Every finding on record at Doctors Nursing & Rehab Center

Based on interview and record review, the facility failed to ensure urostomy appliance changes were completed for 1 of 3 residents (R1) reviewed for quality of care in a sample of 4.The findings include:R1's Resident Face Sheet documented R1 was admitted to the facility on [DATE] at 5:30 PM, with a primary diagnosis of Spastic Quadriplegic Cerebral Palsy and other diagnoses including: Neuromuscular dysfunction of bladder and Extended Spectrum Beta Lactamase (ESBL) resistance-urine.R1's Care Plan with a revision date of 8/6/26 documents a problem area of Resident requires a urostomy, risk for infection hx (history) of recurrent urinary infections, neurogenic dysfunction. Corresponding interventions include: urostomy care every shift and change bag as ordered and as needed with initiation dates of 8/15/26.R1's undated ongoing care plan documented Severe Cognitive Decline and identified R1 as nonverbal and unable to communicate her needs except through nonverbal signs of pain or discomfortR1's Physician's order effective 8/5/2026 directed nursing staff to change R1's catheter bag as needed.On 8/25/2026 at 9:40 AM, V7, Registered Nurse, stated R1 had previously been hospitalized from [DATE] through 8/5/2026, during which a urinary drainage bag dated 8/3/2026 was placed. V7 stated R1's records from the 8/16/2026 hospitalization documented the urinary drainage bag dated 8/3/2026 remained in place and contained a large amount of sediment.R1's Progress Notes dated 8/5/26 documents upon R1's return from the hospital she was on isolation precautions related to MDRO (Multi Drug Resistant Organism)/ CRE (Carbapenem-resistant Enterobacterales) of urine.R1's Progress Note titled Antibiotic Monitoring dated 8/12/26 documents a reason for the antibiotic use of UTI (Urinary Tract Infection) with indwelling catheter.R1's Progress Note dated 8/14/26 documents antibiotic use for Symptoms: Other-sedimentation.On 8/26/2026 at 11:08 AM, V8, Registered Nurse, stated she was unable to locate documentation showing R1's urostomy appliance was changed between 8/5/2026 and 8/16/2026.On 8/26/2026 at 11:35 AM, V2, Director of Nursing, stated V2 was unable to locate or produce documentation showing R1's urostomy bag was changed between 8/5/2026 and 8/16/2026. V2 stated it was possible R1's urostomy bag did not get changed during that period.On 8/27/2026 at 10:20 AM, V20, Registered Nurse, stated that from 8/5/2026 through 8/24/2026, R1's order directed staff to change R1's urostomy urine bag/appliance as needed. V20 stated she had never changed R1's urostomy bag during her employment at the facility, which began approximately mid-July 2026.R1's Physician's Orders document an order with a received date and start date of 8/25/26 for Remove old urostomy appliance with adhesive remover and replace with new appliance. Frequency: Once a day on Mon (Monday), Thu (Thursday)The facility's Ureterostomy Care policy (revision date July 2017) documents The purposes of this procedure are to promote cleanliness and to protect peristomal skin from irritation, breakdown, and infection. Under General Guidelines documents that when the urostomy appliance was replaced, staff were to assess the stoma and surrounding skin and document the care provided, including the date and time, condition of the skin, appliance used, findings, and the resident's tolerance of the procedure.The American Cancer Society website (https://www.cancer.org/cancer/supportive-care/ostomies/urostomy/management.html) under Caring for a Urostomy documents Changing the pouch: Different pouching systems are made to last different lengths of time. Some are changed every 3 days or so, and some just once a week. It depends on type of pouch you use.

