to R1's clinical record for fall prevention R1 is at risk for falls/accidents related to medical complexities, impaired mobility, and uses a wheel chair for mobility. The plan of care interventions does not include interventions of ensuring R1's oxygen tubing as a potential tripping hazard. According to the falling star initiative policy and procedure dated 4/2017 documents a plan of care will be initiated utilizing fall prevention strategies to reduce or eliminate each residents fall risk. According to the hospital record dated 9/13/17 R1 indicates that R1 said that she was getting up to use the restroom and fell from standing. The record documents that R1 has a large hematoma over the crown on the right side of her head, and treated for [REDACTED].

Based on interview and record review, the facility failed to use two or more staff to safely transfer a resident (R2) and failed to complete a wheelchair assessment (R3) for two of three residents reviewed for falls, in the sample of 21. These failures resulted in R2 sustaining a femur fracture and R3 sustaining an orbital fracture. Findings include: 1. Review of the facility's final incident report of 07/13/2017, notes in part: On 10 July 2017, R2's knee buckled during an assisted transfer from her bed to her wheelchair, she was eased to the floor, landing on her left knee. (Z6) was notified, with orders to obtain an x-ray. Radiology report was positive for fracture, and orders were received to send resident to the hospital for further evaluation. (R2) was admitted with a [DIAGNOSES REDACTED]. Review of R2's medical record (Face Sheet) notes, R2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of R2's care plans notes the following: Problems -Resident is at risk for falls related to poor safety awareness, need for staff to assist with ADLs (Activities of Daily Living) including mobility -Interventions Assist of two staff with all repositioning needs (07/27/2016) MDS (Minimum Data Set) 06/19/2017 -Functional Status Transfer: 3/3 (Extensive assistance/Two+ persons physical assist). 9/13/2017 at 3:53 PM E8 (CNA) stated, she got R2 up from the bed by herself (using a gait belt) to a standing position. R2 complained that her legs hurt and started going down. E8 eased R2 to the floor. 2. Review of R3's medical record (Face Sheet) states, R3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's incident (08/30/2017) report, Brief Description of Incident: (R3) fell from a personal wheelchair brought to the facility by family member. Immediate Action Taken: There was a small laceration above the left eye, pressure was applied to the area. Physician was called, gave orders to transfer to the nearest hospital for further assessment via 911. Resident was transferred to local hospital and admitted to trauma unit for further observation. Facts Determined: Family member wanted resident transferred to a travel wheelchair he brought from home. Family member insisted that the resident's wheelchair cushion be used with the travel wheelchair. The nurse educated family member that the cushion was not appropriate for the travel chair, the family member insisted it be used and despite repeated objections by the nurse that the resident's center of gravity would be changed and she could fall. The family member stated we use this chair all the time with this cushion and there isn't a problem, just get her ready so we can leave. While sitting in the chair, the resident pushed up on the wheelchair arms with her hands and tried to reposition herself, she fell forward and hit her head. (R3) fell because of bilateral lower extremity weakness and having her regular wheelchair cushion used in a travel wheelchair. She lost her center of gravity when she attempted to reposition herself by pushing up on the siderail armrests of the travel wheelchair brought from home by family member and his insistence in using the elevated seat cushion of three inches in the travel wheelchair. Resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 9/19/17 at 9:52 AM E14 (Licensed Practical Nurse), said R2's family member tries to do things he's not supposed to do. She said she told family member that the travel wheelchair was inappropriate for R3 because the arm rests were too short and cushion raised R2 up too high in the travel wheelchair. No wheelchair assessment for travel wheelchair was found.

