Every finding on record at Country Health

Based on interview and record review the facility failed to complete a thorough investigations for allegations of abuse for three (R5, R6, R8) residents out of five residents reviewed for Abuse in a sample list of nine residents.Findings include:1. R5 and R6's Final Report to the State Agency dated 4/14/26 documents R5 and R6 were involved in a physical altercation on 4/12/26. This same report and facility investigation file does not include any statements from other cognitively intact residents or any staff member with the exception of V8 CNA who witnessed a portion of the incident. On 5/23/26 at 11:40 AM V6 LPN stated she did not witness the incident between R5 and R6. V6 LPN stated V8 CNA was the one who reported this to V6 and as far as V6 knew, V8 CNA was the only person who actually witnessed anything. V6 LPN stated no one ever asked her what happened or asked her to complete a witness statement. V6 LPN stated she thought that was because she did not witness anything. V6 LPN stated she did document this incident in the progress notes so that if anyone had questions, they could refer to the note.On 5/24/26 at 8:35 AM V1 Administrator stated she only interviewed V8 Certified Nurse Aide (CNA). V1 stated she did not interview any residents other than R5 and R6 and/or staff regarding the R5 to R6 incident which occurred on 4/12/26. V1 Administrator stated a full investigation should have been completed due to R5 did have a history of behaviors with staff and other residents. V1 stated V8 CNA reported the R5 to R6 altercation to V6 LPN.On 5/24/26 at 8:55 AM V8 CNA stated she was exiting the public restroom on the South Hall when she saw R5 and R6 hitting each other at the opposite end of the hall. V8 stated she ran towards both R5 and R6 and separated the two residents. V8 stated she then called for V6 LPN who also then came to assist. V8 stated V6 could not have seen anything due to her location on another hall (between the long hall and the pod on south). V8 stated this happened about 12:15-12:30 right after lunch. V8 CNA stated R5 and R6 had already started fighting when they entered the hallway. V8 CNA stated other staff or residents may have seen R5 and/or R6 shortly before that since the residents were finishing their lunch time and there is supposed to be a staff member present for all meals. 2. R8's Initial report to the State Agency dated 5/24/26 documents V26 Certified Nurse Aide (CNA) 'somewhat forcefully' grabbed R8's wrist on 5/12/26.On 5/23/26 at 9:22 AM R8 stated a staff member (V26) Agency Certified Nurse Aide (CNA) was assisting her from the toilet back to her wheelchair. R8 stated V26 held onto her wrist with a 'bear grip'. R8 stated 'it really hurt' and left a bruise for days. On 5/23/26 at 9:30 AM V1 stated she did not know anything about R8's bruise caused by V26 CNA. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise, so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26). V2 DON stated he did not speak with V26 CNA, any of the other staff or other cognitively intact residents. V2 DON stated any time a staff member causes a bruise, that incident should be fully investigated and reported to the State AgencyOn 5/24/26 at 8:30 AM V1 Administrator stated R8's bruise should have been reported as an allegation of physical abuse. V1 stated the incident should have been initially reported to the State Agency, then V26 CNA should have been removed from resident areas and suspended pending an investigation. V1 stated a full investigation should have been completed and then a Final report to the State Agency should have been completed with the findings. The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriate of resident property, injuries of unknown origin and social media revised January 29, 2026. After an initial report of suspected abuse or neglect is sent to IDPH, the Administrator or designee shall investigate all alleged incidents of abuse or neglect. This same policy documents the investigation shall include interviews with all involved parties and potential witnesses. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes.

Based on interview and record review the facility failed to report an allegation of physical abuse from a staff member to one (R8) resident to the State Agency and failed to report an allegation of resident (R6) to resident (R9) verbal abuse to the Abuse Coordinator out of five residents reviewed for Abuse in a sample list of nine residents. Findings include:1. R8's initial report to the State Agency dated 5/24/26 documents on 5/12/26 V26 Certified Nurse Aide (CNA) grabbed R8's wrist 'somewhat forcefully' causing a bruise. The facility is not able to provide documentation this incident was reported to the State Agency prior to 5/24/26. The facility daily staffing sheets dated 5/12/26 documents V26 CNA was assigned to R8 to provide cares. The facility staffing sheets did not show that V26 CNA worked any shift after 5/12/26. On 5/23/26 at 9:22 AM R8 stated V2 Director of Nurses (DON) asked me about my bruise the day after it happened. R8 stated V26 CNA had a 'bear grip' on my wrist. R8 stated she did not think V26 CNA meant to hurt R8 but was 'very rough' with R8. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26) improperly transferred R8 from her toilet to her wheelchair causing a bruise on R8's Right Forearm. V2 stated he did not report the bruise caused by V26 CNA and should have. V2 DON stated any time a staff member causes a bruise, that incident should be fully investigated and reported to the State Agency. On 5/24/26 at 8:30 AM V1 Administrator stated R8's bruise should have been reported as an allegation of physical abuse. V1 stated the incident should have been initially reported to the State Agency, then V26 CNA should have been removed from resident areas and suspended pending an investigation. V1 stated a full investigation should have been completed and then a Final report to the State Agency should have been completed with the findings. V1 Administrator stated she was not aware of this incident until 5/24/26. 2. R6 and R9's combined initial report to the State Agency dated 5/24/26 documents R6 was verbally aggressive to R9 on 5/17/26.The facility is not able to provide documentation this incident was reported to the State Agency prior to 5/24/26. On 5/24/26 at 12:50 PM V32 Licensed Practical Nurse (LPN) stated she witnessed R6 verbally abuse R9 on 5/17/26 at 7:00 AM but did not report it. V32 LPN stated she did write a nurse progress note about R6's behavior and thought management reviewed the progress notes and would see it. V32 LPN stated she should have reported R6's verbal abuse towards R9 directly to V1 Administrator right when it happened.On 5/24/26 at 2:05 PM V1 Administrator stated V32 LPN should have reported the incident between R6 and R9 on 5/17/26 immediately to V1 Abuse Coordinator or her Designee, V2 Director of Nurses (DON). V1 Administrator stated a resident does not have to use profanity to verbally abuse another resident. V1 stated she would expect staff to make a direct phone call to V1 and/or V2 to report an allegation of abuse instead of only making a progress note. V1 Administrator stated she was not aware of this incident until 5/24/26.The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriate of resident property, injuries of unknown origin and social media revised January 29, 2026. All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. If the incident involves alleged abuse, neglect, or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with initial notice of the alleged abuse, neglect, or incident of unknown origin via the OHCR Portal or by emailing or telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known.

Based on interview and record review the facility failed to ensure the resident's right to be free from verbal abuse for one (R9) resident by another resident (R6) out of five residents reviewed for Abuse in a sample list of nine residents.Findings include:R9's Electronic Medical Record (EMR) documents medical diagnoses of Spinal Stenosis, Chronic Obstructive Pulmonary Disease (COPD), Unsteadiness on Feet, Dementia, Scoliosis, Abnormalities of Gait and Mobility, Muscle Weakness, and Abnormal Posture.R9's Minimum Data Set (MDS), dated [DATE], documents R9 as moderately cognitively impaired. This same MDS documents R9 as dependent on staff for wheelchair mobility and requiring maximum assistance for transfers.R6's Electronic Medical Record (EMR) documents medical diagnoses of Dementia, Anxiety Disorder, Atrial Fibrillation, and Heart Failure.R6's Minimum Data Set (MDS), dated [DATE], documents R6 as moderately cognitively impaired.R6's Nurse Progress Note, dated 5/17/26 at 2:34 PM, documents that R6 was verbally aggressive toward R9. This same note documents that V32, Licensed Practical Nurse (LPN), instructed R6 not to use inappropriate language toward R9. The note further documents that R9 was moved to allow R6 to pass by, as R6 continued to make inappropriate comments toward R9.On 5/24/26 at 12:45 PM, V32, Licensed Practical Nurse (LPN), stated that on 5/17/26 at 7:00 AM, she was passing medications in the hallway. V32 LPN stated that R9 was sitting in his wheelchair in the middle of the hallway when R6 attempted to pass through. V32 LPN stated that R6 began yelling and cursing at R9, stating, Move your fat a** (expletive), Get the hell out of my way, stupid, and You are so dumb you don't know what to do. V32 LPN stated that R9 began moving out of R6's way so R6 could pass through, and R6 again stated to R9, You are so lazy and stupid. V32 stated that R6 had made multiple similar comments to other residents and that it was time someone documented it so that something can be done. V32 LPN stated that R6 was verbally abusive toward R9 on 5/17/26.On 5/24/26 at 2:30 PM, R9 and V33 (R9's family member) were present in R9's room. R9 was sitting in a wheelchair. V33 stated that V2, Director of Nursing (DON), had just informed her and R9 of R6 yelling at (R9). V33 stated, Of course we do not want anyone yelling at (R9), but I don't think (R9) would be distraught by it either. V33 stated that R9 has Dementia and has declined over the past two years, so R9 probably didn't know what was going on. V33 further stated that R9 would not have liked being yelled at but would not have responded to it either.On 5/26/26 at 11:30 AM, V1 Administrator stated that V32 LPN should have notified her immediately of the incident between R6 and R9. V1 Administrator confirmed that R6's use of derogatory language and insults toward R9 constituted verbal abuse.The facility policy titled Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media, revised January 29, 2026, states that all residents have the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; neglect; misappropriation of property; and exploitation. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse includes the deprivation by an individual, including a caregiver, of goods or services necessary to attain or maintain physical, mental, or psychosocial well-being. Instances of abuse, regardless of a resident's mental or physical condition, can result in physical harm, pain, or mental anguish. Abuse may be verbal, sexual, physical, or mental, including abuse facilitated or enabled through the use of technology or social media. Verbal abuse is defined as the use by an employee or agent of oral, written, or gestured language that includes disparaging or derogatory terms directed toward a resident, or used within the resident's hearing or sight, regardless of the resident's age, ability to comprehend, or disability.

Based on observation, interview and record review the facility failed to provide timely incontinence care and failed to prevent cross contamination during incontinence care for one (R2) resident out of three residents reviewed for Activities of Daily Living (ADL) in a sample list of nine residents. Findings include:R2's Electronic Medical Record (EMR) documents medical diagnoses as Unsteady on Feet, Recurrent dislocation of Right Shoulder, Congestive Heart Failure, Dementia, Atrial Fibrillation, Type II Diabetes mellitus, Muscle Wasting and Atrophy and Generalized Weakness.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 is dependent on staff for personal hygiene, toileting and requires maximum assistance for transfers. On 5/23/26 continual observations were made from 8:45 AM to 10:53 AM of R2 when V14 and V23 Certified Nurse Aide (CNA) assisted R2 to her room. R2 was sitting in her wheelchair facing the wall sized window in the resident common area across from the nurses station the entire time with no staff assistance of any kind.On 5/23/26 at 10:53 AM V14 and V23 Certified Nurse Aide (CNA) transferred R2 into her bed using a total body mechanical lift and then provided incontinence care. V14 and V23 CNA's did not change their gloves or perform hand hygiene throughout the entire process. R2 was incontinent of urine and bowel. R2's bilateral Ischial Tuberosities and Coccyx had baseball sized dark reddened areas. R2's buttocks showed multiple red lines/wrinkled areas from sitting on the total body mechanical lift sling for an extended period of time. R2's odor has an extremely foul odor that permeated the room. On 5/23/26 at 11:10 AM V14 Certified Nurse Aide (CNA) stated she provided incontinence care at 7:30 AM and then assisted R2 to the dining room for breakfast. V14 stated R2 had not been assisted with any cares since 7:30 AM. V14 CNA stated she should have provided incontinence care every two hours but got busy and did not have time to check on R2. V14 CNA stated R2's urine has had a strong foul odor for a long time. On 5/24/26 at 3:20 PM V2 Director of Nurses (DON) stated the facility expectation is to follow the standard of practice for incontinence care. V2 DON stated all residents who are not able to voice their toileting needs and who are incontinent of bladder and bowel should be provided incontinence care every two hours and as needed. V2 DON stated the staff would not know if the resident is incontinent or not if the staff are not checking them. V2 DON stated even if the resident is continent at the two hour mark the staff would still need to reposition those residents to help reduce the risk of pressure ulcers from sitting in the same place too long.

Based on observation, interview and record review the facility failed to provide a safe transfer for one (R8) resident causing a bruise out of five residents reviewed for Abuse in a sample list of nine residents.Findings include:R8's Electronic Medical Record (EMR) documents medical diagnoses as Heart Failure, Osteoporosis, Radiculopathy Cervical Region, Repeated Falls, Muscle Weakness, Atrophy, Difficulty in Walking, Anxiety, Unsteady on Feet, Abnormalities of Gait and Mobility, Abnormal Posture and Bone Density disorder. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as moderately cognitively impaired. This same MDS documents R8 requires moderate assistance with transferring on and off of toilet and is dependent on staff for assistance with toileting personal hygiene, bathing, and dressing.R8's Care Plan intervention dated 3/11/25 instructs staff to utilize gait belt for one assist transfers. This same care plan documents an intervention dated 7/1/2025 instruct staff to encourage R8 to wear protective sleeves for skin protection.On 5/23/26 at 9:20 AM R8 was sitting in her wheelchair in her room. R8 was not wearing protective sleeves on her arms. On 5/23/26 at 9:22 AM R8 stated a staff member (V26) Agency Certified Nurse Aide (CNA) was assisting her from the toilet back to her wheelchair. R8 stated V26 CNA did not use a gait belt during the transfer. R8 stated all the other girls use one so I don't know why (V26) didn't. R8 stated V26 CNA had a 'bear grip' on her wrist. R8 stated she did not think V26 CNA meant to hurt R8 but was 'very rough' with R8. R8 stated since V26 did not use a gait belt, V26 held onto her wrist with a 'bear grip'. R8 stated 'it really hurt' and left a bruise for days. On 5/23/26 at 10:00 AM V2 Director of Nurses (DON) stated unknown staff told him that R8 had a bruise so he did speak with R8 on 5/13/26. V2 DON stated the incident occurred on 5/12/26 when an agency CNA (V26) improperly transferred R8 from her toilet to her wheelchair causing a bruise on R8's Right Forearm. V2 stated V26 CNA did not use a gait belt when transferring R8 and did not ensure R8 had her protective sleeves on to help reduce the risk of injury to R8's skin. On 5/24/26 at 9:54 AM attempted to contact V26 Agency CNA with no success. The facility policy titled Safe Resident Handling Program Policy revised March 18, 2018 documents gait belt usage is mandatory for all resident handling with the exception of mechanical lift use, bed mobility & medical contraindications. The gait belt will be considered a part of the certified nursing assistant's uniform.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two (R4 and R6) of three residents reviewed for resident-to-resident physical contact on a sample list of three residents. The facility failed to assess, care plan, and implement effective interventions following repeated altercations. This failure resulted in a physical injury (skin tear) to R6, with actual harm.Findings include:Review of the facility's Abuse Policy, revised 01/29/2026, documented that all residents have the right to be free from verbal, sexual, physical, and mental abuse. The policy further required that appropriate interventions be implemented and included in the resident's care plan, updated with changes in condition, and communicated to direct care staff.R4's Review of the Electronic Health Record (EHR) revealed R4 had diagnoses including Frontotemporal Neurocognitive Disorder, Dementia with Agitation, Mood Disorder, and anxiety disorder.R4's care plan, initiated 01/20/2026, identified behaviors including agitation, hallucinations, exit-seeking, and entering other residents' rooms. Interventions included monitoring behaviors and administering psychotropic medications; however, the care plan lacked specific, individualized interventions to prevent resident-to-resident altercations.Record review revealed a pattern of ongoing aggressive and intrusive behaviors:On 02/01/2026, R4 hit another resident in the dining room.On 03/26/2026, R4 raised a fork toward staff in a stabbing motion.On 04/20/2026, R4 made verbal threats toward staff.On 04/12/2026 at 12:25 PM, R4 was observed swatting at R6 in the hallway. Documentation indicated both residents were actively striking one another. R6 sustained a skin tear three centimeters by one centimeter by five centimeters to the right wrist.Review of the record failed to show the facility implemented effective or consistent interventions following prior incidents to prevent recurrence, such as increased supervision, environmental modifications, or individualized behavioral strategies.On 04/20/2026 at 9:05 AM, R4 was moving rapidly throughout the hallways in a wheelchair and reaching toward others, indicating ongoing intrusive behaviors without staff intervention.On 04/21/2026 at 10:44AM, V10 (R4's) Power of Attorney (POA) revealed a history of behavioral issues requiring additional support and services.On 04/21/2026 at 1:00PM, V11 Clinical Director of Operations confirmed the facility does not provide behavioral services and relies on hospital transfers when behaviors escalate.R6 had diagnoses including Dementia, Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, Anxiety Disorder, Major Depressive Disorder, Repeated Falls, and multiple chronic medical conditions. The care plan identified behaviors including agitation, yelling, resistiveness to care, and potential for making false allegations. Interventions included monitoring behaviors, identifying triggers, and providing redirection.On 02/01/2026, documentation indicated R6 was involved in an altercation with R6 in which both residents engaged in physical contact. R6 sustained a skin tear to the right wrist.Record review failed to show evidence of an abuse-specific assessment or a comprehensive post-incident skin/body assessment following the altercation. There was no documented evidence the facility completed a full assessment to identify the extent of injury or potential additional injuries. Further review revealed the facility failed to revise the care plan to address the risk of continued resident-to-resident altercations or implement individualized interventions following the incident.Record review identified repeated altercations between R4 and R6 from 02/01/2026 through 03/14/2026, indicating an ongoing and unaddressed risk.On 04/21/2026 at 11:00 AM, R6 was observed sitting alone at a dining table.On 04/21/2026 at 11:05 AM, V2 Certified Nursing Assistant stated R4 sits alone due to behaviors of belittling other residents and calling them names, and that behaviors are reported to nursing; however, no evidence was provided that effective interventions were implemented to prevent further altercations.On 04/21/2026 at 12:05 PM, V6 Licensed Practical Nurse stated that allegations of abuse are reported to administration and indicated the behaviors were related to resident diagnoses, suggesting normalization of aggressive behaviors rather than implementation of preventative measures.The facility failed to:Implement its own Abuse Policy requiring interventions and care plan updatesIdentify and address a pattern of aggressive behaviorsProvide adequate supervision and preventative interventionsConduct and document a thorough post-incident assessmentRevise care plans following known altercations These failures resulted in repeated resident-to-resident altercations, including the incident on 02/01/2026, which caused actual harm (skin tear) to R6. The facility's failure to intervene after the initial incident allowed the risk of continued harm to persist.