Based on interview and record review, the facility failed to provide intravenous medications a prescribed to meet the needs of the residents for 1 of 3 residents (R1) reviewed for pharmaceutical services in a sample of 4.The findings include:R1's Resident Face Sheet documented R1's admission date as 1/25/2023 and identified R1's primary diagnosis as Spastic Quadriplegic Cerebral Palsy. The Census Summary further documented diagnoses of Chronic Respiratory Failure with Hypoxia, Extended Spectrum Beta-Lactamase resistance in the urine, Neuromuscular Dysfunction of Bladder, history of urinary calculi, and Bradycardia.R1's Care Plan with a revision date of 8/6/26 documents a Problem of Resident has recurrent Urinary Tract Infection (UTI) with long term antibiotic, current dx (diagnosis) UTI. Corresponding interventions include: Meds per order report to MD if ineffective/adverse effects with an initiation date of 8/21/25. Another Problem on R1's Care Plan documents Resident requires a urostomy, risk for infection, hx (history) of recurrent urinary infections, neurogenic dysfunction. Corresponding interventions for this area includes: meds/ antibiotics per order and report to md if ineffective/adverse effects with an initiation date of 8/15/25.R1's Medication Administration Record (MAR), dated 8/1/26 to 8/25/2026, documents orders for Meropenem 1 gram 50mL (milliliters) intravenously every 8 hours with order dates of 8/6/26 to 8/10/26 and 8/10/26 to 8/13/26. The MAR documents 23 scheduled doses with 20 doses as administered 3 doses as not administered (1 dose on 8/8/26 and 2 doses on 8/10/2026).On 8/25/2026 at 12:10 PM, V8, Registered Nurse, stated R1's Meropenem was administered, over one hour, through a peripherally inserted central catheter in R1's right upper arm. V8 stated the peripherally inserted central catheter infused slowly throughout treatment and an antibiotic ordered to infuse over one hour took approximately two to three hours to administer.On 8/25/2026 at 12:45 PM, V3, Licensed Practical Nurse, stated R1's Meropenem course was considered completed on 8/13/2026, at which time V3 discovered several doses remaining in the medication cart. V3 stated she could not recall the exact number of remaining doses but recalled there were several and placed them in the facility medication storage room.On 8/26/2026 at 9:33 AM, V14, Pharmacist, stated the pharmacy dispensed a total of 24 Meropenem one-gram doses for R1: 15 doses on 8/6/2026, 6 doses on 8/10/2026, and 3 doses on 8/12/2026 (a total of 24 doses). V14 stated 21 doses were required to complete the prescribed seven-day course and the additional three doses represented one additional day of medication.On 8/26/2026 at 11:05 AM, eight prefilled Meropenem one-gram intravenous doses labeled for R1 were observed in a clear bag in the facility medication storage room. V7, Registered Nurse, was present and confirmed the bag contained eight Meropenem one-gram doses intended for R1.On 8/26/2026 at 3:10 PM, V2, Director of Nursing, stated two doses of R1's Meropenem one gram were not administered on 8/10/2026 because staff reported intravenous tubing was unavailable. V2 stated that upon returning to the facility on 8/11/2026, V2 obtained intravenous tubing from emergency pharmacy stock maintained at the facility.The facility's Medication Administration policy, revised June 2026, documented medications were to be administered safely and appropriately.The facility's undated Infusion Therapy Products - General Information policy documented infusion therapy products were to be safely and accurately administered by an authorized nurse.

Based on interview and record review, the facility failed to respond to call lights in a timely manner for 3 of 12 residents (R3, R11 and R12) reviewed for call lights in a sample of 12 residents.This past noncompliance occurred from 7/8/26-7/9/26.Findings include:1.) On 7/22/26 at 9:08 AM, R3 who was alert and oriented to person, place and time stated there is frequently only 2-3 Certified Nurse Aides/CNA staff on night shift (6p-6a) for the whole building. R3 stated when night shift only has 2-3 CNAs it takes staff up to 30 minutes to answer call lights.2.) On 7/22/26 at 11:19 AM, R11 who was alert and oriented to person, place and time stated call lights are answered on average in approximately 30 minutes at the facility. 3.) On 7/22/26 at 11:30 AM, R12 who was alert and oriented to person, place and time stated call lights are answered on average in 20 minutes but can extend to as long as 30 minutes sometimes.Resident Council Minutes dated 7/8/26 at 2:00 PM, documents, They (residents) say when they have call light on it takes a while for them (CNAs) to come.On 7/23/26 at 11:42 AM, V2, Director of Nurses/DON stated she heard in the last resident council meeting (July 2026) the residents brought up the concern about call lights not being answered timely. V2 stated she believed 5-10 minutes was a reasonable amount of time to respond to a call light. V2 stated regarding call lights not being answered for up to 30 minutes she would have to look at the individual situation to see what the circumstances were to determine if it was an appropriate amount of time. V2 stated administration staff had done education with the CNA staff about the importance of answering call lights timely.Facility's policy titled Answering the Call Light dated revised July 2014 documents to Answer the resident's call as soon as possible.Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 7/9/26 with V2, V20, (Assistant Director of Nursing/ADON, and V15, CNA Coordinator and V21, Respiratory Therapist in attendance. The QAPI Ad Hoc form documents under A. Immediate corrective action for those affected by the deficient practice: Immediate education of current C.N.A. staff in facility on call light policy and timeliness of answering of call lights. Under B. Process/Steps to identify others having the potential to be impacted by the same deficient practice the form states All residents have the potential to be affected by complaints of resident council call lights not being answered timely. Under C. Measures put into place/systematic changes to ensure the deficient practice does not recur documents, Education completed with C.N.A. staff by Director of Nursing or Designee regarding answering of call lights and facility policy and procedure regarding answer call lights. Education initiated immediately and will be kept at the facility for review. Under D. Plan to monitor performance to ensure solutions are sustained documents, Audit of call lights, 10 residents a week for 4 weeks to ensure compliance with policy by management staff of answering of call lights, with special focus on timeliness.2.Education/in-service documentation documents that all facility CNA and Nursing staff were educated on the Call Lights policy & Procedure and ensuring all call lights answered timely and are within residents' reach. This in-service was completed on 7/8/26. 3. Weekly monitoring of call light audits were done on 7/10/26 and 7/14/26. These audits included asking residents if their call lights were being answered timely. V4, V14, V15, V17, V18 and V19, CNAs all verified they had been educated on importance of answering call lights promptly, attending an in-service about call lights and verified for this surveyor the signatures on the in-service sign in sheet were their signatures regarding answering call lights appropriately and promptly.

Based on interview and record review the facility failed to ensure staffing is sufficient to meet the needs of the residents timely. This has the potential to affect all 50 residents currently residing at the facility. Findings Include:The facility Resident Roster dated 4/8/26 documents 50 residents currently reside at the facility.1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I am incontinent of bowel and toileting. I require assistance to remain dry and clean. I use briefs, pads and I require assistance to maintain application and incontinent supplies as required.On 4/9/26 at 11:17 AM, V19 (Family Member) stated it takes longer for facility staff to respond to call lights in the evening and R1 had to sit in feces/urine for up to two hours.2. R2's Resident Face Sheet with a print date of 4/11/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, anemia, chronic kidney disease, and overactive bladder.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toilet hygiene.R2's current Care Plan documents a Problem area with a start date of 3/11/26 of, Resident admitted to (name of facility) for (skilled LTC/long term care) care [sic]. I require a Baseline Care Plan identifying care needs, risks, strengths and goals within the first 48 hours. This Problem area includes the intervention with a start date of 3/11/26 of, Bowel and Bladder: I am occasionally incontinent for urine and toileting. I am continent for bowel and toileting. I am at risk for bladder and bowel incontinence and require assistance to remain dry and clean. I use briefs and require assistance to maintain application and incontinent supplies required.On 4/9/26 at 10:25 AM, R2 stated it takes an hour or more for facility staff to answer call lights at times. R2 stated she is incontinent and had to sit in urine when it takes them longer.On 4/11/26 at 8:31 PM, when asked if they answer call lights timely, V12 (Certified Nursing Assistant/CNA) stated they do the best they can. V12 stated there are about 50 residents in the facility at least 12 of them require assistance of two staff for incontinence care.On 4/11/26 at 8:37 PM, V13 (CNA) stated it usually takes 15-20 minutes to answer the call lights.On 4/11/26 at 8:45 PM, V14 (CNA) stated it takes 15-30 minutes to answer call lights at times. V14 stated three CNA's are not enough to meet the needs of the residents timely. V14 stated they have three CNA's and two nurses on the 12-hour night shift and one of the nurses leaves at 3 AM. When asked if residents