Based on interview and record review facility failed to follow their safe lifting and movement of residents policy for two residents (R1,R6) of four residents reviewed for transfers. This failure resulted in R1 going to hospital for left humerus fracture and R6 going to the hospital for vaginal laceration. Findings include: R1s' nursing note dated 9-8-13 denotes nurse called into R1s' room to assess open area to buttock, CNA turned R1 on her side and noticed that R1s' left arm was flaccid with swelling. Supervisor, family and doctor called, R1 sent to the hospital. R1s ' hospital record dated 9-8-13 denotes R1 sent from nursing home due to left arm pain and swelling. R1s' hospital X-ray dated 9-8-13 denotes an acute fracture of the proximal and mid shaft distribution of the left humerus, significant displacement is demonstrated. R1s' hospital surgeon date of service 9-9-13 procedure, open reduction internal fixation of the left humerus. R1s ' incident report dated 9-8-13 denotes CNA stated that she transferred R1 without assistance of staff and accidently bumped R1s ' left arm on the wheelchair. E2 (Certified Nurse Aide) stated on 9-12-13 at 2:30 PM, worked on Saturday (9-7-13) 7am-7pm and was not aware R1 was a resident that had to be transferred by mechanical lift/two people. E2 stated used draw sheet and slid R1 from the bed to her chair that day by herself. Record review of E2s ' incident statement signed & dated 9-9-13 denotes " I transfered R1 on Saturday 9-7-13 and mistakenly hit her arm left side, I wasn ' t aware she was a mechanical lift " . E5 (Restorative Nurse) stated on 9-12-13 at 3:50 PM, R1 needed extensive care and staff has to do most of the work for her. E5 stated R1 definitely needed two people for transfer or mechanical lift. R1s ' minimum (MDS) data set [DATE] Section G: Functional Status transfer to or from bed, chair, wheelchair and standing position total dependence two + persons physical assist. E6 (Minimum Data Set Coordinator) stated on 9-12-13 at 3:25 PM, R1 required 2-3 people for transfer from bed to chair. R1s ' care plan dated 7-10-13 states R1 is at risk to fall/injury, has impaired activity of daily living CNA to transfer using mechanical lift. Facility ' s Safe Lifting and Movement of Residents policy states staff will document resident transferring and lifting needs in the care plan. Staff responsible for direct resident care will be trained in the use of manual (gait, transfer belts, lateral boards) and mechanical lifting devices. Facility ' s Lifting Machine, Using a Portable policy denotes the purpose of this procedure is to help lift residents using a manual lifting device. The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure. Z4 (Doctor) stated on 9-17-13 at 11:35 AM, R1 sustained the left humerus fracture from being transferred roughly. Z4 stated R1 required an open internal fixation reduction of the left humerus. Z4 stated the injury could have been avoided if the CNA knew more about R1 and was more experienced in transferring residents. E2s ' employee report dated 9-9-13 denotes, transferred resident without the use of mechanical lift. CNA should have made sure of transfer status of all residents on her assignment. Employee action/discipline: warning. R6s ' incident report dated 9-10-13 states R6 attempted to stand and fell landing straddling the edge of the wheelchair and footrest. R6 sustained a cut to the vaginal area. R6 sent to the hospital for evaluation. Z1 (Doctor) stated on 9-17-13 at 10:55 AM, R6 had to go to the hospital to get the outside of her vagina sutured. Z1 stated when R6 hit the wheelchair she hit the opening of her vagina on the chair which required R6 to be admitted to the hospital for sutures to stop the bleeding. R6s ' hospital record dated 9-10-13 denotes computed tomography abdomen and pelvic impression consistent with peritoneal injury; admitted for vaginal trauma/laceration, sent to operating room. Procedure performed: Perineal laceration repair, findings: large perineal laceration to the vaginal introitus on the external genitalia, labia extending from the vaginal introitus to the perineal area. E9 (Certified Nurse Aide) stated on 9-13-13 at 11:30 AM R6 was in the hallway sitting in her wheelchair then rolled her into the tub room. E9 stated, asked R6 to stand up and R6 stood up on her own and grabbed onto the bar in the washroom with her good hand. E9 stated she pulled off her wet diaper cleaned her and put another diaper on. E9 stated she told R6 to sit down and had one hand on R6s ' waist. E9 stated R6 squatted down too fast and landed on the leg bar of the wheelchair. E9 stated "I helped R6 stand up and noted a lot of blood soaking R6s ' diaper and reported to the nurse". E9 stated was supposed to use gait belt when resident can ' t stand or is really weak on one side. E9 stated she did not use a gait belt for R6 because she was able to stand. R6s ' minimum (MDS) data set [DATE] denotes functional status impairment on one side upper and lower extremity. Moving from seated to standing position not steady, only able to stabilize with human assistance. R6s ' physical therapy note dated 8-16-13, R6 hypertonicity to right lower extremity, discharge summary dated 8-30-13 denotes R6 required minimal assist for transfers. Z2 (Physical Therapy Manger) stated on 9-13-13 at 12:20 PM, R6 required minimal assist for transfer which means somebody has to be holding on to her while they are transferring her. Z2 stated sit to stand and stand to sit is a transfer and staff was instructed to use safe transfer technique-gait belt when transferring R6. E5 (Restorative Nurse) stated on 9-13-13 at 11:50 AM, "R6 can ' t speak and is without function on her right side of her body". E5 stated R6 needed assistance with activities of daily living. E5 stated all staff was in-serviced to use gait belt for all transfers. Review of facility's fall in-service dated 2013, denotes: gait belts should be worn at all times and used when transferring and ambulating. R6s ' care plan dated 8-15-13 denotes R6 is at risk for fall/injury. Has impaired mobility, unsteady gait, and impaired functional ability in transfer. Needs extensive assist in bathing and grooming. Facility's Safe Lifting and Movement of Residents policy denotes, staff will document resident transferring and lifting needs in the care plan. Staff responsible for direct resident care will be trained in the use of manual (gait, transfer belts, lateral boards) and mechanical lifting devices.