Based on observation, interview, and record review, the facility failed to ensure appropriate behavioral health services were provided for two (R4 and R6) of three residents reviewed for behavioral concerns, when the facility failed to implement effective behavioral health interventions, failed to provide coordinated behavioral health services, and failed to ensure adequate assessment and communication regarding psychotropic medication management. These failures resulted in continued unsafe behaviors and a resident-to-resident physical altercation that caused actual harm (skin tear) to R6.Findings Include:Facility has no Policy on Behavioral ServicesReview of the Electronic Health Record (EHR) revealed R4 had diagnoses including Frontotemporal Neurocognitive Disorder, Dementia with Agitation, Mood Disorder, and Anxiety Disorder.R6's EHR revealed R6 had diagnoses including Dementia, Anxiety Disorder, Major Depressive Disorder, and multiple chronic medical conditions affecting overall health status.Both residents had documented behavioral concerns requiring monitoring and intervention.R4's care plan, initiated 01/20/2026, identified behaviors including agitation, hallucinations, exit-seeking, and intrusive behaviors toward other residents. Interventions included monitoring behaviors and administering psychotropic medications; however, the care plan did not include an effective, individualized behavioral health treatment plan or structured behavioral health services.Record review revealed a pattern of escalating behaviors:On 02/01/2026, R4 hit another resident in the dining room.On 03/26/2026, R4 displayed aggressive behavior toward staff.On 04/20/2026, R4 made verbal threats toward staff.On 04/12/2026, R4 engaged in a physical altercation with R6.On 04/12/2026 at 12:25 PM, R4 was observed swatting at R6 in the hallway, with both residents actively striking one another. R6 sustained a skin tear to the right wrist, resulting in actual harm.Record review indicated R4 was undergoing a gradual dose reduction (GDR) of psychotropic medications. Interview with the V10 (R4's) Power of Attorney (POA) revealed V10 did not understand why medications were being reduced and stated the facility told V10 it was due to state law, without further clinical explanation or education. There was no evidence that the facility provided adequate education or individualized clinical justification to V10 POA regarding medication changes in relation to behavioral symptoms.R6 had documented behaviors including agitation, yelling, resistiveness to care, and emotional instability. The care plan included general interventions such as monitoring behaviors, identifying triggers, and redirection.However, record review failed to show evidence of effective behavioral health services, such as psychiatric consultation follow-up, structured behavioral intervention planning, or individualized behavioral support beyond routine care measures.There was no evidence that R6 received behavioral health services to address risk factors related to repeated exposure to aggressive residents or to reduce vulnerability in shared environments.On 04/21/2026 at 1:00PM, V11 Clinical Director of Operations confirmed the facility does not provide behavioral health services on-site and relies on hospital transfers when behaviors escalate. No evidence was provided of ongoing behavioral health specialist involvement, behavioral programming, or structured interdisciplinary behavioral care planning.On 04/20/2026 at 9:05 AM, R4 was moving rapidly through hallways in a wheelchair and reaching toward others, demonstrating ongoing behavioral instability without effective intervention.The facility failed to:Provide or coordinate behavioral health services for residents with known behavioral symptoms.Develop and implement effective, individualized behavioral intervention plans.Ensure ongoing behavioral assessment and monitoring for both residents.Provide appropriate education and clinical justification to the POA regarding psychotropic medication reductions.Implement protective behavioral strategies to prevent resident-to-resident altercations.The lack of behavioral health services, ineffective behavioral interventions, and inadequate psychotropic medication management resulted in continued unsafe behaviors by R4 and increased vulnerability for R6. These failures contributed to a resident-to-resident physical altercation that caused actual harm (skin tear) to R6 and placed other residents at risk for harm.

Based on record review, observations, and staff interviews, the facility failed to ensure physician-ordered direction and care planning for an indwelling urinary catheter and failed to maintain an accurate and updated care plan reflecting the resident's current clinical condition and skin integrity needs. This deficient practice affected one resident (R1) of three residents on sampled list reviewed.Findings Include: R1 was admitted to the facility on [DATE]. R1's diagnoses include Malignant Neoplasm of the Colon, Malignant Neoplasm of the Breast, Chronic Diastolic Heart Failure, Hypertension, Type 2 Diabetes Mellitus, Coronary Artery Disease, Acute Kidney Failure, Neuromuscular Dysfunction of the Bladder, Generalized Weakness, Muscle Wasting and Atrophy, and is receiving hospice/palliative care services. The admission assessment documented an indwelling urinary catheter (16 French) that was patent; however, the electronic health record and staff interviews revealed there was no physician order for catheter placement, maintenance, or indication for ongoing use, and no corresponding care plan interventions addressing catheter management or monitoring.The resident also presented with multiple skin integrity issues on admission, including a surgical wound to the right breast mastectomy site, moisture-associated skin damage to the buttocks measuring 10 cm (centimeters) by 12 cm, and moisture-associated skin damage to the labia, in addition to other areas of skin concern. Although the care plan identified the resident is at risk for impaired skin integrity related to diabetes and muscle wasting, it was not updated to reflect current wound status or a suspected in-house acquired pressure injury to the left thigh.On 4/20/2026 at 8:45AM, R1 was observed lying in R1's bed reading a book. R1, who is cognitively intact stated that R1 had a catheter when being admitted to the facility and every time a Certified Nursing Assistants would reposition R1 the plastic part on the catheter would have pressure on it and it would hurt. R1 stated R1 told many Certified Nursing Assistants that it was hurting, but nobody looked at the catheter tubing to see what was hurting. R1 stated that when V8 Registered Nurse/Wound Nurse looked on 4/9/26, there was an open wound underneath the catheter tubing. R1 stated V8 Registered Nurse/Wound Nurse cleaned the wound which made it feel better and less painful, but R1 was going to see the wound doctor during their rounds. R1 stated nobody had changed the catheter since being admitted into the facility, but the Certified Nursing Assistants have emptied out the catheter bag daily. On 04/20/2026 at 12:40 PM, V6 Registered Nurse stated that R1 had a catheter since admission and confirmed there were no physician orders for catheter use and no care plan interventions related to the catheter.On 04/20/2026 at 12:46 PM, V7 Licensed Practical Nurse confirmed the resident had a catheter but was unable to determine when it was placed and further confirmed there were no physician orders or care plan interventions in the electronic medical record addressing catheter care.On 04/20/2026 at 12:50 PM, V8 Registered Nurse/Wound Nurse stated V8 had not been informed of the left thigh wound until 4/9/26 and identified it as a potential pressure injury acquired in-house and confirmed the resident's care plan had not been updated to reflect current skin conditions or interventions. V8 further confirmed that updates were needed to ensure the care plan reflected current physician orders and wound management needs.The facility failed to ensure coordination of care, timely care plan updates, and implementation of physician-ordered interventions for a resident with complex medical conditions and active skin integrity issues, resulting in noncompliance.

Based on interview and record review, the facility failed to ensure pain medication was administered as ordered for one (R6) of three residents reviewed for medication administration in the sample of 23.Findings include:On 12/11/25 at 10:05 AM R6 stated that in the summer V17 Nurse Practitioner increased R6's pain medication. R6 stated that for a week, R6 was given the original dose and not the higher dose. R6 stated that V2 Director of Nursing did inform R6 that for a week R6 was given the lower dose and not the new prescribed dose.On 12/11/25 at 1:06 PM V2 Director of Nursing stated that on 7/11/25 R6's Hydrocodone-Acetaminophen was increased from 5 milligrams to 7.5 milligrams. V2 stated that on 7/19/25 V16 Previous Agency Licensed Practical Nurse informed V2 that R6 was receiving the wrong dose of Hydrocodone-Acetaminophen. V2 stated that staff did not remove and destroy the Hydrocodone-Acetaminophen 5-325 milligrams card, they just placed the new Hydrocodone-Acetaminophen 7.5-325 milligrams card behind it and continued to administer the 5-325 milligrams instead of reading the order and card and administering the prescribed 7.5-325 milligram dose. V2 stated that a Medication Error Report was completed on 7/19/25, and the 5-325 milligrams of remaining medications were destroyed per protocol. R6's Physicians Order Sheet dated 7/1/25 at 1:50 PM documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give one tablet by mouth every six hours as needed for pain. Discontinued on 7/11/25 R6's Physicians Order Sheet dated 7/11/25 at 1:50 PM documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 milligrams, give one tablet by mouth every six hours as needed for pain. R6's Medication Administration Record dated 7/11/25 to 7/19/25 documents R6 received Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams on 7/11, 7/12, two doses on 7/13, 7/14, two doses on 7/15, two doses on 7/16, 7/17 and 7/18/25. R6's Controlled Drug Receipt Record documents R6 received Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams on 7/11, 7/12, two doses on 7/13, 7/14, two doses on 7/15, two doses on 7/16, 7/17 and 7/18/25. V16's Medication Error Report dated 7/19/25 documents R6's Hydrocodone-Acetaminophen 5-325 milligrams was changed to Hydrocodone-Acetaminophen 7.5-325 milligrams. Type of Error (s): Wrong dose. Person Making error: Floor staff from 7/11/25-7/18/25. The Facility's Medication Administration Policy not dated documents: Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It's the policy of this facility to accurately administer medication following physician's orders.

Based on observation, interview, and record review the facility failed to implement interventions to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure caused R1 to fall sustaining an acute nasal Fracture and a laceration to (R1's) nose requiring five sutures to close.Findings Include:R1's Care Plan updated 10/14/25 includes the following diagnoses: Osteoarthritis, Heart Disease, Lumbar Disc Displacement, Anxiety, Vertigo, Repeated Falls, Glaucoma, Type II Diabetes, Difficulty in Walking, and Psychotic Disturbance with Hallucinations.R1 Fall Risk assessment dated [DATE] document R1 as being at high risk for falls and having a recent history of falls. R1 has current physician's orders for the following narcotics and psychotropic medications: Haldol (Antipsychotic) one mg (Milligram) every eight hours as needed, Dilaudid (Narcotic) two mg every four hours as needed, and Fentanyl (narcotic) transdermal patch 50mcg/Hr (Microgram/Hour). Change patch every 72 hours. All these medications list an increased risk for falls as a side effect in manufacturer's inserts. R1s Fall Incident Report and progress notes dated10/4/25 at 7:10AM document R1 was found on the floor while alone in R1's room. R1's emergency room report dated 10/4/25 at 9:05AM documents R1 required five sutures to repair the laceration on R1s nose resulting from the fall at the nursing home and sustained an acute nasal bone fracture. On 10/21/25 at 10:41AM, V3 Certified Nurse's Aide (CNA) verified V3 was the first staff to respond to R1 on 10/4/25. V3 stated I got report on 10/4/25 from an agency CNA who told me (R1) had been restless during the night, but she was now asleep in her room. A little later I heard (R1) call out and went right to (R1's) room. There were no fall mats on the floor. The bed was not in the low position. The nightstand was between the wall and the bed on (R1's) right side. R1 was under the bed from the waist down. The nightstand and the bed were covered in blood. I called and V4, Certified Nurse's Aide (CNA) came into the room with the nurse. We got (R1) out from under the bed and put her on the bed. The nurse cleaned (R1's) face and found the big cut on her nose. (R1) was then sent out to the emergency room and came back with bruises and stitches. On 10/21/25 at 10:45AM, V4 CNA stated I came to (R1's) room with (V6), Licensed Practical Nurse (LPN) when I heard (V3) calling for help. (R1) is a high fall risk, but the fall mats were not in place, and the bed was not low, because (R1) had her legs and hip all the way under the bed between the wall and the bed. The nightstand on the side (R1) fell was covered with blood. We helped the nurse clean up (R1) and the nurse sent (R1) out to the hospital to get stiches. R1 was observed on 10/20/25 at 1:35PM lying in her bed. The bed was not in the lowest position. V2 Director of Nursing verified the bed was not in the lowest position. V2 lowered the bed to its lowest position. V2 verified if the bed had been in the lowest position at the time of the 10/4/25 fall it would not have been possible for R1 to have gotten her lower half under the bed as the space is too small between the bed and the floor.

Based on observation, interview, and record review the facility failed to ensure care plans were comprehensive to include medications, diagnoses, behaviors, accidents/injuries, and incontinence for three of 18 residents (R6, R8, R45) reviewed for care plans in the sample list of 31. The facility's Care Plan policy dated November 2017 documents A Comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. 1.) On 09/21/2025 at 10:32 AM R6 stated R6 used an electric wheelchair up until about three weeks ago when she hit her right leg on the bed frame causing a hematoma that ended up having to be lanced at the hospital. On 9/22/25 at 10:20 AM R6 stated R6 was given enemas while in the hospital and the staff there rubbed R6's buttocks very hard which made the wounds worse/raw. R6 confirmed R6 requires staff to provide R6's incontinence care. On 9/21/25 at 11:51 AM V19 Wound Nurse and V7 Licensed Practical Nurse administered R6's right lower leg wound treatment. R6's wound was superficial, wound bed was pink/red and moist, and was almost the entire length of R6's calf. On 9/22/25 at 10:00AM V16 Registered Nurse administered wound treatment to R6's buttocks and reapplied R6's incontinence brief. R6 had raw areas to inner buttocks, with two small areas that were bleeding. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact, always incontinent of bowel and bladder, and requires dependence on staff for toileting. R6's Physician Order dated 9/20/25 documents to clean Moisture Associated Skin Damage (MASD) to bilateral buttocks with soap and water, pat area dry, skin protectant to peri wound, apply calcium alginate to wound and cover with hydrocolloid dressing. R6's Nursing Note dated 8/3/2025 documents at 7:00 PM R6 somehow managed to pinch her leg between the wheelchair and her bed while alone in her room. At 7:30 PM there was a large bump, similar to a blood blister, that measured approximately 3 inches by 2 inches. At 9:00 PM the bump on R6's leg was slightly larger and measured 9 centimeters by 5.5 centimeters. R6's active care plan does not include problem, goals, and interventions to address R6's incontinence and R6's accident/injury with the electric wheelchair. On 9/23/25 at 2:20 PM V19 stated V19 entered MASD and surgical wound on R6's care plan. V19 and V4 MDS Coordinator confirmed R6's care plan does not include problem, goals, and interventions for R6's incontinence and accident/injury. 2.) R8's September 2025 Medication Administration Record documents R8 takes Tramadol (opioid) 50 milligrams by mouth twice daily since 2/5/25, MiraLAX 17 grams every other day, and R8 was given Milk of Magnesia on 9/11/25. R8's active care plan does not include problem, goal, and intervention for opioid use, including risk for constipation. On 9/23/25 at 2:20 PM V4 confirmed R8's care plan does not address opioid use and risk for constipation. 3.) R45's active diagnosis list includes Dementia with Agitation as of 8/15/25. R45's Nursing Notes document between 2/5/25 and 9/21/25 R45 had episodes of behaviors including refusing medications and meals, wandering the facility, forgetting the location of her room, and being aggressive and angry towards staff. R45's active care plan does not include problem, goals, and interventions to address R45's Dementia and related behaviors. On 9/23/25 at 2:15 PM V15 Social Services Director stated V15 is responsible for updating behaviors on the care plan. V15 Confirmed R45's care plan did not address Dementia and related behaviors. V15 stated V15 just updated R45's care plan to include this.