get checked and changed timely. V14 stated they usually do but if they have call lights going off during bed checks then the call lights have to wait.On 4/12/26 at 2:36 PM, V15 (Licensed Practical Nurse/LPN) stated they have three CNA's and two nurses on the 12-hour night shift. V15 stated she is the only nurse from 3 AM to 5 AM. V15 stated V2 (Director of Nurses/DON) comes in at 5 AM since there is only one nurse working. V15 stated during that time frame she is passing medications and doing treatments and answers call lights when she can. V15 stated the CNA's are doing bed checks during that time frame and they have to prioritize which call lights to answer. V15 stated some people may have to wait longer, especially if they have been on their light a lot and the staff know they have been cared for. V15 stated she wasn't aware of a negative impact that had occurred yet, but if something happened during that time frame, things that should get done wouldn't. V15 stated the staff provide good care, they are just burnt out from taking care of too many residents.On 4/12/26 at 7:03 PM, when asked if she had any concerns/complaints related to call lights being answered timely and/or incontinence care being provided timely, V6 (RN/Registered Nurse) stated, At night, yes because I don't feel like we are adequately staffed. V6 stated all the night shift CNA's are good and work timely but they can only do so much when there is only three of them.On 4/12/26 at 8:27 PM, V2 (Director of Nurses) stated they have enough staff for the census but not for the acuity of the residents. V2 stated there are residents who require assist of two staff and if someone needs help while they are assisting those residents then they have to wait. When asked if answering call lights timely is an issue, V2 stated, I think they answer them as soon as they can. But when you are busy and doing something else it won't be soon. V2 stated if they are doing bed checks they can't answer call lights.On 4/11/26 at 9:11 PM, V1 (Administrator) stated they follow the state agency guidelines related to staffing. V1 stated they have three CNA's and one nurse from 3 AM to 6 AM.The facility April 2026 Schedule Sheet for CNA's documents three CNA's work from 6 PM to 6 AM each night.The facility April 2026 Schedule Sheet documenting licensed nurse schedules document one licensed nurse working from 7 PM to 7 AM on 4/2, 4/3, 4/6, and 4/11 and on 4/1, 4/7, 4/8, and 4/9 there are two licensed nurses from 7 PM to 3 AM and one from 3 AM to 7 AM.The facility untitled and undated policy documents, The Facility provides adequate staff to meet needed care and services for our resident population and according to regulatory staffing requirements.

Based on interview and record review the facility failed to ensure call lights were answered timely for 2 of 4 (R1 and R2) residents reviewed for call lights in the sample of 14.Findings Include:1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 was dependent on staff for toilet hygiene.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I am incontinent of bowel and toileting. I require assistance to remain dry and clean. I use briefs, pads and I require assistance to maintain application and incontinent supplies as required.On 4/9/26 at 11:17 AM, V19 (Family Member) stated it takes longer for facility staff to respond to call lights in the evening and R1 had to sit in feces/urine for up to two hours.On 4/15/26 at 10:55 AM, V21 (Family Member) stated she arrived to the facility on an unknown date and R1's call light was on. V21 stated R1 had a bowel movement and had feces on him. V21 stated she waited 45 minutes after arriving at R1's room and then went and found staff to clean R1 up. V21 stated on another unknown date R1 had a bowel movement and they waited an hour for assistance before she left the room to locate a staff member to clean R1 up.2. R2's Resident Face Sheet with a print date of 4/11/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, anemia, chronic kidney disease, and overactive bladder.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toilet hygiene.R2's current Care Plan documents a Problem area with a start date of 3/11/26 of, Resident admitted to (name of facility) for skilled LTC (long term care) care. I require a Baseline Care Plan identifying care needs, risks, strengths and goals within the first 48 hours. This Problem area includes the intervention with a start date of 3/11/26 of, Bowel and Bladder: I am occasionally incontinent for urine and toileting. I am continent for bowel and toileting. I am at risk for bladder and bowel incontinence and require assistance to remain dry and clean. I use briefs and require assistance to maintain application and incontinent supplies required.On 4/9/26 at 10:25 AM, R2 stated it takes an hour or more for facility staff to answer call lights at times. R2 stated she is incontinent and had to sit in urine when it takes them longer.On 4/11/26 at 8:31 PM, when asked