Based on interview and record review the facility failed to ensure a resident's right to dignity while dining for R20, and by staff talking on cell phones during resident care for R8, R43, and R58. These failures affected four out of 29 residents (R20, R8, R43, and R58) reviewed for dignified care on the sample list of 31. Findings include:1.) R20's current diagnosis list documents the following diagnoses: Pain in right shoulder; Poly-osteoarthritis, unspecified; Other injury of unspecified body region (unidentified-R20 does have a left-hand amputation noted on observation below); Alzheimer's disease, unspecified; Personal history of other diseases of the circulatory system; Weakness; and [NAME] syndrome (a rare neurological syndrome that affects the eye and surrounding area on one side of the face).R20's current Physician Order Sheet documents the following: regular diet, regular texture, thin-consistency liquids.R20's Minimum Data Set (MDS) dated [DATE] documents R20 has severe cognitive impairment and requires: Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittently.The same MDS documents R20 requires: Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). Partial/moderate assistance - helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.R20's Care Plan dated 6/27/25 documents R20 is at risk for altered nutrition and self-feeds with cueing in the assisted dining room for supervision with meals.On 9/21/25 between 12:10 p.m. and 12:20 p.m., R20 sat in the resident feeding-assistance dining room, in a wheelchair, feeding herself with her right hand. R20's left hand was amputated above the wrist. The wheelchair was locked. The armrests of the wheelchair were approximately one foot from the table. There were no staff members seated at the half-moon-shaped feeding-assistance table. Two cognitively impaired residents were seated at the same table eating.R20 had a regular plate and regular tableware, without any modification device to promote successful self-feeding. R20's plate contained a regular diet consisting of pork loin pieces, rice, and spinach greens, and there was an empty, regular, unlidded plastic beverage glass. R20's right hand and fingers were covered with rice and spinach. She did not receive physical or verbal assistance from staff, though several unidentified staff members intermittently walked by her.R20 had rice and spinach on her bilateral cheeks and multiple grains of rice stuck to and dangling from the tip of her nose. The tabletop surrounding her regular plate had copious amounts of food that extended approximately six inches around the outer edge of the plate. The plate was approximately seventy-five percent emptied.The thigh area of R20's slacks was smothered in rice pieces, greens, and pork pieces, which extended to the seat of her wheelchair. R20's clothing protector had a trail of food approximately eight inches wide, extending from the neckline over her chest and down to her abdomen and slacks. There was spilled clear fluid and food around and under her wheelchair on the floor.On 9/21/25 at 12:21 p.m., this surveyor asked V4, Restorative/MDS Licensed Practical Nurse (LPN), if R20 was supposed to be provided assistance with dining. V4 stated, No, she can eat by herself. She is in the resident assistive dining room for supervision only. It doesn't look like she got much supervision today, by the way her clothes are covered in food. V4 then stated, (R20) does not use any assistive devices. It would probably benefit her to have a plate guard or something to prevent all the mess. I wouldn't want to sit like that.V4 then walked over to R20's chair and asked R20 if she could wipe her right hand off. R20 raised her hand but did not talk. V4 continued to clean R20's face and clothes, then assisted R20 out of the dining room.On 9/21/25 at 12:25 p.m., V5, Certified Nursing Assistant (CNA), stated R20 does not get assistance with dining and that She pushes our hand away. V5 also stated, Yes, that is a dignity issue-to be covered in food like that.On 9/21/25 at 12:40 p.m., V4, LPN/MDS/Restorative, stated, I think we can do better to accommodate (R20's) dining needs. I will find out what would work best for her. I would say by the amount of food on her clothes and face, it is a dignity issue. The right plate guard may make the difference so we can still foster her independence.2.) The facility's Resident Council Minutes dated 08/21/25 document the following: Residents are tired of CNA's (Certified Nursing Assistants) on their phones while providing care.R8's MDS dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15/15, indicating no cognitive impairment.R43's MDS dated [DATE] documents a BIMS score of 13/15, indicating no cognitive impairment.R58's MDS dated [DATE] documents a BIMS score of 15/15, indicating no cognitive impairment.R74's MDS dated [DATE] documents a BIMS score of 14/15, indicating no cognitive impairment.On 09/22/25 from 10:30 a.m. to 11:50 a.m., R8, R43, R58, and R74 all stated Agency Certified Nursing Assistants (CNAs) are still (since the Resident Council minutes dated 8/21/25) providing resident care in resident rooms while talking on their cell phones.On 9/22/25 at 12:32 p.m., V10, Registered Nurse, stated she has had to direct some Agency CNAs to stay off their phones when providing resident care. V10 stated, I have had it happen a couple times recently. This is a dignity issue. If the CNAs are talking on the phone during care, they are not talking to the residents. That is rude and unacceptable. This is supposed to be resident-centered care. I have interrupted care because of this situation a lot previously. Recently a couple times. It has gotten better but should not be happening at all.On 9/23/25 at 9:05 a.m., V9, Activity Director, confirmed the Resident Council group continues to report concerns about CNAs being on the phone while performing care.The facility provided the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities pamphlet, revised November 2018, which documents the following: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal law. As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities.Your rights to dignity and respect: You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.

Based on observation, interview, and record review the facility failed to follow pharmacy instruction for the safe administration of physician ordered medication, for two of eight residents (R66 and R78) reviewed during medication observation. These failures resulted in three errors out of 29 opportunities for a 10.39 percent medication administration error rate. Findings include:R66's Minimum Data Set (MDS) dated [DATE] documents R66's Brief Interview of Mental Status (BIMS) score as 10 out of a possible 15, indicating moderate cognitive impairment.R66's current Physician Order Sheet (POS) documents the following: R66 is on a regular diet with regular-texture food and thin-consistency liquids, which indicates R66 does not have difficulty chewing.The same POS documents 15 oral medications scheduled for administration during the morning medication pass. The oral medications include:Potassium Chloride Crystal, ER (Extended Release) 20 mEq tablet, give three tablets by mouth each morning, andAspirin EC (Extended Release), Low Dose Oral Tablet Delayed Release, 81 mg, one tablet by mouth each morning.R66's Potassium Chloride [NAME] tablet pharmacy-labeled card documents: May be broken or allowed to disintegrate in water (stir well) before swallowing. Rinse down with water, but do not chew all of the remaining particles.The pharmacy instruction pamphlet inserts for the facility's stock bottle of Aspirin Enteric-Coated tablets document the following: DIRECTIONS: do not exceed recommended dose - drink a full glass of water with each dose - swallow whole, do not chew or crush.On 9/22/25 at 8:10 a.m., V8, Agency Registered Nurse (RN), prepared 17 oral medications in a 30 cubic centimeter (cc) medication cup. The 17 pills included:three 3/4-inch Potassium tablets (with pharmacy directions to swallow whole and drink adequate water),R66's enteric-coated aspirin (with directions to swallow whole), andthirteen other oral medications.The medication cup was more than half full of R66's oral medications. V8, RN, filled the medication cup with applesauce to approximately 25 cc in the 30-cc cup. R66's medications were firmly compacted as V8 stirred the medications into the applesauce.V8 spooned four bites of the compacted oral tablets (mixed with applesauce) into R66's mouth. R66 had multiple missing front teeth and chewed the medications with his side and back teeth.As V8 spooned the four spoonfuls of compacted medications in applesauce, V8 did not provide water for R66 to drink between bites. R66 paused after the third spoonful and asked V8 to wait before the next spoonful of pills. R66 coughed momentarily and swallowed. V8 did not offer water and continued to give R66 the fourth spoonful of medication. V8 did not direct R66 to swallow the medications whole without chewing.R66 took one small sip (approximately 5 cc) of water after V8 administered the 17 oral medications. V8 again failed to encourage R66 to drink more water.On 9/22/25 at 8:15 a.m., V8, RN, stated, I don't think (R66) really chewed that much. He doesn't like the taste of the potassium. As far as the aspirin, it is small, it likely went down whole.V8, RN, removed the medication card from the medication cart and read it. V8 stated, The potassium alert on the card says 'may,' not 'have to,' dissolve in water. The card doesn't say any certain amount of water after. He had a small (surveyor observed approximately 5 cc) amount after.2.) R78's MDS dated [DATE] documents R78 has moderate cognitive impairment.R78's Current Diagnoses Sheet documents the following diagnosis: Gastrostomy Status (has a surgically inserted abdominal feeding tube).R78's current POS documents the following:Cyanocobalamin Oral Tablet Disintegrating 500 mcg (micrograms) - Give 1 tablet by mouth one time a day for healthcare maintenance; Give 1 tablet under the tongue every day.On 9/22/25 at 11:35 a.m., V10, Registered Nurse, crushed and mixed together four other medications with R78's sublingual (under the tongue) Cyanocobalamin oral tablet. V10 administered the medications via R78's G-tube.On 9/23/25 at 8:25 a.m., V2, Director of Nursing, confirmed she has completed medication error reports regarding R66's medications and R78's medication error. She has notified physicians and family and educated the nurses.On 9/23/25 at 12:35 p.m., V17, Registered Nurse, who stated she most often takes care of R78 and administers R78's medication, opened the medication cart and confirmed R78's Cyanocobalamin Oral Tablet Disintegrating 500 mcg tablet is supposed to be administered sublingually, as the pharmacy label and physician order indicate. V17, RN, then stated, I have always given it wrong. I thought it was crushed and by G-tube with her other meds.Facility PolicyThe facility policy Medication Administration dated January 11, 2010 documents the following:Objective: To provide accuracy during medication pass to assure quality care for residents.Policy: It is the policy of this facility to accurately administer medication following the physician's orders.Procedure:6. Compare label with MAR.7. Crush only meds that can be crushed or for which a physician has given orders to crush.9. Administer meds with adequate fluids. Dilute medications, if needed, in juice or water according to pharmacy guidelines and the resident's dietary restrictions.16. Report known medication errors as soon as possible. Notify physician of known medication error and follow orders received. Monitor resident and document interventions. Complete Medication Error Report and counsel and/or in-service staff as needed.

Based on observation, interview and record review, the facility repeatedly failed to follow a physician order to discontinue the administration of a medication, for one of five residents (R69) reviewed for unnecessary medications on the sample list of 31.Findings include:R69's Minimum Data Set, dated [DATE] documents R69's Brief Interview of Mental Status score as three out of a possible 15, indicating severe cognitive impairment.R69's Medication Administration Sheet (MAR) dated 9/1/25- 9/30/25 documents: Nuedexta (can cause excessive drowsiness), Oral Capsule 20-10 MG (Dextromethorphan HBr-Quinidine Sulfate), Give 1 capsule by mouth every morning, and at bedtime for the diagnoses of Pseudobulbar Disease (neurological disorder, uncontrolled laughter, crying and involuntary movements). This Physician order documents to start R69's Nuedexta 11/19/2024. R69's MARs for May, June, July, and August also documents R69 received Nuedexta every morning and at bedtime.R69's Quarterly Medication assessment dated [DATE] documents no involuntary movements, excessive drowsiness, crying, or laughing outburst.The facility pharmacy sent a request dated 05/20/25, to R69 providers to consider discontinuing R69 Nuedexta medication. The pharmacy request documented Resident that has been taking the medication above since November 2024. CMS is not specific regarding a GDR (Gradual dose reduction) for Nuedexta (neurological medication), but since the medication is being utilized for psychotropic reasons (outburst of crying, and laughing), please reassess for continued use. V20, Nurse Practitioner response I have documented that assessment. No Pseudobulbar Affect Behaviors. I have No plans to resume Nuedexta.On 9/21/25 during initial tour 8:30 am -9:30 am, and throughout the survey 9/21-9/24/25, R69 sat in a geriatric chair, alert and pleasantly conversing with staff, surveyor, and other residents in the main common areas on the north pod of the facility. R69 did not show any signs of excessive tearfulness, uncontrolled laughter, sedation, or neurological involuntary movements, for which Nuedexta was ordered.On 9/24/25 at 12:00 pm V18, Nurse Practitioner (NP) stated (R69's) Nuedexta order should have been discontinued 5/20/25 or at least clarified by the facility nurses. I do not feel there was any harm or a potential for harm. I have known (R69) in the past. Her Pseudobulbar symptoms were present for a long time. She had been on Nuedexta for a long time before she admitted to the facility. There has not been any negative outcome, she has no indication of sedation. If anything, this medication, together with her other medications have been a benefit. I am not going to make any changes to the Nuedexta order, at this time. (V20, Nurse Practitioner) will be back in the facility Monday (9/29/25). She is off right now related to a family members health issue. She (V20, NP) and I (V18, NP), together will review this. I believe (R69) would benefit from continuing Nuedexta, just knowing (R69) and her, current status. She is doing great. I remember in the past when she was not. It shouldn't have happened ( Nuedexta been administered since 5/20/25). Pharmacy has reviewed her (R69) meds (medication) monthly since. (V20, NP) has also seen (R69) since 5/20/25. I know it was not discontinued (5/20/25), I can see that in (R69's) medical records. I just could not see anywhere that Neudexta, may have been re-instated. These are questions I have for (V20, NP).

Based on record review and interview the facility failed to ensure a resident's right to choose their own wake -up time. This failure affected four of 29 residents (R8, R43, R58 and R74) reviewed for resident rights on the sample list of 31.Findings include: R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impairment.R43's MDS dated [DATE] documents R43's BIMS Score of 13 out of a possible 15, indicating no cognitive impairment.R58's MDS dated [DATE] documents R58's BIMS Score of 15 out of a possible 15, indicating no cognitive impairment.R74's MDS dated [DATE] documents R74's BIMS Score of 14 out of a possible 15, indicating no cognitive impairment.On 09/22/2025 at 10:30 am - 11:50 am during a resident group meeting that R8, R43, R58 and R74 attended, R43 stated This morning at 3:00 am agency staff got me (R43) up, cleaned me up for the day, dressed me, then put me back to bed. R43 said R43 told them, R43 did not want to get up for the day, dressed for the day, and did not want to sleep in clothes. R58 stated that the agency people don't know the residents and don't realize this is the residents' home. They think we get up when they want us to. No matter what we say. I have to insist they let me stay in bed until at least 6:00 am.R8 and R74 both stated the agency staff get them up according to the agency staff schedule, not their desired time. R8 then added We hear all the time this is our home, it doesn't feel like it, when agency staff come in to get us up.On 9/22/25 at 1:25 pm V2, Director of Nursing confirmed residents have a right to determine their own sleep schedule. The facility provided Illinois Long-Term Care OMBUDSMAN PROGRAM RESIDENTS' RIGHTS or People in Long-Term Care Facilities pamphlet dated revised November 2018 which documents the following: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal law: As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities.Your rights to dignity and respect, You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.

Based on interview and record review the facility failed to revise a care plan with fall interventions for one of 18 residents (R4) reviewed for care plans in the sample list of 31. Findings include:The facility's policy titled Care Plan Process with the revision date of 11/2017 documents a comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals., and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment.Review of incident report reported to Illinois Department of Public Health on 5/30/25 at 7:50 AM documents R4 sustained a fall on May 30, 2025 at 7:50 AM. R4 was observed sitting in front of her recliner chair, legs extended out, and head resting on the foot of the chair. R4 stated I fell out of this chair right here. R4 complained of hip pain so the facility sent R4 to be evaluated and treated to the local hospital on 5/30/25 at 8:08 AM.R4 was interviewed on 9/22/25 at 11:30 AM and R4 did not remember what happened. Minimum Data Set (MDS) dated [DATE] Section C documents R4 with a BIMS (Brief Interview for Mental Status) of 3 which is severe cognitively impaired.R4's care plan dated 5/20/25 states R4 has had previous falls with a list of interventions. The care plan does not list the fall of 5/30/25 at 7:50 AM.V2, Director of Nurses stated in interview on 9/24/25 at 9:45 AM Yes the care plan should of been updated with (R4's) most recent fall. My expectations are the care plan should be updated after each fall.

Based on observation, interview and record review the facility failed to respond to a resident grievance in a timely manner, for one of four residents (R58) reviewed for grievances in the group meeting, on the sample list of 31.Findings include: On 09/22/2025 at 10:30 am - 11:50 am during the resident group meeting. R58 sat in a wheelchair without a shoe on her left foot. R58 stated she had filed a grievance by sending a letter to V1, Administrator within the last month. R58 stated I haven't been able to wear a shoe, because of a toe ulcer, I have had for about a year. I saw a podiatrist, at an outside the facility four to six months ago. The corn was removed, and my pinky toe never healed. I still can't wear a shoe and the Administrator never responded to the letter.On 9/24/25 at 3:25 pm V1, Administrator provided an undated, handwritten grievance letter from R58. V1 confirmed the letter had been written by R58, and was given to V1, Administrator within the last several weeks. V1 also confirmed she had not put this grievance on her grievance log and therefore had not followed up with Nursing to figure out a resolution to R58's pains and inability to wear a shoe on her left foot. R58's undated, handwritten letter documented the grievance and explained that R58 has not been able to wear a shoe on her left foot because of pain in her left, pinky toe. R58 further explained in the letter that she had pain when standing on the mechanical stand lift and does not want to be downgraded to the use of a full mechanical lift for transfers. R58 letter documents that on 5/8/25, R58 was seen by a podiatrist outside the facility, who diagnosed the pinky toe as an ulcer, in the location a previous corn that had been removed. After seeing podiatrist regarding her ulcer on left, pinky toe- she continued to suffer from pain from the toe. R58 documented the ulcer has not healed. The facility provided Illinois Long-Term Care OMBUDSMAN PROGRAM RESIDENTS' RIGHTS or People in Long-Term Care Facilities pamphlet dated revised November 2018 which documents the following: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal law: As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities.You have the right to complain to your facility and to get a prompt response.

Based on interview and record review the facility failed to investigate an injury of unknown origin for one of one resident (R6) reviewed for abuse in the sample list of 31. Findings include:The facility's Abuse Prohibition Policy dated 8/25/25 documents injuries of unknown origin will be immediately reported to the administrator and will be investigated. R6's Emergency Department Note dated 8/15/25 at 5:27 PM documents R6 presented with shortness of breath and chest discomfort described as constant pressure that worsens with inspiration. R6's Chest Computed Tomography (CT) dated 8/5/25 at 7:18 PM documents Likely acute/recent T10 compression fracture with approximately 25% central vertebral body height loss. Other chronic compression fractures are demonstrating similar height loss relative to the CT from 10/20/2022. R6's Hospital admission History and Physical dated 8/5/25 documents R6's hospital admission diagnoses included Acute/recent T10 fracture and neurosurgery was consulted for further evaluation. R6's Neurosurgery Note dated 8/5/25 documents R6 has a T10 compression fracture thought to be newer. R6 is alert and oriented to person, place, time and situation; and R6 reported having chronic back pain that increased over the last few months. R6 denied any recent trauma other than a hematoma to her right lower leg caused from getting her leg caught between her dresser and bed.R6's Thoracic Spine X-ray dated 9/11/25 documents compression deformity of endplate of T11 (previously reported as T10), which has not significantly changed from prior radiographs and CT. Chronic compression deformity of T8 also noted. R6's Neuroscience Progress Note dated 9/11/25 documents R6 was evaluated for T11 fracture identified on R6's x-ray, and there is another old fracture higher up. This note documents that sometimes cement injection is done, but R6 is too far down the line for that and R6 isn't a surgical candidate. Recommendation made for R6 to return in four weeks with a follow up x-ray. R6's ongoing diagnoses log documents the facility added WEDGE COMPRESSION FRACTURE OF UNSPECIFIED THORACIC VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING on 8/14/25.The facility's abuse log does not document any allegations of abuse or injury of unknown origin after 7/18/25. On 9/22/25 at 10:20 AM R6 confirmed compression fracture of vertebrae identified at hospital in August 2025. R6 stated R6 was unsure what caused the fracture and denied that she had any recent falls or incidents that could have caused this type of injury. On 9/22/25 at 2:46 PM V2 Director of Nursing confirmed R6's acute compression fracture was not investigated. On 9/23/25 at 4:00 PM V2 stated V2 thought R6's compression fracture was previously noted and was not new, she will look for documentation to provide for this. On 9/24/25 at 8:30 AM V2 stated she was not able to find any other documentation to show that R6's compression fractures were old and previously documented. At 11:10 AM V2 stated we weren't aware of the acute fracture found during R6's August 2025 hospitalization. On 9/24/25 at 11:15 AM V1 confirmed the acute fracture noted in R6's 8/5/25 hospital records should have been considered an injury of unknown origin and investigated.

Based on interview and record review the facility failed to report an injury of unknown origin to the administrator and the state survey agency for one of one resident (R6) reviewed for abuse in the sample list of 31. Findings include: The facility's Abuse Prohibition Policy dated 8/25/25 documents injuries of unknown origin will be immediately reported to the administrator and the administrator will notify the Illinois Department of Public Health (IDPH). R6's Emergency Department Note dated 8/15/25 at 5:27 PM documents R6 presented with shortness of breath and chest discomfort described as constant pressure that worsens with inspiration. R6's Chest Computed Tomography (CT) dated 8/5/25 at 7:18 PM documents Likely acute/recent T10 compression fracture with approximately 25% central vertebral body height loss. Other chronic compression fractures are demonstrating similar height loss relative to the CT from 10/20/2022. R6's Hospital admission History and Physical dated 8/5/25 documents R6's hospital admission diagnoses included Acute/recent T10 fracture and neurosurgery was consulted for further evaluation. R6's Neurosurgery Note dated 8/5/25 documents R6 has a T10 compression fracture thought to be newer. R6 is alert and oriented to person, place, time and situation; and R6 reported having chronic back pain that increased over the last few months. R6 denied any recent trauma other than a hematoma to her right lower leg caused from getting her leg caught between her dresser and bed. R6's Thoracic Spine X-ray dated 9/11/25 documents compression deformity of endplate of T11 (previously reported as T10), which has not significantly changed from prior radiographs and CT. Chronic compression deformity of T8 also noted. R6's Neuroscience Progress Note dated 9/11/25 documents R6 was evaluated for T11 fracture identified on R6's x-ray, and there is another old fracture higher up. This note documents that sometimes cement injection is done, but R6 is too far down the line for that and R6 isn't a surgical candidate. Recommendation made for R6 to return in four weeks with a follow up x-ray. R6's ongoing diagnoses log documents the facility added WEDGE COMPRESSION FRACTURE OF UNSPECIFIED THORACIC VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING on 8/14/25. The facility's abuse log does not document any allegations of abuse or injury of unknown origin after 7/18/25. On 9/22/25 at 10:20 AM R6 confirmed compression fracture of vertebrae identified at hospital in August 2025. R6 stated R6 was unsure what caused the fracture and denied that she had any recent falls or incidents that could have caused this type of injury. On 9/22/25 at 2:46 PM V2 Director of Nursing confirmed R6's acute compression fracture was not reported to IDPH. On 9/23/25 at 4:00 PM V2 stated V2 thought R6's compression fracture was previously noted and was not new, she will look for documentation to provide for this. On 9/24/25 at 8:30 AM V2 stated she was not able to find any other documentation to show that R6's compression fractures were old and previously documented. At 11:10 AM V2 stated V1 Administrator was not aware of R6's acute compression fracture either, V1 and V2 both thought the fracture noted in September was old, due to the report. V2 stated we weren't aware of the acute fracture found during R6's August 2025 hospitalization. On 9/24/25 at 11:15 AM V1 confirmed V1 was not aware of R6's compression fracture identified during R6's August 2025 hospitalization. V1 stated V1 and V2 were only aware of R6's compression fracture identified when R6 was transferred to the hospital in September for low back pain, but the report identified it as being an old fracture. V1 confirmed the acute fracture noted in R6's 8/5/25 hospital records should have been considered an injury of unknown origin and should have been reported to V1 and IDPH.

Based on observation, interview, and record review the facility failed to prevent cross-contamination during catheter care for one of two residents (R53) reviewed for urinary catheter care on the sample list of 31. Findings Include:R53's Medical Diagnoses List dated May 20, 2025 documents R53 is diagnosed with Infection and inflammatory reactions due to indwelling urethral catheter and Retention of urine.R53's Minimum Data Set (MDS) dated [DATE] documents R53 has severe cognitive impairment, uses a wheelchair, is always incontinent of bowel, and is dependent on staff for toileting, hygiene, and transfers.R53's Care Plan dated 7/29/25 documents R53 has an indwelling Foley catheter.On 9/22/25 at 11:15 a.m., V27, Certified Nursing Assistant (CNA), wearing a personal protective gown, donned gloves and placed a basin of water on the bedside table, which also contained washcloths and towels. V27 placed a washcloth in the water, wrung out the excess water, and proceeded to wash R53's inner right thigh with the washcloth. V27 then placed the same washcloth back into the basin of water and washed R53's inner left thigh using the same area of the washcloth.V27 then obtained a new washcloth, placed it into the water basin, and began to clean R53's penis shaft on the right and left sides. Afterward, using the same washcloth, V27 placed it back into the water basin and washed the catheter insertion site at the meatus. R53 made noises indicating discomfort. V27 apologized to R53, stating she would try to be gentler.V27 then cleaned R53's catheter tubing by holding the catheter at the insertion site and wiping downward on the catheter tubing. V27 again placed the washcloth into the water basin and repeated wiping the catheter tubing using the same area of the washcloth. V27 then retrieved a dry towel and dried R53's body.On 9/22/25 at 11:25 a.m., V27 was asked if there was soap in the water. She stated, No, it is just plain water. V27 then stated she was finished with the catheter care.V27 was asked about using the same area of the washcloth while cleaning R53. V27 stated, Yes, I forgot to turn the cloth to wash the new area I was cleaning.On 9/24/25 at 12:20 p.m., V2, Director of Nursing, stated her expectations for catheter care: I expect peri wash or soap to be used when catheter care is being done for the residents, and they are supposed to use a clean washcloth each time they complete one area and start a new area.The facility's policy titled Catheter Care - Male, dated 8/1/05, documents the following:Procedure:8. Pull back foreskin gently.9. Cleanse area of insertion of catheter into meatus using a clean washcloth prepared with soap and water or peri-care cleanser. Cleanse downward from top to bottom on one side, and then repeat on the other side using a clean washcloth.10. Cleanse catheter tubing 11/2 to 2 inches down from the insertion site.11. Rinse well with clean cloths, following same procedure as for washing.12. Dry with a clean towel.

Based on interview and record review the facility failed to supervise a resident after providing the resident with a hot beverage. This failure affects one (R504) is one of three residents reviewed for supervision in the sample of 3. This failure resulted in R504 spilling hot liquid on R504's lap sustaining redness and 6 blistered areas to R504's bilateral upper extremities requiring subsequent treatment for 3days. Findings Include: R504's Facility Census documents R504 was admitted to the facility on [DATE] and has the following medical diagnoses: Congestive Heart Failure, Reflux Disease, Alzheimer ' s Disease, Dementia, Difficulty in Walking, Age-Related Physical Debility, Muscle Wasting and Atrophy, Fall, Muscle Weakness, Hypertension, , Cognitive Communication Deficit, Repeated Falls, Personal History of Mental Behavioral Disorders, [NAME] ' s Syndrome, Cerebral Infarction, Pulmonary Embolism without Acute Cor Pulmonal and Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction. R504's Minimum Data Set (MDS) dated [DATE] documents R504's Brief Interview for Mental Status (BIMS) score 5, severe cognitive impairment and eating supervision or touching assistance. R504's Care Plan dated 10/10/24 documents R504 is at risk for altered nutrition due to diagnosis of Dementia, Hypertension, Dehydration, Congestive Heart Failure, Reflux disease. R504 am a regular diet, R504 self-feed's unassisted in assisted dining room with supervision, R504 weight is at high end of desired body mass index (BMI) range 60 cubic centime (cc) med pass supplement three times a day (TID). Intervention: R504 self-feed 's with queuing in the assisted dining room. R504's Health Status Note dated 11/30/24 at 3:41pm documents R504 was in dining room when V8 Registered Nurse was notified at 11:15am that the R504 was attempting to remove R504's lid off R504's hot tea and spilled hot tea on R504 self. Upon arriving to dining room R504 upper thighs pant legs were wet. Removed R504 immediately to R504's room and placed R504 on the toilet as V8 removed R504's clothing immediately. V10 Certified Nursing Assistant (CNA) arrived, and this nurse requested V10 remain with R504 while V8 retrieved wound supplies. R504 had no blisters present at this time. Applied Zinc oxide skin protectant to reddened region and notified on call V21 Nurse Practitioner at 11:35am and awaiting return call, at 11:39am family notified of incident with tea, 11:55am V1 Administrator notified of incident. Ice pack wrapped applied on for 10 minutes off 20 minutes. Fluid filled blisters appeared (x6) (Left lateral W 4.5 centimeters x L 1.0 centimeters,) (Left medial thigh W L 4.0 centimeters x W 6.0 centimeters), (Left inner medial L 1.0 centimeters x W 2.5 centimeters), (left inner thigh lateral aspect L 1.0 centimeters x3.8 centimeters), ( Left inner thigh lateral posterior aspect W 1.2 centimeters x L 1.0 centimeters), (Right leg blister inner lateral L W 3 centimeters x 1 centimeters). At 1:08 pm V21 Nurse Practitioner returned call and notified of appearance of blisters. V21 stated to monitor every shift then upon rupture of blisters apply zinc ointment x 3 days and refer to inhouse wound nurse. Added Tylenol 1000 mg 3 times a day x 3 days, then 3 times a day as needed to help manage pain and discomfort. V8 Registered Nurse witness statement dated 11/30/24 documents V22 Dietary Aide reports to V8, R504 was taking the lid off R504's teacup and spilled hot tea on R504's self. Upon arrival to the dining room, R504 was sitting at the table in front of R504's pants were wet. Removed R504 to R504's room and removed clothing while placing R504 on toilet in R504's room. Noted redness to front, lateral and medial left thigh and medial right thigh. V19 Certified Nursing Assistant remained with R504 while V8 obtained zinc paste cream to apply to reddened region. Applied ice pack for 10 minutes then off. Made notifications to Family, Nurse Practitioner, V1 Administrator. V10 Certified Nursing Assistant witness statement dated 11/30/24 documents arrived in residents room, V8 Registered Nurse was present with R504 on toilet, soiled clothing was off resident. redness present on legs. V8 requested V10 stay with resident while V8 grabbed treatment. Treatment applied, R504 dressed and back in dining room for lunch. R504 last toileted at 10:30am. V20 [NAME] witness statement dated 11/30/24 documents V20 passed hot tea to R504, with a lid on top of the coffee cup. A few minutes later, V20 heard R504 scream that R504 spilt R504's tea all over R504's legs and pants. V20 than ran to get V22 Dietary Aide to inform V8 Registered Nurse that R504 had spilt R504 ' s hot tea all over R504's legs and pants. V22 Dietary Aide witness statement dated 11/30/24 documents V22 was informed by V20 [NAME] that R504 had burned R504's self with R504's hot tea. V22 went down to the nurses station and informed North hall nurse V8 Registered Nurse. On 12/11/24 at 1:10pm V2 Director of Nursing stated that R504 is able to feed R504's self but should have supervision. V2 said, R504 eats in the assisted dining room, the assisted dining room is for residents who need supervision or the resident needing to be assisted in being fed by staff. V2 stated that supervision is a least 1 nursing staff being present in the dining room when residents are present with food or beverages. V2 stated that on the day of the incident there were no nursing staff present in the assisted dining room at the time of R504's incident. On 12/11/24 at 1:25pm V10 Certified Nursing Assistant said, on 11/30/24 V10 went to assist V8 Registered Nurse in R504's room. V10 said, V8 already had R504 transferred onto the toilet and had R504's wet pants off. V10 said, V10 observed redness to the top of R504's legs, and V8 asked V10 to stay with R504 while V8 went and got a treatment. V10 said, R504 was not able to remember what happened, just that R504 spilled tea. V10 said, V10 last toileted and changed R504 at 10:30am before lunch started. V10 said, V10 does not know if there was any nursing staff in the dining room at the time of the incident, V10 was assisting other residents. On 12/11/24 at 1:40pm V22 Dietary Aide said, on 11/30/24 at around 11:15am V22 was cutting oranges in the kitchen when V20 [NAME] came into the kitchen and stated R504 just burned R504's legs with hot tea, what should V20 do. V22 stated that V22 told V20 to stay with R504, and V22 would go get a nurse. V22 stated, V22 went to the North Hall where R504 resides and informed V8 Registered Nurse what happened. V22 stated, at the time of the incident there were no Certified Nursing Assistants or Nurses in the dining room, it was only V20. On 12/11/24 at 2:10pm V23 Wound Care Registered Nurse stated that on 12/2/24 when V23 reported to work V23 was informed that on 11/30/25 R504 sustained 6 burn/blisters wounds to R504's bilateral upper extremities. V23 stated on 12/2/24 V23 assessed R504's 6 burn wounds to R504's upper legs. V23 stated that the facility had already received treatment orders from V21 Nurse Practitioner on 11/30/24 and will continue with those orders and monitor R504's burn wounds daily.

Failures at this level require more than one deficient practice statement. A. Based on interview and record review the facility failed to monitor a resident (R22), with Dysphagia (difficulty swallowing), after administering oral medication. This failure affects one resident (R22) of 7 residents reviewed for medication administration in the sample list of 44. R22 experienced a choking episode when staff had left R22's room after oral medication administration. Upon staff hearing R22's coughing, staff returned to R22's room and performed the Heimlich Maneuver to expel the tablet from R22. B. Based on interview and record review the facility failed to thoroughly investigate falls and document falls in the resident's medical record for one (R17) of nine residents reviewed for accidents in the sample list of 44. Findings include: a.) R22's Facility Census documents R22 was admitted to the facility on [DATE] and has the following medical diagnoses; Muscle Wasting and Atrophy, Muscle Weakness, Anxiety Disorders, Dysphagia Oropharyngeal Phase and Forms of Stomatitis. R22's Minimum Data Set (MDS) dated [DATE] documents R22's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. R22's Physicians Order Sheet dated 10/3/24 documents Simethicone Tablet Chewable 80 milligrams, Give 1 tablet by mouth every 8 hours as needed for lower GI gas and bloating. R22's Care plan documents R22 has impaired Nutrition; Interventions-Assist with meals (Feed/Set-up) as needed, Encourage R22 to eat slowly, using pursed lip breathing between bites, Ensure R22 is in proper position for eating. R22's Health Status note dated 10/3/24 at 9:05 am documents administered as needed gas relief as ordered, educated R22 on chewing tablet very well, walked into hall by residents room, V8 Certified Nursing Assistant (CNA) walked past and saw R22 coughing, walked out room, V7 Licensed Practical Nurse heard R22 gasp and grab R22 throat, V7 yelled out for help, V8 and V11 Certified Nursing Assistant helped this V7 remove R22 from bed, R22 lips blue, still grabbing at R22's throat, one maneuver of Heimlich completed, R22 was able to clear R22's airway successfully. vital within normal limits, Medical Doctor aware Power of Attorney aware. Respiratory assessments ordered twice a day for 72 hours changed by mouth gas x to Mylanta liquid to prevent further choking hazards. Facilities Medication Administration Policy dated 1/11/10 documents: Objective; To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Procedure: 9. Administer meds with adequate fluids. Dilute medications, if needed, in juice or water according to pharmacy guidelines and the resident's restrictions. 13. Make sure the resident takes the medication. Generally-Do not leave meds at bedside. On 10/21/24 at 11:38am V8 Certified Nursing Assistant said, on 10/3/24 at 9:00am V8 and V11 Certified Nursing Assistant were pushing residents back to South Hall from breakfast. V8 said, V7 Agency Licensed Practical Nurse (LPN) was outside of R22's room by the medication cart. V8 said, walking back from South Hall, V8 heard R22 coughing. V8 said, V8 observed V7 go into R22's room and then heard V7 call out for help. V8 said, V8 and V11 entered R22's room and R22 was holding R22's throat. V8 said, V3 and V11 assisted R22 to the edge of the bed, and V8 got R22 out of bed and administered the Heimlich maneuver and R22 spit something out of R22's mouth and stopped choking. V8 said, V8 did not see what R22 spit out, only that R22 informed them that it's out. V8 said, V11 informed V8 that it was a pill that R22 spit out. On 10/21/24 at 1:18pm R22 said, a couple of weeks ago while R22 was in bed just after breakfast, R22 had a stomach ache a V7 Agency Licensed Practical Nurse gave me medication. R22 stated that after V7 gave R22 the medication, V7 left the room and R22 began to choke on the medication, and staff came back in and help R22 spit it out. On 10/21/24 at 1:38pm V11 Certified Nursing Assistant (CNA) said, on 10/3/24 R22 was in V11's group. V11 said, after breakfast V11 assisted R22 back to bed and was in a sitting up position. V8 said, at 9:00am V11 and V8 Certified Nursing Assistant were pushing residents back to the South Hall. V11 said, V11 observed V7 Licensed Practical Nurse outside R22's room. V11 said, after bringing the residents back to South Hall and walking back to the dining room, V11 heard V7 call out for help from R22's room. V11 said, V11 and V8 went into the room and observed R22 holding R22's throat. V11 said, V11, V3 and V8 got R22 up to the edge of the bed, and V8 administered the Heimlich Maneuver and R22 spit out a pill, and R22 stated, it came out'. On 10/22/24 at 9:34am V2 Director of Nursing said, V2 conducted the investigation regarding R22's choking incident. V2 said, on 10/3/24 V7 Agency Licensed Practical Nurse (LPN) administered R22 a chewable tablet per physicians orders. V2 said, V7 left the room prior to R22 thoroughly chewing and swallowing the tablet and began to choke. V2 said, V7 and V8 heard R22 coughing, and then V7 heard R22 gasping for air. V2 said, V7 entered the room and observed R22 grabbing R22's throat and V7 called out for help. V2 said, V7, V8 and V11 Certified Nursing Assistant got R22 to the edge of the bed and V8 administered the Heimlich maneuver and R22 was able to clear the medication. V2 said, V7 should have never exited the room until R22 chewed and swallowed the medication to ensure there were no issues with R22 swallowing the medication. On 10/23/24 at 8:39am V7 Agency Licensed Practical Nurse said, on 10/3/24 at 9:00am V7 administered R22's medication and R22 informed V7 that R22's stomach was upset. V7 said, V7 went and got R22 Simethicone for R22's upset stomach and put it in R22's mouth and told R22 to chew it. V7 said, V7 turned and walked out of the room and V8 Certified Nursing Assistant was walking by and R22 began to cough, V7 turned around and went back into R22's room and R22 was gasping for air and holding R22's throat. V7 said, R22's lips were blue, and V7 yelled for help, and V8 and V11 Certified Nursing Assistant came into R22's room. V7 said, V8 and V11 assisted in getting R22 up and V8 administered one stomach thrust and R22 spit the pill/medication out and was able to breath. V7 acknowledge that V7 should have stood at bedside and ensured that R22 had chewed and swallowed the medication, before turning and leaving the room. 40385 b.) On 10/20/24 at 12:17 PM R17 stated R17 had a prior fall in R17's bathroom and broke R17's back. R17's Minimum Data Set (MDS) dated [DATE] documents R17 is cognitively intact, R17 requires partial/moderate staff assistance for toileting hygiene and sitting to standing, and R17 requires substantial/maximum staff assistance for toilet transfers, chair/bed transfers, and walking. This MDS documents R17 is occasionally incontinent of urine and always incontinent of bowel R17's Nursing Note dated 6:42 PM documents R17 was observed lying on the floor on his right side, there was urine on the floor, and the bedpan was on the floor behind R17. R17 reported R17 was reaching for the bedpan that was on the floor and rolled out of bed. R17's Nursing Note dated 9/27/2024 at 8:40 AM documents R17 has continued to have hallucinations and multiple falls during the night which and was sent to the emergency room for evaluation. There is no documentation in R17's nursing notes, besides this note, regarding R17's falls on 9/26/24. R17's 8/30/24 fall investigation documents the root cause of the fall was R17 attempted to reach for an item on the floor and slid out of bed, and the post fall intervention was education to call for assistance and staff educated to leave items within reach. R17's 9/22/24 fall investigation documents R17 fell on [DATE] at 10:50 AM in R17's room while self-transferring in R17's room and sustained a nondisplaced fracture of the medial epicondyle (left arm) and a mild acute T10 (spine) superior endplate compression fracture post fall. R17's 9/26/24 3:20 PM fall investigation documents R17 was found on the floor of his room at 3:20 PM with his head resting on the foot of R17's bed. R17 pointed to his wheelchair and stated, I need to get all that stuff of mine situated for work and R17 thought he was working in a post office. This investigation only includes one staff statement dated 9/26/24 that documents R17 had been hallucinating all day and R17's bed was in low position when R17 was found on the floor. R17's 9/26/24 10:00 PM fall documents nurse walked past R17's room and found R17 lying on the floor parallel to the bed, bed was in low position and fall mats were in place. There is no documentation that staff were interviewed to determine when R17 was last toileted or checked on prior, or what R17 was doing when R17 was last observed prior to R17's falls on 8/30/24 and 9/26/24. On 10/22/24 at 12:25 PM V2 Director of Nursing stated V2 talks with staff regarding falls and documents staff statements, but V2 was unable to locate this documentation for R17's 8/30/24 and 9/26/24 falls. V2 confirmed this information would include interventions in place at the time of the fall, last time toileted or checked on prior to the fall, and activity when last observed. V2 stated resident falls should be documented in the resident's nursing notes, and the nurse has to check a box so that the note pulls from the incident report into the nursing notes. V2 confirmed this was not done for R17's 9/26/24 falls. The facility's Fall Assessment and Management policy dated June 2024 documents fall interventions will be based on fall risk assessments and circumstances regarding falls and risk for injury. This policy documents the nurse will assess the resident following a fall including a description of how the resident was observed, information regarding the fall, environmental factors, first aid treatment, physician and responsible party notification, and initiating an incident report. This policy documents to document post fall assessments for 72 hours after the incident.

Based on observation, interview and record review the facility failed to provide targeted interventions to prevent skin breakdown, failed to assess, evaluate and document resident skin on a regular basis, and failed to obtain appropriate treatment orders for pressure ulcers for two (R20, R58) of five residents reviewed for pressure ulcers from a total sample list of 44 residents. These failures resulted in one resident (R20) developing a new, unstagable, deep tissue injury and a second resident (R58) developing seven, new stage two pressure wounds. Findings include: The facility Wound and Ulcer Policy and Procedure dated 3/28/24 documents that it is the policy of this facility to provide nursing standard for assessment, prevention, treatment and protocols to manage resident at any level of risk for skin breakdown and for wound management. A skin assessment will be documented daily for resident assessed to be at moderate or high risk for the development of pressure ulcers. When a resident is found to have a wound, the wound will be documented in the medical record, a treatment protocol will be initiated, the physician and family will be notified and orders implemented. 1.) The facility provided ulcer on-going summary report documents that R20 has an in-house acquired stage two wound on her sacrum and a bruise on her left wrist. R20's Minimum Data Set, dated dated dated [DATE] documents that R20 is cognitively intact. R20's facility skin assessment dated [DATE] documents R20 is as at moderate risk for skin breakdown. R20's October 2024 medical record does not document daily skin checks. On 10/20/24 at 10:57AM, R20 was laying in bed with her heels resting directly onto the mattress. No specialty mattress was observed. R20 stated, I have a wound on my backside and my foot hurts, pointing to her left foot. R20 was wearing non-slip footwear and said that she had no dressings on her feet. On 10/21/24 at 3:35PM, R20 was laying in bed with her heels pushing into the mattress. No specialty mattress was observed. R20 stated, My left foot hurts and it has for at least a week. I've told them that it hurts. On 10/21/24 at 3:38PM, V19 Certified Nursing Assistant (CNA) removed R20's left non-slip sock and exposed a quarter sized, black, deep tissue injury, unstagable. When V9 Licensed Practical Nurse (LPN) entered the room she stated that R20 only had a wound on her sacrum. V19 CNA showed V9 LPN, R20's left heel. R20 then stated that her left foot had been hurting for at least a week. V19 LPN said that she was unaware that R20 had a heel wound and had no idea how long it had been there. V19 confirmed that there was no treatment order for R20's heel wound because no one knew about it. On 10/21/24 at 3:55PM, V2 Director of Nursing stated that she was unaware of R20's wound on her left heel and that the staff should report any skin issues to the nurses who should then assess the issue, obtain orders from the physician, and that all residents with a stage two or greater should be on a specialized mattress. On 10/22/24 at 9:20AM, V6 Wound Nurse said that the CNA's are supposed to fill out shower sheets every time that they give a shower and mark on the sheet if there are any changes to the skin. The nurses are then supposed to let the Infection Preventionist, the Physician and the Family know when there is a skin change and get orders for a treatment. None of these things happened. I usually do a skin sweep, but that didn't happen either. Based on its size and color I would guess it has been present for 3-4 weeks. I suggested when she broke her arm (July 2024) that she needed a (specialty) mattress, but it was not ordered. This unstageable wound will likely open and could cause an infection or other issues. 2.) The facility provided wound summary report dated 10/18/24 documents that R58 has wounds on her right upper inner thigh, left buttock and right buttock. All were documented as developed in house on 8/6/24. R58's Minimum Data Set, dated dated dated [DATE] documents R58 as cognitively intact. R58's facility skin assessment dated [DATE] documents R58 is a high risk for skin breakdown. R58's medical record does not contain daily wound assessments. R58's physician orders dated 8/31/24 document to cleanse the right buttock with soap and water, pat dry apply calcium alginate to wound bed and cover with silicone border dressing daily and as needed and to cleanse the left buttocks with soap and water, pat dry apply calcium alginate to wound bed and cover with silicone border dressing daily and as needed. On 10/21/24 at 11:46AM, V6 Wound Nurse removed R58's brief and no dressings were on R58's seven open areas on her buttocks and inner thighs. V6 stated that there are new wounds on R58's buttocks and thighs and that when a new wound is found, an assessment should be completed, the wound nurse and physician notified, treatments orders obtained and notifications made and that none of these things were done. R58 was sitting in a wet brief and stated that she was last changed at 8:00AM that morning. On 10/21/24 at 3:55PM, V2 Director of Nursing stated that she was unaware of R58's new wounds on her buttocks and thighs and that the staff should report any skin issues to the nurses who should then assess the issue, obtain orders from the physician, and that all residents with a stage two or greater should be on a specialized mattress. On 10/23/24 at 11:45AM, V6 Wound Nurse stated that R58 should have had a dressing on her wounds or a refusal if the resident would not allow the dressings to be completed, neither of which was done. On 10/23/24 at 11:20AM, V30 Nurse Practitioner stated that failing to do skin checks, failing to implement interventions such as alternating air mattresses or repositioning a resident every two hours, and failing to find and address wounds sooner could certainly cause harm to the resident and in the case of R20, did cause the wound to become an unstagable, deep tissue wound.

Based on observation, interview, and record review the facility failed to identify significant weight loss, prevent significant weight loss, develop/implement a care plan including interventions for weight loss, implement nutritional interventions/recommendations, timely implement physician's orders, and report significant weight loss to the physician and registered dietitian for two of five residents (R45, R83) reviewed for nutrition in the sample list of 36. These failures resulted in R45 experiencing a severe weight loss of 13.73 % (percent) in four months. Findings include: The facility's Weight Management Policy and Procedure with revised date of February 2016 documents residents will be weighed at least monthly or more frequently if warranted, residents will be monitored for significant weight changes, weights will be compared at least monthly, dietary staff will review the Weight and Vitals Exception Report weekly, significant weight loss will be addressed at the time identified, significant weight loss will be reported to the dietitian and physician, and the dietitian recommends nutritional interventions to the physician. The facility's Dietitian Recommendation Process dated January 2022 documents the dietitian will document recommendations in the medical record, the Director of Nursing (DON) and Food and Nutrition Services Manager are responsible for implementing the recommendations, the DON will obtain physician orders for the recommendations, and responses should be obtained within two to three days. The facility's Nutrition Documentation policy dated January 2022 documents the Food and Nutrition Services Manager and Dietitian are responsible for documenting the resident's nutritional care to ensure residents receive appropriate/timely nutritional care and interventions. This policy documents the DON and Food and Nutrition Services Manager will refer residents to the dietitian upon admission/readmission, annually, and with significant weight changes or nutritional problems. 1.) On 9/11/23 at 10:20 AM R45 stated R45's food is ground up and R45 does not like that. R45 has lost weight but was unsure how much weight R45 had lost. R45 stated R45 had stomach flu symptoms last week. R45 was lying in bed and appeared thin. On 9/11/23 at 12:35 PM R45's noon meal contained ground taco meat, peas, carrots, and pureed chocolate cake. On 9/11/23 at 1:25 PM R45 had ate all R45's lunch but a few bites of meat and carrots. On 9/12/23 at 8:43 AM R45's breakfast tray contained pureed breakfast casserole, diced peaches, oatmeal, and yogurt. On 9/12/23 at 12:18 PM R45 stated R45 did not like the pureed breakfast casserole and did not care for the way it looks since it is pureed. R45 stated R45 ate half of the oatmeal, half of the yogurt, and bites of peaches, and then R45 felt full. R45 stated the nurses give R45 a nutritional supplement three times a day, R45 likes the supplement and drinks all the supplement. On 09/12/23 at 12:33 PM R45's noon meal contained noodles, ground meat with tomato sauce, green beans, diced peaches and pears, and pureed garlic bread. At 1:07 PM R45 ate all the green beans, 75% of the meat, half of the fruit, and none of the garlic bread. R45 stated R45 is very nauseated. R45's Weight Log documents R45's weight as 134 lbs. on 5/8/23 (admitted ), 128.6 on 5/22/23, 127.2 on 5/29/23 (5.07% loss since 5/8), 125 on 6/1/23 (6.72% loss since 5/8), 124.4 on 7/1/23 (7.16% since 5/8), 119.6 on 8/1/23 (10.75 % loss since 5/8), 115.6 on 9/1/23 (13.73 % loss since 5/8 and 7.52% since 6/1/23), and 116 on 9/7/23. There are no documented weights between 7/1/23 and 8/1/23, and between 8/10/23 and 9/1/23. R45's Minimum Data Set, dated dated dated [DATE] does not identify R45's significant weight loss. R45's Care Plan dated 5/8/23 documents R45 is at risk for altered nutrition and receives supplements to aid in weight/skin. This care plan includes interventions to monitor intakes, monitor weights monthly or as needed, report changes/issues to the director of nursing (DON), refer to dietitian and speech therapy as needed, and administer supplements as ordered. This care plan does not identify R45's significant weight loss or any new interventions after 5/18/23. R45's May-September 2023 Medication Administration Records (MARs) document nutritional supplement 60 milliliters (ml) twice daily from 5/31/23-7/21/23, 90 ml twice daily from 7/21/23-9/6/23, and 90 ml three times daily implemented on 9/6/23 for weight loss. R45's Dietitian assessment dated [DATE] documents R45 has gradual weight loss of 4% since admission, has depression and Dysphagia (difficulty swallowing), and R45's diet is soft, and bite sized. Goals include stabilizing weight with less than 5% change within a one-month period. This assessment includes a recommendation for nutritional supplement 60 ml twice daily to aid in weight stabilization. This supplement was not implemented until five days later 5/31/23, after R45's weight loss was 5.07% (significant). R45's Speech Therapy Discharge Summary dated 6/19/23 completed by V23 (Speech Therapist) documents R45 received speech therapy from 5/10/23-6/19/23. R45 has limited intake, avoids therapy, and would benefit from a referral to ENT (Ear Nose Throat) physician or GI (Gastroenterologist) due to difficulty with esophageal issues, vomiting, and feeling of fullness during intakes. R45's Speech Therapy Speech Language Pathology (SLP) Evaluation and Plan of Treatment dated 8/16/23 and completed by V23 (SLP), documents R45 was evaluated per R45's request for diet upgrade and reports of recent nausea and epigastric pain. R45 feels GI pain is related to R45's diet texture. R45 has feelings of esophageal pressure, nausea, and painful swallowing. R45 was evaluated for Dysphagia and noted to have a swallowing disorder involving the pharyngeal and esophageal phases. This evaluation includes a recommendation for Dysphagia treatment, speech therapy is not warranted, and R45 could benefit from a GI consult for further evaluation. There is no documentation in R45's medical record that a referral was made for a GI or ENT consult. There is no documentation that R45's significant weight loss noted on 8/1/23 was identified and reported to a physician and V25 (Registered Dietitian). There is no documentation that R45's weight loss was evaluated by a physician/practitioner after 7/21/23 until 8/28/23, that R45 was evaluated by V25 after 7/10/23, or that new nutritional interventions were implemented after 7/21/23 until 9/6/23. R45's Progress Note dated 7/19/23 documents R45 was evaluated for chronic disease management and notes R45 has occasional vomiting associated with reflux, currently asymptomatic, and denied esophageal/abdominal discomfort. This note documents R45 had a 9.6 lb. weight loss since admission, receives nutritional supplement 60 ml twice daily, and intakes vary 25-75%. Orders include decreasing R45's Carafate to 1 gram before meals twice daily with ongoing monitoring and if tolerated the medication will be to reduce at the next scheduled visit and increase the nutritional supplement to 90 ml three times daily. R45's Progress Note dated 8/28/23 and recorded by V24 (Nurse Practitioner/NP) documents R45 was evaluated for persistent GI issues and weight loss. R45 reported having reflux daily, not eating much, and vomiting after meals. This note documents nursing staff feels R45's problems worsened when R45's Carafate was decreased approximately 1-2 months ago, and speech therapy recommended referral for GI consult. V24 gave orders to increase R45's Carafate back to three times daily before meals, increase nutritional supplement 90 ml three times daily, obtain Complete Metabolic Panel (CMP), Complete Blood Count (CBC), B12 Level, Iron/Total Iron Binding Capacity (TIBC), and Thyroid Stimulating Hormone (TSH), and weekly weights. This note is documented as being uploaded into R45's electronic medical record on 8/29/23. V24's orders from 8/28/23 were not implemented until 9/6/23 and R45's CMP was not scheduled until 9/14/23. R45's Nursing Notes document the following: On 7/10/23 R45 was evaluated by the dietitian, R45 was trending weight loss that was not significant, and there were no recommendations at that time. On 8/4/23 dietary notes that R45 triggered for a significant weight loss over 180 days, R45 does not like R45's diet, continues supplements, and continue to monitor. On 8/17/23 R45 complained of nausea. On 8/18/12 dietary notes R45 does not like R45's diet and intakes vary between 25-50% of meals. On 8/19/23 R45 did not eat breakfast and lunch and complained of stomach issues. On 8/21/23 R45 reported GI issues and V24 NP was notified of GI consult. V24 to decide if GI consult appropriate at this time. On 9/11/23 at 11:27 AM R45 reported feeling better since the increase in Carafate last week and denied any nausea. On 9/11/23 at 1:32 PM V24 NP evaluated R45 and ordered Zofran (antinausea) 4 milligrams (mg) daily 30-60 minutes before lunch, increase nutritional supplement to 120 ml three times daily, and draw CMP on 9/14/23. On 9/12/23 at 12:35 PM V21 (Certified Nursing Assistant/CNA) stated R45's appetite has not been good, and R45 says R45 is full or that R45's stomach is upset. V21 stated R45's appetite decline has been gradual over the last few weeks. On 9/12/23 at 1:57 PM V4 (MDS Coordinator) stated V1 (Administrator), V3 (Infection Preventionist), and V4 have access to obtain V24's orders from (electronic record system) after V24's visits. V4 stated V24's orders are then given to the nurses to implement. V4 stated there was an issue with V24's orders on 8/28/23 not being implemented due to an unidentified staff person was viewing the orders which caused the orders to disappear and no longer show up in (electronic record system). The CMP ordered in August was not resubmitted by V24, and therefor was missed. Yesterday V24 resent the order for the CMP, and it is scheduled to be drawn on 9/14/23. V4 confirmed R45 has not had a GI consult since R45 admitted to the facility. V4 stated V24 increased R45's Carafate and gave orders for laboratory tests on 8/28/23. V4 stated R45's electronic medical record system did not identify R45's significant weight loss and that is why it was not coded correctly on R45's MDS, and V4 confirmed R45's care plan was not updated to reflect significant weight loss and new interventions. On 9/12/23 at 2:53 PM V2 (Director of Nurses/DON) stated there was an issue with V24's orders not being implemented, and last week V2 requested that from now on V24 communicate V24's orders verbally to the nurses or V2. V2 stated prior to that, V3 or V4 were obtaining V24's orders from (electronic record system). V2 stated V25 (Registered Dietitian/RD) rounded at the facility yesterday, and V2 had to ask V25 on V25's process for communicating V25's recommendations to the facility. V2 stated V25 sends V25's recommendations by electronic mail to the DON. On 9/12/23 at 3:38 PM V2 stated V2 followed up and V25 was not sending V25's recommendations to V2. V2 stated both V2 and V25 are new to their positions. V2 stated V2 is now going to have V25 send the recommendations to V28 (Dietary Manager). V2 stated there was a lot of changes in both the nurse management and dietary departments. V2 stated these are key staff for this area (weight loss), and V28 has been working as a cook a lot of the time. V2 stated R45 was referred to V24 on 8/21/23 regarding the GI consult. V2 stated there is no follow up documentation of the consults/referrals. On 9/13/23 at 9:47 AM V25 (RD) stated V25's employment began as of July 2023 and V25 last rounded at the facility on 9/11/23. V25 stated V28 (Dietary Manager) provides a list of weights, significant weight changes, and new admissions for V25. V25 stated V25 reviews the weights documented in the resident's electronic medical record. V25 stated V25's visits and evaluations are noted in a progress note in the resident's electronic medical record. V25 stated V25 and the physician should be notified of significant weight loss. V25 stated V25 sends V25's recommendations to the administrator, dietary manager, and DON at the end of V25's visits via electronic mail. V25 expects V25's recommendations to be implemented within a week, about the time it takes for physician approval. V25 confirmed that the sooner the recommendations are implemented, the sooner it could help with weight stabilization. V25 was asked if V25 would have recommended anything additional for R45's weight loss after 7/10/23. V25 stated if V25 had been notified, V25 would have increased R45's nutritional supplement to three times daily since R45 continued to have further weight loss and decreased appetite. V25 stated if the electronic medical record did not flag R45's significant weight loss, then that is likely why V25 missed it. V25 stated residents should be weighed at least monthly and weekly for four weeks if trending weight loss, and if the weight does not stabilize then weekly weights should be continued. On 9/13/23 at 10:24 AM V22 (SLP) stated R45's speech therapy treatments focused on swallowing and possibly improving intakes. V22 stated R45 admitted on a certain type of diet and has not consumed a lot historically. V22 stated V22 was trying to assess the best way to meet R45's nutritional needs and V22 recommended a GI consult, and this was reported to the floor nurse that day. V22 stated V22 thinks R45's issue is more of a GI issue rather than a speech therapy issue, and V22 could benefit from a GI consult. V22 stated R45 reported feeling nauseated and not wanting to eat due to feeling like R45 will vomit. V22 stated that is not a Dysphagia symptom and needs to be investigated further by a GI specialist. On 9/13/23 at 10:58 AM V1 (Administrator) confirmed all documentation that could be located regarding R45's weight loss, notification of physician and dietitian, nutritional evaluations and interventions was provided. On 9/13/23 at 11:02 AM V24 (NP) stated significant weight loss should be reported to the physician/NP so that interventions can be ordered. V24 stated approximately 3 weeks ago V22 told V24 that R45's problems were not related to swallowing issues, it was more related to R45 feeling full/nauseated, and V24 adjusted R45's medications and ordered laboratory tests. V24 stated all V24's orders did not get implemented right away due to an issue with the orders being checked in the electronic system by someone at the corporate level. V24 stated V24 resubmitted V24's orders from 8/28/23 on 9/6/23. V24 stated generally V24's orders should be implemented within 24 hours. V24 stated R45's nutritional supplement was increased and R45 likes the supplement. V24 stated R45 was last evaluated by GI on 4/20/22 and V24 wanted to evaluate R45's laboratory results and response to medication changes prior to referring R45 to a GI specialist. V24 stated increasing R45's nutritional supplement sooner (prior to 9/6/23) could have stabilized R45's weight and prevented additional weight loss. 37813 2.) R83's Care plan initiated 8/10/23 documents the following diagnoses: Gastroesophageal Reflux Disease (GERD), Chronic Peptic Ulcer, Depression, Abdominal Pain, Dementia, and Anxiety. R83 is at risk for altered nutrition due to diagnosis of dementia, reflux disease. This Care Plan also documents R83 is on a regular diet, self feeds to some extent but needs verbal cues and reminders to eat, will eat meals in the supervised dining room to get that assistance, weight is at low end of range, supplements provided as ordered. R83's Weight and Vital Signs record documents on 8/10/2023 R83 weighed 104.6 lbs. (pounds). On 8/16/202 R83 weighed 99.4 pounds which is a -4.97 % (percent) weight loss in six days. There is no documentation the physician was ever notified of this weight loss. R83's Registered Dietitian Admission assessment dated [DATE] by V25 (Registered Dietitian) documents [AGE] year-old resident admitted on a Regular Diet. Ht 62 (inches) Weights: 8/4 100.4# (pounds), 8/10 104.6# -4.2# since admission, Body Mass Index 18.4-under weight for age. Intakes 50-75% with improvement noted per nursing notes. (R83) is independent at meals per nursing notes. Labs: 8/23 Within Normal Limits with glucose 129(High). Medications: reviewed. Skin: Left femur incision treated, no other red or open areas noted per nursing notes. (R83) at nutrition risk for unavoidable weight loss and decreased appetite due to diagnoses of Dementia, GERD, Fractured Femur, Amnesia, Peptic Ulcer Disease and Advanced Age. Recommend adding (frozen nutritional supplement) twice daily due to weights, intakes, and healing. Diet with supplement adequate to meet estimated needs with 50-100% of meals to meet estimated needs to maintain/gain weight. Continue to honor any food preferences noted. Providing milk twice daily and Vitamin C juice daily. Continue to offer Menu Alternative when intakes less than 50% at meals. Continue to encourage fluids and intakes, but respect resident's right to refuse. Recommend Multiple Vitamin for optimal nutrition. Continue to monitor weights, intakes, labs, skin/healing. Refer to Registered Dietitian as needed. On 9/12/23 at 11:47AM R83 ate 75% of lunch. No frozen nutritional supplement or milk was offered until prompted. R83 was not on the list in kitchen for resident receiving a frozen nutritional supplement. V28 (Dietary Manager) stated, I don't think (R83) gets milk unless (R83) wants milk or a (frozen nutritional supplement). On 9/12/23 at 2:00PM V2 (DON) verified that the dietitian's order recommendation for (frozen nutritional supplement) and milk should have been followed and the physician should have been notified of (R83's) significant weight loss.

Based on observation, interview and record review the facility failed to provide effective pain control and positioning aids for R50. The facility also failed to follow physician orders for R44. R44 and R50 are two of two hospice residents reviewed from a total sample list of 36. These failures resulted in R50 experiencing uncontrolled pain by grimacing, moaning, and closing her eyes while wound treatments were performed on a stage three and an unstageable wound. Findings include: 1.) The facility Hospice Patient Care Coordination Policy dated 7/2005 documents that coordination of care and services will be completed between the facility and the Hospice provider using the interdisciplinary process of the facility. The facility provided, the hospice company agreement dated 2/7/22, documents Hospice responsibilities including but not limited to; providing medical direction and management of the Hospice Patient, nursing, counseling, including spiritual, dietary and bereavement; social work, therapy as needed, medical supplies and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions. R50's undated diagnosis sheet documents a diagnosis of Alzheimer's dementia. R50's Minimum Data Set, dated dated dated [DATE] documents severe cognitive impairment. R50's physician orders dated 8/30/23 documents a regular diet with pureed consistency. R50's physician orders dated 8/2/23 documents, (Name of Hospice) to evaluate and treat. R50's physician orders document and order dated 9/2/23 for Tylenol 325 milligrams x 2 for pain. R50's pain assessment dated [DATE] documents pain with wound care rated by staff of a 5/10. R50's physician orders dated 9/2/23 document wound dressing changes daily on R50's coccyx and right ankle. R50's physician orders dated 9/8/23 documents to provide a wet to dry dressing twice daily on R50's coccyx and right ankle. On 9/11/23 at 1:49PM, R50 was sitting in the common area in a reclining wheelchair with R50's head raised approximately six inches off the headrest without anything supporting R50's head. On 9/13/23 at 8:42AM, R50 was observed lying in bed with her head raised approximately three inches away from the pillow without anything supporting her head. On 9/12/23 at 1:30PM, R50 was sitting in the common area and V16 (Registered Nurse/RN) stated, We asked hospice to get her a chair, but this one doesn't fit her at all, she looks uncomfortable. On 9/13/23 at 8:51AM, V3 (Wound Nurse) provided wound care to R50. R50 had a stage three ulcer on the coccyx approximately the size of a quarter that was cleansed with saline and then a wet to dry dressing was applied. Prior to placing the wet to dry dressing in R50's coccyx, R50 was resting quietly. When the wet to dry dressing was applied into the coccyx wound, R50 grimaced and began breathing more rapidly. R50's unstageable right ankle wound was full of slough and a black spot. When this wound was cleansed, R50 grimaced, closed her eyes, began to breathe heavier and moaned. On 9/13/23 at 9:05AM, V3 stated, I've been asking hospice for a couple of weeks for better pain control for (R50). She is definitely in pain. I can tell from the grimacing. We have Tylenol for her, but that just isn't enough. On 9/13/23 at 9:10AM, V2 (Director of Nursing) said that there was a new hospice nurse for the facility and that the hospice company wasn't responsive to facility requests. I don't know why we didn't contact the Medical Director and I don't know why they didn't give us a comfort pack with morphine. On 9/13/23 at 9:15AM, V1 (Administrator) said that the facility does not fill the hospice comfort kits which include Morphine unless the resident has an immediate need for pain control. I can't answer to why the primary care provider wasn't contacted for pain control. On 9/13/23 at 9:30AM, V27 (Hospice Registered Nurse) stated, There was an order on our end for liquid morphine and the rest of the comfort pack. All of our hospice patients get that. I do not understand why the facility didn't ask us for morphine if they didn't think that they had the order. Of course (R50) should have been medicated with something stronger. It was harmful for (R50's) pain not to be controlled. 40385 2.) R44's Physician Order dated 2/15/23 documents to apply compression hose daily for edema and remove at night. There is no documentation in R44's medical record that R44 refuses to wear the compression hose. On 9/11/23 at 10:05 AM, R44 was sitting in a wheelchair in the dining area. R44 had on regular socks and was not wearing compression hose to R44's bilateral lower extremities. At 10:48 AM R44 was sitting in R44's recliner in R44's room and R44 was not wearing compression hose. At 11:53 AM R44 was sitting in the dining room and at 3:40 PM R44 was sitting in the lounge area. R44 was not wearing compression hose. On 9/12/23 at 8:29 AM R44 was sitting in the dining room and R44 was not wearing compression hose. On 9/12/23 at 11:40 AM, V20 (Licensed Practical Nurse) stated R44 has an order to wear compression hose for edema and R44 has been compliant with wearing them. V20 stated no one has reported to V20 on 9/11/23 or 9/12/23 that R44 refused to wear the compression hose. V20 stated V20 will have a Certified Nursing Assistant apply them now.

Based on observation, interview, and record review the facility failed to ensure safety of a resident by failing to ensure R1 was assessed for independent safe handling of extremely hot liquids. This resulted in R1 sustaining 2nd degree [CONDITION(S)] to R1's right thigh. The facility also failed to develop and implement a care plan to include R1's coffee spill and [CONDITION(S)], and interventions to prevent reoccurrence. R1 is one of three residents reviewed for accidents in the sample list of 39. Findings include: The facility's Report to IDPH (Illinois Department of Public Health) dated 2/16/22 documents the following: On 2/10/22 at approximately 6:15 AM R1 was attempting to get coffee and spilled coffee on R1's right upper thigh. R1 was assessed and there was an open blister to R1's right thigh. After investigation, the facility determined that R1 independently attempted to obtain R1's coffee. When R1 went to apply the lid to the cup, the cup tipped and spilled coffee onto R1's right thigh. R1's Nursing Note dated 2/10/2022 1:26 PM documents R1 spilled coffee on R1's thigh and burned an area that measured 6.25 cm (centimeters) by 5 cm. R1's Progress Note recorded by V11 Nurse Practitioner dated 2/10/22 documents: R1 was evaluated after a coffee spill to R1's right thigh. There was an area with skin peeled away to R1's right inner thigh. R1 had a superficial burn of the right lower extremity. V12 Physician Progress Note dated 2/17/22 documents R1 has a 2nd degree burn and right thigh injury. R1's undated Diagnosis List documents R1 has a diagnosis of [CONDITION(S)]/[CONDITION(S)] following [CONDITION(S)] Disease affecting the right side. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact, R1 requires supervision of one staff person for eating, and R1 has impaired range of motion to one upper and lower extremity. There is no documentation in R1's medical record that R1 was assessed for safe and independent handling of hot beverages. On 3/1/22 at 2:12 PM V8 Licensed Practical Nurse (LPN) removed R1's dressing to R1's right thigh. There was a large pink/red area with peeled skin, and two small pink areas to R1's right thigh. On 3/1/22 at 9:46 AM R1 stated R1 had gotten coffee by R1's self that morning (2/10/22) like R1 usually does. R1 placed the cup on R1's lap to attempt to apply the lid, and the cup tipped and spilled onto R1's lap. The coffee burned and blistered R1's groin. On 3/1/22 at 11:17 AM R1 was sitting in the assisted dining room in a wheelchair, feeding R1's self with R1's left hand. R1's right hand/arm was positioned at R1's side. R1 was drinking from a coffee cup with a sipping lid. The coffee machine was located on the counter of the dining room, near the edge, and within access of the residents. On 3/1/22 at 12:05 PM the coffee was sampled from the dispenser in the assisted dining room. The coffee tasted very hot. The February 2022 Coffee Temperature Log documents the coffee temperature ranged from 166-171 degrees Fahrenheit (F.) On 3/1/22 at 9:42 AM V7 Certified Nursing Assistant (CNA) stated: If they (residents) are with it (cognitively intact) they go and get coffee themselves. Most of the time the residents ask staff to get coffee for them and we put a lid on it. R1 does go and get coffee independently. On 3/1/22 at 11:31 AM V5 Dietary Aide stated: The facility used to have a coffee machine that had an on/off switch. We could turn it off to prevent residents from getting their own coffee. We got a new machine about two months ago. We haven't been able to figure out a way to turn it off like the last one. R1 does get R1's own coffee. On 3/1/22 at 12:00 PM V6 Dietary Manager stated: Usually the coffee temperature ranges from 158-170 degrees F. Yesterday the coffee was 169. V6 obtained coffee from the machine located in the dining room near the administrative hall. V6 calibrated V6's thermometer and obtained a temperature of 171 degrees F. In general staff get coffee for the residents, but sometimes the residents sneak in to the dining room and get coffee. The coffee machine in this dining room is on 24 hours per day for staff to get coffee. V6 has heard that R1 comes into the dining room and gets coffee on R1's own. Following R1's coffee spill we monitored the temperature of the coffee for 4 days. Other than that I'm (V6) not aware that we have done anything different. On 3/1/22 at 2:49 PM V9 LPN stated: R1 often gets up at 3:00 AM and gets R1's own coffee in the dining room. On 2/10/22 shortly after 6:00 AM, R1 told V9 that R1 had spilled coffee on R1's lap and R1 said it [CONDITION(S)]. V9 assessed R1, and R1 had ripped open a blister to R1's right thigh and had applied barrier cream to the area. V9 measured the burn. R1 reported to V9 that R1 had attempted to get the coffee by R1's self. The cup spilled when R1 attempted to apply the lid. R1 can only use the left hand, due to a stroke. R1 can only grasp with R1's right fingers. On 3/2/22 at 10:30 AM V10 Certified Occupational Therapy Assistant (COTA) stated: V10 had treated R1 for OT previously in November 2021. R1 had no functional range of motion to R1's right upper extremity upon R1's discharge from OT. R1 would use R1's left hand to feed R1's self. It would require two hands to safely apply a coffee lid. V10 was not aware that R1 had been getting R1's own coffee. The facility has been using sipping lids for the coffee cups. If V10 was aware that R1 was independently getting coffee, V10 wouldn't have recommended anything other than R1 may not have required the use of the lid. On 3/2/22 at 10:51 AM V11 Nurse Practitioner stated V11 was asked to evaluate R1 on 2/10/22 following a coffee spill. V11 stated the coffee burned R1's right thigh. V11 was asked if V11 had any concerns regarding R1's ability to safely and independently obtain coffee. V11 stated V11 would have recommended for R1 to be re-evaluated by OT. On 3/3/22 at 9:46 AM V11 stated: V11 assessed R1's right thigh burn today. V11 is referring R1 to a wound clinic. V11 was told that R1 had gotten coffee, and while attempting to put the lid on the cup, the coffee spilled onto R1's lap. V11 thought the burn looked a little worse today, and a couple areas are starting to blister. V11 agreed with V12's assessment, that the burn is a 2nd degree burn. Scarring would be based on the healing process, and R1 is a diabetic so healing will take longer. On 3/2/22 at 11:00 AM V2 Director of Nursing stated R1 was not assessed for the ability to safely and independently obtain R1's coffee since R1 is alert and oriented. On 3/2/22 at 9:36 AM V1 Administrator stated R1 reported to the nurse that R1 had spilled coffee on R1's lap. R1 had attempted to get the coffee by R1's self. We have now instructed staff and R1 that staff are to get R1's coffee. R1 still tries to get R1's coffee independently, and staff continue to re-educate R1. At 9:56 AM V1 Administrator stated the facility does not use an assessment tool to determine a resident's ability to safely and independently obtain hot beverages. At 1:05 PM V1 Administrator stated the facility does not have a policy for the provision of hot beverages or accident prevention regarding hot beverages.

Based on interview and record review the facility failed to prevent misappropriation of property for one (R2) of 39 residents reviewed for abuse in the sample list of 39. This failure resulted in R2's personal money in the amount of $64.00 being taken without permission from R2's purse that was stored in R2's bedroom. Findings include: On 3/1/22 at 8:56 AM R2 stated: About three weeks ago R2 noticed R2's money was gone. R2 had about $66 in R2's purse, and there was only $2 left. R2 had went to therapy that day and left R2's purse in the 3rd drawer of R2's dresser, and later that day R2 had the purse under R2's bed sheets. R2 had last checked R2's money about 3 days prior to the day R2 noticed it was missing. R2 had received $30 cash from family the beginning of August 2021, and a few weeks ago V14 Licensed Practical Nurse (LPN)/R2's Family had given $100 cash to R2 to go out to eat. R2 had money leftover that R2 placed into R2's purse, near the back pocket with R2's wallet. R2 has not had any problems with missing items or money for the last year and a half. R2 said there were two newer staff that R2 suspected may have taken the money. One was an agency Certified Nursing Assistant (CNA) (V38) who gave R2 a shower prior to 2/10/22. (V38) had left the shower room a few times to get towels, and R2's money may have disappeared then. The facility also had a new janitor (V15 Agency Housekeeper) that worked on R2's unit. R2 stated whoever took it must have needed the money more than me (R2.) R2's Minimum Data Set, dated dated dated [DATE] documents R2 is cognitively intact. The facility's Report to Illinois Department of Public Health dated 2/16/22 documents: On 2/10/22 at 8:30 PM R2 reported that R2 was missing $64 from R2's room. Following Investigation and search of room, reported money is unable to be located. Interview with (R2) reports that (R2) is not sure when the money went missing and is not exactly sure how much money (R2) is missing. Interviews with staff report no one aware of the location of the money. Investigation concluded, however facility staff will continue the search. V16's (LPN) written statement dated 2/11/22 documents: On 2/10/22 at 8:00 PM R2 was going through R2's purse. R2 showed V16 that R2 had $2.00 in R2's wallet. R2 said that R2 had $64.00 that was missing from R2's wallet. R2 said that R2 checks R2's money every couple days and the money was there 2-3 days prior. R2 didn't know where the money went. R2's room was searched and the money was not found. The undated note with a time of 9:50 AM documents V13 CNA said R2 had money in R2's wallet on Monday (2/7/22), and R2 stated a dark skinned employee gave R2 a shower and cleaned R2's room. R2's Audit Report documents V38 Agency CNA gave R2 a shower on 2/9/22. On 3/1/22 at 11:51 AM V14 (R2's family) stated: V14 had given R2 $100 cash to go out to eat with family (at an unidentified time.) R2 refused to give V14 the remaining change. R2 may have had $50 left over. R2's family member gave R2 $30 for R2's birthday in August 2021, and R2 kept that money in R2's purse. R2 has not had any prior problems with missing money. R2 told V14 that R2 was missing about $60. R2 thinks it was two agency staff that stole R2's money, and that they had it planned. R2 usually takes R2's purse into the shower, but this time they whisked (R2) away. R2 left R2's purse behind in the room. R2 is pretty smart about (R2's) money. R2 told V14 they didn't take the one dollar bills or (R2's) change. On 3/1/22 at 2:57 PM V13 CNA stated: On 2/11/22 R2 told V13 that R2 had $64 that was missing. On 2/7/22 R2 pulled out money from R2's wallet to offer to pay V13 for animal wall decor that V13 had given to R2. V13 refused money from R2. V13 was not sure the exact amount that R2 had. R2 told V13 that R2 believed a dark skinned employee took R2's money while R2 was out of R2's room during a shower that week. R2 told V13 that R2 had left R2's purse on the floor in R2's room, and R2 usually takes the purse with R2 to the shower. On 3/2/22 at 9:01 AM V16 LPN stated: On the evening of 2/10/22 R2 told V16 that R2 was looking through R2's wallet and $64 dollars was missing. R2 showed V16 that R2 had two one dollar bills remaining. R2 told V16 that R2 checks R2's purse every couple of days, and R2 thought the money was gone within the last couple of days. On 3/1/22 at 12:18 PM V24, Housekeeping Supervisor stated V15, Agency Housekeeper worked on R2's unit on 2/7, 2/8, 2/9 and 2/10/22, and V15 no longer works in the facility. On 3/1/22 at 1:26 PM V2 Director of Nursing reviewed the facility's hall assignments from 2/7-2/10/22. V2 confirmed V38 Agency CNA worked on R2's unit between 2/7/22 and 2/10/22. On 3/2/22 at 9:58 AM V1 Administrator stated: On 2/10/22 around 8:30 PM, V16 LPN reported that R2 was missing money. R2 said the money went missing a few days ago, and wasn't sure of an exact day or how much money was missing. We searched R2's room and was unable to locate R2's money. The facility's Abuse Prohibition policy revised 3/15/18 documents the following: No person shall misappropriate or steal any resident ' s Property.

Based on observation, interview, and record review the facility failed to assess for a resident's fall/accident risk and failed to provide supervision and assistance with a transfer per the resident's care plan for one of six residents (R74) reviewed for falls/accident hazards in the sample list of 45. This failure resulted in R74 falling and sustaining a patellar [MEDICAL CONDITION] knee and a laceration to the right forehead that required sutures. Findings include: 1. R74's Face Sheet dated 9/11/19 documents R74's [DIAGNOSES REDACTED]. R74's Minimum Data Set ((MDS) dated [DATE] documents R74 has severe cognitive impairment, uses extensive assistance of one staff for transfers, and has impaired balance when moving from a seated to standing position needing staff assistance to stabilize. R74's Fall Risk assessment dated [DATE] documents R74 is at high risk for falls. R74's Progress Note documented by V13 RN (Registered Nurse) on 7/5/19 documents at 3:15 AM R74 was heard yelling out and found lying on the floor next to R74's bed with knees bent and head next to the night stand. The facility's Fall Assessment and Management Policy revised on (MONTH) 2019 documents the facility will assess a resident's fall risk on admission, quarterly and after each fall. This policy documents Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. There are no other documented Fall Risk Assessments after 4/30/19 in R74's medical record. R74's Fall Investigation Report dated 8/3/19 documents on 8/3/19 at 2:10 AM V14 CNA (Certified Nursing Assistant) observed R74 standing at the bedside. R74's knees buckled and R74 fell to the floor hitting the right side of R74's head on the nightstand resulting in a laceration to the right forehead. This report documents R74 complained of right knee pain and was sent to a local hospital. This report documents (R74) had been confused earlier in the evening talking about going up the stairs when there were none (stairs). V3 RN written interview with V15 Former RN dated 8/5/19 documents V15 entered R74's room and observed R74 sitting on the side of the bed. This statement documents V15 told R74 that V15 would get V14 to assist R74 and left the room to notify V14. V14's written interview dated 8/3/19 at 2:10 AM documents V14 had left the unit and upon returning V15 told V14 (R74) was sitting on the side of the bed wanting to get up. This written interview documents I automatically put my supper down to get (R74) and as soon as I was walking into the room (R74) tried to stand up before I could get to (R74) and fell . There was no documentation that V15 utilized the call light to request assistance before leaving R74. R74's Emergency Department Notes dated 8/3/19 at 4:02 AM by V17 emergency room Physician document (R74) presents to the emergency department from nursing home after an unwitnessed fall. Staff report patient fell out of bed, hitting (R74's) head on the dresser. Staff deny L[NAME] (Loss of Consciousness.) Laceration to right side of forehead. No anticoagulant use. Patient reports right knee pain on arrival. These notes document R74 received four sutures to the right [MEDICAL CONDITION]. R74's Right Knee Radiology Report dated 8/3/19 documents Nondisplaced lateral patellar (knee cap) fracture. R74's Care Plan dated 12/8/18 documents R74 needs prompt response to all requests for assistance. Revision on 8/20/19 documents R74 uses extensive assistance from staff for transfers. This Care Plan documents R74 is at risk for falls due to gait and balance problems and a history of falls. 09/12/19 10:40AM V3 RN states R74 transferred with extensive assist of one prior to R74's fall on 8/3/19. On 9/09/19 at 9:23 AM R74 was sitting in a wheelchair in the lounge area. R74's right leg was in an immobilizer and elevated on the foot pedal of R74's wheelchair. R74 stated R74 had fallen, but was unable to recall the details of the fall. On 9/10/19 at 4:20 PM V14 CNA stated V14 was working on 8/3/19 when R74 fell around 2:00 AM. V14 stated V14 had left the unit to heat up V14's supper and when V14 returned, V15 Former RN (Registered Nurse) told V14 that R74 was sitting on the side of the bed and V14 needed to go assist R74. V14 stated when V14 entered R74's room, R74 was witnessed to attempt to stand from R74's low bed, R74's knees buckled causing R74 to fall and hit R74's head on the night stand. V14 stated R74 has a history of falls and restlessness during the night, and staff would have to assist R74 out of bed. V14 stated R74 has a history of attempting to stand from the low bed, but R74 is not able to transfer without assistance. V14 stated, I think the nurse (V15) could have helped (R74) back into bed and that would have given a little more time for me to get to (R74) and possibly prevent (R74) from falling. On 09/11/19 at 10:08 AM V3 RN stated V3 investigated R74's 8/3/19 fall. V3 stated V15 left R74 sitting on the side of R74's bed to notify V14 that R74 needed assistance. V3 stated the CNAs are more familiar than the nurses with how to transfer the residents. V3 stated V3 would have thought that V15 would have assisted R74 up into the wheelchair or laid R74 back down if V15 thought R74 would have gotten up. V3 stated R74 is impulsive with transfers at times. V3 stated R74's post fall intervention was to be gotten up when R74 is restless. V3 stated Fall Risk Assessments are completed quarterly and verified R74's last documented Fall Risk Assessment was 4/30/19. On 09/11/19 at 2:35 PM V18 (R74's Physician) stated per R74's emergency room notes on 8/3/19, R74 hit the right side of R74's head causing a laceration and sustained a fractured right patella due to trauma as a result of a fall.

Based on record review and interview, the facility failed to assess and recognize the need for physician intervention for weight gain related to fluid overload. This failure resulted in R1's decline and requiring hospitalization . R1 is one of three residents reviewed for weights in the sample of five. Findings include: R1's Physician order [REDACTED]. The same POS documents an order for [REDACTED]. The Plan of Care for R1 documents a focus area of (R1) has altered cardiovascular status related to ([MEDICAL CONDITION], Hypertension, Arrhythmia). Interventions documented for this focus area include: Daily weights, call (physician) of (two) pound weight gain in 24 hours or five pound weight gain in one week. Progress Notes dated 2/3/18 document R1 complaining of a headache. Vitals are documented as heart rate of 125, blood pressure 135 systolic and 86 dyastolic. R1 was short of breath with oxygen saturations of 86 percent. No temperature was recorded. Progress notes document R1 complaining of R1's legs and feet being painful in the 30 days prior. R1 was sent to the emergency room at 3:25 pm and admitted to the Crital Care Unit [MEDICAL CONDITIONS] and Pneumonia. The facility weight records documents R1's weights as follows: 1/31/18 - 337.6 pounds, 1/24/18 - 336.0 pounds, 1/17/18 - 327.6 pounds (8.4 pound weight gain). There is no documentation in R1's medical record of any physician notification. A facility document titled Dietary Manager Tasks in Preparing for Dietician documents the following: Complete the Nutritional Tracking Form or RD (Registered Dietician Referral Form) keep the form out every month and add to it as new residents are admitted or readmitted , Significant weight losses or gains (weight exception report from electronic medical record). Meet with Dietician briefly to update at the begining of each visit. R1's Medical Record does not contain any assessment by the Registered Dietician for these weight gains as directed per facility policy or Progress Notes. The last Registered Dietician assessment documented in R1's Medical Record is dated 4/14/17 with a recommendation for a 1600 cc (cubic centimeter) fluid restriction and a cardiac diet. R1's Progress Notes do not have any documentation of physician notification for R1's weight gain of 8.4 pounds. On 2/15/18 at 1:55 pm V4, Medical Director and Primary Care Physician for R1 stated V4 did not recall being notified of R1's 8.4 pound weight gain in the week of 1/17/18 through 1/24/18. V4 stated had notification of R1's weight gain been reported V4 would have initiated assessments and interventions for fluid overload if indicated given R1's history of [MEDICAL CONDITION]. V4 stated any significant weight gain such as this should be reported to the physician, especially with R1's history of [MEDICAL CONDITION]. V4 stated, 'the (facility) missed this. On 2/15/18 at 1:10 pm V6, Food Service Supervisor acknowledged that the Registered Dietician (V5) should have seen R1 due to R1's weight gain. V6 stated R1 did trigger for weight gain and was referred to see the RD (V5) but there is no assessment in R1's chart since 4/14/17. Hospital Records document R1 being received into the emergency roiagnom on [DATE]. Hospital records document on this date On exam patient (R1) appears to be in respiratory distress with expiratory wheezing, tachepnea, accessory muscle usage. She has a large amount of lower extremity [MEDICAL CONDITION] with a history of [MEDICAL CONDITION]. Admit to Hospital with Acute combined systolic and diastolic [MEDICAL CONDITION], Acute [MEDICAL CONDITIONS], due to unspecified organism and Pneumonia. Laboratory values were completed, including a BNP (Brain Natriuretic Peptide). The laboratory value for R1 documented for this specific test on 2/3/18 was 4424 picograms per milliliter (pg/ml). The normal range documented is 0 - 450 pg/ml. Critical Care was consulted. Critical Care Physician documents the following: The patient (R1) required interventions to treat and or prevent the high probability of developing imminent or life threatening condition(s) of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Intensive Care Unit Assessment documents that R1 has three plus [MEDICAL CONDITION] in both legs up to the knees and bilateral arms up to the elbows. Right lower extremity is red, indurated, hot, small skin openings, serossanguinous fluid coming from that. Pulses: Radial arteries two plus, lower extremities pulsations absent. Hospital scale weight documented as 324 pounds. Blood cultures growing Gram positive cocci resembling Streptococcus seen in two of two bottles. Intravenous antibiotic of [MEDICATION NAME] started. Hospital Records dated 2/6/18 document: Assessment - 1.[MEDICAL CONDITION]: resolving Blood Cultures positive for Beta-[DIAGNOSES REDACTED] Streptococcus Group C recovered from two of two bottles. Most likely source from [MEDICAL CONDITION] on the right lower extremity and less likely to be pneumonia. [MEDICAL CONDITION] Congestions. Currently on [MEDICATION NAME]. 2. Right Lower extremity [MEDICAL CONDITION]/wound infection: most likely streptococcus. 3. Bilateral lower extremity [MEDICAL CONDITION]: needs gentle diuresis 4. [MEDICAL CONDITION] 5. Acute on Chronic CKD ([MEDICAL CONDITION]) 6. [MEDICAL CONDITION]. 7. Probable Aortic Valve Endocarditis: Patient has strep Group C bacteremia and [MEDICAL CONDITION] echocardiogram (TEE) showed prominent lambl's excrescences seen on edges of aortic valve cannot rule out vegetations serial imaging to ensure Lambl's excrescences recommended. Patient (R1) will be treated with six weeks of [MEDICATION NAME] and need follow-up per cardiology recommendation. R1 was re-admitted to the facility on [DATE] at 5:38 pm with orders that include: follow-up with Infectious disease related to [MEDICAL CONDITION] of lower extremity in four weeks, daily weights with reporting parameters of three pound gain in one day and five pound gain in 7 days, and Intravenous anti-biotic with an end date of 3/18/18. R1's weight on discharge from the hospital is documented as 285.0 pounds (39 pounds less than on hospital admit 2/3/18). On return to the facility R1 weighed 279.2 pounds per facility scale and documentation, 58.4 pounds less than documented on 1/31/18.

Based on record review and interview, the facility failed to notify R1's physician of a significant weight gain. This failure resulted in the decline and fluid overload with the subsequent hospitalization of R1. R1 is one of three residents reviewed for weights in the sample of five. Findings include: R1's Physician order [REDACTED]. The same POS documents an order for [REDACTED]. The Plan of Care for R1 documents a focus area of (R1) has altered cardiovascular status related to ([MEDICAL CONDITION], Hypertension, Arrhythmia). Interventions documented for this focus area include: Daily weights, call (physician) of (two) pound weight gain in 24 hours or five pound weight gain in one week. The facility weight records document R1's weights as follows: 12/6/17 - 309.0 pounds, 12/13/17 - 316.6 pounds (7.6 pound weight gain) 2.46 percent, 12/27/17 - 315.4 pounds, 1/3/18 - 319.8 pounds, 1/10/18 - 324.6 pounds, 1/17/18 - 327.6 pounds, 1/24/18 - 336.0 pounds, (a significant weight gain of 8.4 pounds) 2.57 percent, and 1/31/18 - 337.6 pounds. These figures document significant weight gain over a one week period of time (2.57 percent) and an insidious weight gain over an eight week period of time from 12/6/17 to 1/31/18 of 28.6 pounds (8.5 percent). The facility's policy titled Weight Management Policy and Procedure dated (MONTH) (YEAR) directs staff as follows: The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietician. There is no Dietician recommendations for R1 in her medical record for this weight gain of 8.4 pounds. The last Dietician assessment and/or recommendation for R1 is dated 4/14/17. Nursing Progress Notes do not document any physician notification of the weight gain of R1 between 12/6/17 and 12/13/17 (2.46 percent) nor is there any documentation of physician notification for R1's weight gain between 1/17/18 and 1/24/18 (2.57 percent). Facility Nursing Notes dated 2/3/18 document that R1 was admitted to the hospital into the Critical Care Unit for [MEDICAL CONDITION]. Hospital Records document R1 being received into the emergency roiagnom on [DATE]. Hospital records document on this date On exam patient (R1) appears to be in respiratory distress with expiratory wheezing, tachepnea, accessory muscle usage. She has a large amount of lower extremity [MEDICAL CONDITION] with a history of [MEDICAL CONDITION]. Admit to Hospital with Acute combined systolic and diastolic [MEDICAL CONDITION], Acute [MEDICAL CONDITIONS], due to unspecified organism and Pneumonia. Laboratory values were completed, including a BNP (Brain Natriuretic Peptide, test for heart function). The laboratory value for R1 documented for this specific test on 2/3/18 was 4424 picograms per milliliter (pg/ml). The normal range documented is 0 - 450 pg/ml. Critical Care was consulted and admitted to the Critical Care Unit. Critical Care Physician documents the following: The patient (R1) required interventions to treat and or prevent the high probability of developing imminent or life threatening condition(s) of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Intensive Care Unit Assessment documents that R1 has three plus [MEDICAL CONDITION] in both legs up to the knees and bilateral arms up to the elbows. Right lower extremity is red, indurated, hot, small skin openings, serossanguinous fluid coming from that. Pulses: Radial arteries two plus, lower extremities pulsations absent. Hospital scale weight documented as 324 pounds. Blood cultures growing Gram positive cocci resembling Streptococcus seen in two of two bottles. Intravenous antibiotic of [MEDICATION NAME] started. Hospital Records dated 2/6/18 document: Assessment - 1.[MEDICAL CONDITION]: resolving Blood Cultures positive for Beta-[DIAGNOSES REDACTED] Streptococcus Group C recovered from two of two bottles. Most likely source from [MEDICAL CONDITION] on the right lower extremity and less likely to be pneumonia. [MEDICAL CONDITION] Congestions. Currently on [MEDICATION NAME]. 2. Right Lower extremity [MEDICAL CONDITION]/wound infection: most likely streptococcus. 3. Bilateral lower extremity [MEDICAL CONDITION]: needs gentle diuresis 4. [MEDICAL CONDITION] 5. Acute on Chronic CKD ([MEDICAL CONDITION]) 6. [MEDICAL CONDITION]. 7. Probable Aortic Valve Endocarditis: Patient has strep Group C bacteremia and [MEDICAL CONDITION] echocardiogram (TEE) showed prominent lambl's excrescences seen on edges of aortic valve cannot rule out vegetations serial imaging to ensure Lambl's excrescences recommended. Patient (R1) will be treated with six weeks of [MEDICATION NAME] and need follow-up per cardiology recommendation. R1 was re-admitted to the facility on [DATE] at 5:38 pm with orders that include: follow-up with Infectious disease related to [MEDICAL CONDITION] of lower extremity in four weeks, daily weights with reporting parameters of three pound gain in one day and five pound gain in 7 days, and Intravenous antibiotic with an end date of 3/18/18. R1's weight on discharge from the hospital is documented as 285.0 pounds (39 pounds less than on hospital admit 2/3/18). On return to the facility R1 weighed 279.2 pounds per facility scale and documentation, 58.4 pounds less than documented on 1/31/18. On 2/15/18 at 1:55 pm V4, Medical Director and Primary Care Physician for R1 stated V4 did not recall being notified of R1's 8.4 pound weight gain in the week of 1/17/18 through 1/24/18. V4 stated had notification of R1's weight gain been reported, V4 would have initiated assessments and interventions for fluid overload given R1's history of [MEDICAL CONDITION]. V4 stated any significant weight gain such as this should be reported to the physician, especially with R1's history of [MEDICAL CONDITION]. V4 stated, the (facility) missed this. V4 acknowledged fluid stasis/overload in the extremities over a period of time will cause [MEDICAL CONDITION].

Based on interview and record review the facility failed to ensure that fall interventions per the care plan were implemented for (R1). (R1) sustained a fall by rolling out of the bed which resulted in (R1) receiving an acute angulated fracture of the distal right femur, an acute angulated displace fracture of the left proximal tibia and acute right forehead hematoma. (R1) is one of three residents reviewed for falls in a sample of three. Findings include: The physician's orders [REDACTED]. R1's comprehensive assessment titled Minimum Data Set ((MDS) dated [DATE] documents R1's cognitive status to be severely impaired, requires extensive assistance with one staff for bed mobility and total dependence with two staff members for transfers and toileting. R1's fall assessments dated 1/6/16, 4/18/16 are documented as High Risk for falls. The fall assessment dated [DATE] documents R1 as being a Moderate Risk for falls. R1's care plan dated 7/13/16 documents the following interventions which was initiated for R1 under falls on 11/28/12, Bed to be in floor position, floor mat with sensor and bolsters to bed. An intervention of mechanical lift for all transfers was implemented 9/9/14. R1's nurses notes dated 8/5/16 at 5:30 PM written by E4, RN (Registered Nurse) documents At 3:30 PM this nurse was called to (R1's) room by CNA (Certified Nurse Assistant). Found (R1) lying on her left side on the floor next to the bed. (R1) had a complaint of pain upon range of motion. Ice pack applied to bruising on forehead. Order received to send to emergency room for evaluation and treatment .(R1) was not moved till EMT's (Emergency Medical Technicians) placed (R1) on the stretcher. EMTs left the facility at 4:02 PM in route to hospital. Facility's form titled and dated 8/5/16 CNA and Nurse Post Fall Investigation documents under the section Factors observed at the time of the fall: documents Bed height not appropriate: bed in knee high position. E3, CNA stated on 8/9/16 No there were no bed bolsters on the bed or in the room, I never knew bed bolsters were to be used . I have never seen (R1's) care plan, I did not know bed bolsters were to be used and the bed is to be in the lowest position. E1, Administrator stated on 8/6/16 at 12:05 PM R1's fall care plan states bed bolsters to on bed. The bolsters were not on the bed when the fall took place and the bed height was not at the lowest to the floor, the bed should of been in the lowest position. Z1, R1's Primary Physician stated on 8/9/16 at 9:42 AM The orders / interventions were written for a reason to help (R1) from falling out of bed. If these interventions were not in place most definitely the fall from the bed would cause for (R1) to fracture. The facility should of had these interventions in place. R1's hospital records titled X-ray Image Report dated 8/5/16 documents under Findings . Bones: Angulated fracture of the distal right femur is noted .Acute angulated displaced fracture of the proximal left tibia is evident The scalp reveals acute right forehead hematoma . The facility policy titled: Fall Assessment, Risk Identification and Management Policy revised dated 3/20/12 states under C and D The potential for injury will be care planned when appropriate, based on the results of the Fall Assessment. The interdisciplinary care plan will be individualized to reflect the specific needs and risk factors of the resident. All staff providing care to the resident will have access to the care plan and interventions.

Based on interview and record review the facility failed to ensure the safe use of an assistive device to prevent an avoidable accident for one of three residents (R1) reviewed for use of a electric/lift recliner chair, in the sample of five. The facility failed to identify and implement interventions to minimize the risk of injury related to the misuse of an electric lift recliner chair, resulting in R1 lifting the chair to a standing position and falling to the floor. R1 sustained a Right Distal Femur Fracture. Findings include: The physician progress notes [REDACTED]. The note by Z1, Physician documents (R1) states her legs still hurt .Has not been sitting in recliner chair with feet elevated .continues to sleep in recliner chair with feet down Chronic pain .positioning likely contributes to leg pain . The Minimum Data Set ((MDS) dated [DATE] documents that R1 has severe cognitive impairment and requires extensive assist of one with transfer, ambulation, dressing, toilet use and bed mobility. The MDS documents that R1 has problems with balance during transitions and walking. R1 is unsteady and only able to stabilize with staff assist for the following walking and transition items : moving from seated to standing; Walking; Turning around; moving on and off toilet and surface to surface transfers (transfer between bed and chair and wheelchair). The Fall assessment dated [DATE] documents R1 is at high risk for falling. The Care Plan dated as reviewed on 2/24/16 documents R1 is at risk for falls/Safety risk related to SOB (shortness of breath) on exertion, anemia, osteopathic, general weakness to lower extremities, chronic edema to legs, visual deficits . The following interventions are identified: Prompted toileting plan She will ask to use bathroom but is forgetful at times ; (R1) prefers to sleep in a recliner for sob and comfort ; Transfers: one assist stand pivot ; Slipper socks or other non-skid footwear present when out of bed . The Occupational Therapy (OT) Evaluation dated 2/23/16 documents the referral was for a custom seating evaluation for a specialized w/c (wheelchair). The evaluation documents that R1 has not fallen but leans laterally and significantly forward head is forward down Thoracic Spine= (equals) Kyphosis. The assessment documents R1's sitting balance during activities of daily living is fair-(Min (A) (minimal assist) or UE (upper extremity) support, w/o (without) LOB (loss of balance) and to reach ipsilaterally; unable to weight shift). The assessment documents that R1 follows directions but has Safety Awareness=Impaired. Functional Limitations as Result of Posture: (R1) at risk for falls out of w/c secondary to decreased postural control with significant leaning forward and sideways in her w/c . On 4/12/16 at 2:00pm Z3, Occupational Therapist stated R1 would fall asleep in the wheelchair and was getting more lethargic. Z3 stated the point of the evaluation was because R1 was becoming more lethargic and having periods of sleeping in the wheelchair. Z3 stated R1's safety awareness was impaired because R1 was not consistent about locking the wheelchair brakes during the observation. Z3 stated when R1 was sleeping in the wheelchair she had decreased postural control with leaning forward and sideways in the chair. Z3 stated she never saw R1 sitting in the recliner chair during the evaluation. Z3 stated R1 was able to have a conversation with her family, but didn't think R1 was clear, not sharp, don't think she was accurate on details. On 4/7/16 at 1:40pm Z2, Nurse Practitioner when asked about R1's cognitive function stated, I think her mental status has deteriorated The Personal Recliner Review dated 2/24/16 documents the following : The recliner is electric ; (R1) is able to adjust the chair position independently . Yes. ; (R1) is able to transfer/ambulate without weight bearing support .No. ; (R1's) feet touch the floor when sitting upright Yes. ; (R1) able to sit upright without assistive device No. ; Transfers independently with or without assistive device No. ; Requires extensive assist to transfer, with or without assistive device Yes. and Dependent on staff for all transfers, or utilizes a mechanical lift No. Based on the responses above, indicate the IDT (Interdisciplinary Team) decision regarding Personal Recliner use by this resident (R1) (R1) demonstrates safe use of the evaluated recliner-no intervention needed On 4/12/16 at 9:50am E4, RN (Registered Nurse), Restorative stated R1 had a room move in February (2016) and that's when she was changed to an electric recliner lift chair. E4 stated R1's comfort level was problematic and R1 for a longtime had a recliner in the lobby but it wasn't electric. E4 stated R1 had restless leg, complained of leg pain and at night would sit on the side of the bed. E4 stated, For her comfort (it was) decided that the regular recliner would make (R1) more comfortable-then the room came available-it all happened-changed (R1) to electric recliner. When asked how she did the Personal Recliner Review (2/24/26) E4 stated she asked R1 all the questions, watched a transfer and checked to see if R1 had the dexterity to operate the remote. E4 stated R1 was able to put her feet on the floor and able to use the remote when asked with no cueing. E4 stated based on all that she felt R1 was safe to use the electric lift recliner chair. When asked if she considered that R1 was assessed to have severe cognitive impairment, E4 stated, (R1) was able to do all those things. (R1) told me she had an electric recliner at home and said she slept in it all the time. If (R1) was not able to do any of the directions on the assessment or if she needed cueing-may have to do a modification I had no idea (R1) would put it up and try to stand. The Occurrence Reports document previous falls on 12/16/14, 1/30/15 and 6/20/15. There are no further falls documented until the Occurrence Report dated 3/9/16. The Occurrence Report dated 3/9/16 at 5:10am documents (R1) on the floor in front of her lift chair which was in it's highest raised position. (R1) sitting on floor leaning back onto her arms, both knees bent, right (to) left Fully dressed, slipper socks on, floor dry. Lap blankets still on her legs Stated she was going to get up. Slid off chair. The statement dated 3/9/16 of an interview with R1 by E4, RN documents the following: I was in my chair and my legs hurt. I was moving to get comfortable. I felt myself starting to slip I tried to stop myself I slid right off the chair. The statement dated 3/9/16 written by E5 and E7, CNA's (Certified Nurse Aide) documents the following: call (light) came on .Heard (R1) yelling. Found her on the floor in front .lift chair .(R1's) chair in the high position . On 4/13/16 at 5:50am E5, CNA stated she had taken R1 to the bathroom around 4 or 4:30am that night (3/9/16). E5 stated, .heard (R1) call light came on, on the way down heard (R1) yelling .was on the floor said her knee hurt. On 4/11/16 at 11:20am E7, CNA stated (E5) and I heard her (R1) calling out--found chair was in the highest position--(R1) was on the floor next to the chair said she fell out of chair saw her (R1) at 4:30am--had to go to bathroom The statement dated 3/9/16 written by E8, LPN (Licensed Practical Nurse) documents the following: (R1) on the floor I saw the chair up high. (R1) was on the floor, knees bent, she was fully dressed. (R1) told me that she slid off the chair . On 4/11/16 at 11:10am E8, LPN stated she last saw R1 after wrapping her legs, probably around 4:40am and was passing pills when she was told R1 had fallen. E8 stated, electric lift chair was up as high as it could be, (R1) had to slip straight down .said her knee hurt The Patient Report (xray) dated 3/9/16 documents the following: (R1) fell ,[DATE] raising lift chair and slide off, pain, limited ROM (range of motion)-new onset The report documents a Right Distal Femoral Fracture. The Emergency Department Report dated 3/9/16 documents the following: (R1) states she fell .earlier this morning and landed on her right leg unable to straighten right knee with significant tenderness and swelling .Xray from outside was read as indeterminate fracture but she has a distal comminuted femur fracture that is closed .CT (Computerized Tomography) of the right knee shows-Comminuted fracture of the right distal femoral metaphysis with moderate displacement and moderate angulation . On 4/12/16 at 3:20pm Z1, Attending Physician was asked if R1's fracture was caused by her fall (3/9/16), and Z1 stated, It sure sounds like the fall caused (it)-would lead me to believe (with the) type of fracture, (it) was caused by the fall .

Based on observation, interview, and record review the facility failed to implement and provide safe transfer as directed and wheelchair transport for five of nine residents (R8, R3, R12, R5, R13) reviewed for falls on the sample of 17. These failures contributed to a fall for R8 resulting in R8 sustaining a laceration requiring hospital treatment. The findings include: 1. The Occurrence Report states on 6/5/14 at 4:20 AM, R8 was "dropped" by E13 (Certified Nursing Assistant/CNA) during transfer. The report states R8 sustained a 2.5 centimeter laceration to the left side of her scalp. The report also includes E13's statement that she transferred R8 without using the sit-to-stand mechanical lift. The Investigation Report, signed by E1 (Administrator) on 6/9/14, states R8 was transferred by E13 using a stand-pivot transfer, without a stand lift. E13 pivoted R8, realized the chair was too far away, and lowered R8 to the ground. R8 then struck her head on the edge of the nightstand, sustaining a laceration to the top of her head. Nurse's Note dated 6/5/14 at 4:40 PM states R8 was transferred to the hospital. Nurse's Note dated 6/5/14 at 10:50 AM states R8 returned from the hospital with six staples to her scalp. On 10/15/14 at 12:50 PM, E2 (Director of Nurses) stated, at the time of the fall, R8 was to be transferred by sit-to-stand lift. E2 stated E13 knew that R8 was to be transferred using a sit-to-stand lift. The facility's Resident Handling Policy states initial screenings are performed on all residents to assess transfer status. Resident transfer status will be tagged in the resident's rooms to inform the staff of the appropriate transfer to use. 2. On 10/14/14 at 11:07 am, E5 Activity Aid) pushed R3's wheel chair through the lobby into the dining room. R3 grimaced while she leaned forward as she held the onto the arms of the wheel chair. R3's feet were bent underneath the wheel chair seat and R3's toes dragged the floor. On 10/14/14 at 11:12 am, E5 stated, "Sometimes she (R3) can keep her feet up and sometimes she can't. They don't really train us on what to do when the residents drag their feet, I just know we can't pull them backwards." 3. On 10/14/14 at 1:04 pm, E6, (CNA) pushed R12's wheel chair out of the dining room, through the lobby and down the hall. R12's feet drug under the wheel chair seat for the duration of the 75 foot transport. On 10/14/14 at 1:08 pm, E6 stated "(R12) tends to drag her feet alot, it doesn't stop the wheel chair very often." 4. On 10/14/14 at 4:30 pm, E7 Housekeeper pushed R5's wheel chair at a fast pace down the hall, through the lobby and into the dining room, approximately 200 feet. R5's legs were extended with the heels of his shoes abruptly skipping on the tile floor. On 10/14/14 at 4:37 pm, E7 stated, "(R5) has a [DIAGNOSES REDACTED] so sometimes he can't help it and other times he drops his feet on purpose." 5. On 10/15/14 at 8:58 am, E8, Beautician/CNA, pushed R13's wheel chair from the dining room to the south hall corridor approximately 50 feet. R13 leaned forward with her feet knocking along the tile floor, stating, "Oh, oh, oh" during the transport. On 10/15/14 at 9:04 am, E8 stated "sometimes she (R13) won't keep her feet up no matter how many times we remind her." On 10/15/14 at 9: 15 am, E11, Physical Therapy Program Manager stated, "The residents should not be expected to hold their feet up for extended periods of time . . ." The undated facility policy titled "Transport Procedure" states "If the resident becomes uncooperative, feet drop or drag you are to stop and get a licensed staff."