if they answer call lights timely, V12 (Certified Nursing Assistant/CNA) stated they do the best they can. V12 stated there are about 50 residents in the facility and at least 12 of them require assistance of two staff for incontinence care.On 4/11/26 at 8:37 PM, V13 (CNA) stated it usually takes 15-20 minutes to answer the call lights.On 4/11/26 at 8:45 PM, V14 (CNA) stated it takes 15-30 minutes to answer call lights at times. V14 stated three CNA's are not enough to meet the needs of the residents timely. V14 stated they have three CNA's and two nurses on the 12-hour night shift and one of the nurses leaves at 3 AM. When asked if residents get checked and changed timely. V14 stated they usually do but if they have call lights going off during bed checks then the call lights have to wait.On 4/12/26 at 2:36 PM, V15 (Licensed Practical Nurse/LPN) stated they have three CNA's and two nurses on the 12-hour night shift. V15 stated she is the only nurse from 3 am to 5 am. V15 stated, V2 (Director of Nurses/DON) comes in at 5 AM since there is only one nurse working. V15 stated during that time frame she is passing medications and doing treatments and answers call lights when she can. V15 stated the CNA's are doing bed checks during that time frame and they have to prioritize which call lights to answer. V15 stated some people may have to wait longer, especially if they have been on their light a lot and the staff know they have been cared for. V15 stated she wasn't aware of a negative impact that had occurred yet, but if something happened during that time frame, things that should get done wouldn't. V15 stated the staff provide good care, they are just burnt out from taking care of too many residents.On 4/12/26 at 7:03 PM, when asked if she had any concerns/complaints related to call lights being answered timely and/or incontinence care being provided timely, V6 (RN/Registered Nurse) stated, At night, yes, because I don't feel like we are adequately staffed. V6 stated all the night shift CNA's are good and work timely but they can only do so much when there is only three of them.On 4/12/26 at 8:27 PM, V2 (Director of Nurses) stated they have enough staff for the census but not for the acuity of the residents. V2 stated there are residents who require assist of two staff and if someone needs help while they are assisting those residents then they have to wait. When asked if answering call lights timely is an issue, V2 stated, I think they answer them as soon as they can. But when you are busy and doing something else it won't be soon. V2 stated if they are doing bed checks they can't answer call lights.On 4/11/26 at 9:11 PM, V1 (Administrator) stated they follow the state agency guidelines related to staffing. V1 stated they have three CNA's and one nurse from 3 AM to 6 AM.The facility policy titled Answering the Call Light dated July 2014 documents, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines.8. Answer the resident's call as soon as possible.

Based on observation, interview, and record review the facility failed to ensure comfortable water temperatures for 3 of 4 residents (R1, R2, and R14) residents reviewed for environment in the sample of 14.Findings Include: 1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Activities of Daily Living: Overall I require.extensive assistance with bathing.On 4/9/26 at 11:17 AM, V19 (Family Member) stated R1 no longer resided at the facility and would not be interviewable. V19 stated R1 took showers on Monday's and Thursdays and during his stay at the facility the water in the shower on R1's hall was cold.2.R2's Resident Face Sheet with a print date of 4/11/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, anemia, chronic kidney disease, and overactive bladder.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2 is cognitively intact. This same MDS documents R2 is dependent on staff for bathing.R2's current Care Plan documents a Problem area with a start date of 3/11/26 of, Resident admitted to (name of facility) for (skilled LTC (long term care) care (sic). I require a Baseline Care Plan identifying care needs, risks, strengths and goals within the first 48 hours. This Problem area includes the intervention with a start date of 3/11/26 of, Activities of Daily Living: Overall I require.extensive assistance with bathing.On 4/9/26 at 10:25 AM, R2 stated she showers twice weekly and hasn't had an issue with the water temperature. R2 stated she uses the shower on her hall to bathe in most of the time but has been taken to other halls to shower.3. R14's Resident Face Sheet with a print date of 4/11/26 documents R14 was admitted to the facility on [DATE] with diagnoses that include aphasia, hemiplegia, hemiparesis, history of falling, blindness, and anorexia.R14's MDS dated [DATE] documents R14 has a severe cognitive impairment and requires substantial/maximal assistance with bathing.R14's current Care Plan documents a Problem area with a start date of 6/26/25 of, Category: ADL's (Activities of Daily Living) Functional Status/Rehabilitation Potential: Resident needs lim/ext (limited/extensive) assist for activities of daily living r/t (related to): REQUIRES ASSIST, rt (right) hemiplegia. This Problem area includes the intervention with a start date of 6/26/25 of, Shower per shower day.The facility (name R1, R2, and R14's hall) Shower Schedule documents R1's shower days on Tuesday's and Friday's, R2's shower days on Wednesday's and Saturday's, and R14's shower days on Tuesday's and Friday's.On 4/9/26 at 9:29 AM, this surveyor with V2 (Director of Nurses) present verified the accuracy of the surveyor's thermometer by placing it in a cup of ice water. The thermometer read 33.6 degrees Fahrenheit. At 9:38 AM on this same day, this surveyor with V2 present entered the shower room on R1, R2, and R14's hall and checked the temperature of the water in the shower. The temperature reading was 98.4 degrees Fahrenheit. The water was allowed to run for several more minutes (untimed) and was rechecked and was 96.8 degrees Fahrenheit. V2 stated they rarely use this shower room. V2 stated she wasn't sure if the staff ever used this shower room.On 4/9/26 at 9:56 AM, V3 (Certified Nursing Assistant/CNA) stated she was working on R1, R2, and R14's hall and had not given any showers yet. V3 stated there were no showers scheduled but she did give showers on Monday and Tuesday of this week including R1's shower. V3 stated she used the shower on their hall and they didn't complain about the water temperature but she had to let it run for about ten minutes before it heated up.On 4/9/26 at 12:14 PM, V4 (Maintenance Director) stated he had an unknown housekeeper check the water temperature in R1, R2, and R14's shower room and the temperature was 98.6 degrees Fahrenheit. V4 stated he was taking residents on transports and when he returned he would adjust the temperature of the water. V4 stated today was the first time he was made aware the water temperature in that shower room was too low. V4 stated his goal temperature was 100-115 degrees Fahrenheit. V3 entered the room where this surveyor and V4 were talking and stated it takes 5-10 minutes to heat up. V4 left the room and returned sometime later and stated the water did not heat up to the correct temperature after running it for the suggested 5-10 minutes.On 4/9/26 at 2:03 PM, this surveyor and V4 entered R1, R2, and R14's shower room and checked the water temperature in the shower after V4 stated they had adjusted the temperature of the water. The water temperature was 104.2 degrees Fahrenheit on V4's thermometer and 105.6 degrees Fahrenheit on this surveyor's thermometer.The facilities untitled and undated policy documents, It is the policy of (name of facility) that the facility monitor and maintain a reasonable and comfortable temperatures and environment for the residents, employees, and guests. Procedure.3. A random sampling of water temperatures will be monitored routinely. 4. The hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times. 5. Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit.

Based on interview and record review the facility failed to ensure residents were free from misappropriation of medications for 3 of 3 (R3, R4, and R5) residents reviewed for abuse in the sample of 14.This past non-compliance occurred between 3/27/26 and 4/1/26.Findings Include:The Long Term Care Facility and IID (Individuals with Intellectual Disabilities) -Serious Injury Incident Report dated 3/28/26 documents under Detailed Incident Summary, Administration was notified of possible drug diversion at the facility regarding (R3's) oxycodone. It was discovered that (R3's) narcotic card had been tampered with and the medication in the card was metoprolol and not oxycodone. Investigation continued and MD (physician), POA (power of attorney) and local police were notified of the investigation. Nurses currently on shift were immediately drug tested and were negative. Call was made to (V7/Registered Nurse-RN) for interview and drug test. (V7) did not answer the call so the DON (Director of Nurses/V2) made arrangements to meet (V7) at the facility prior to her next shift for drug testing. Prior to her shift on 3/29/26, (V7) sent a text message to the DON and stated that she needed to take personal time due to mental health issues and would not be returning to the facility to participate in the investigation. The facility continued the investigation and found 2 additional cards of narcotics had been tampered with and the hydrocodone/acetaminophen had been replace [sic] with potassium 10 meq (milliequivalents). All nurses were then drug tested with the exception of (V7). The facility has not been able to make contact with her since the beginning of the investigation. All nurses' urine tests were negative. MD, POA's of affected residents, pharmacy, and police were notified of additional results of the investigation. Affected residents' medications has been replaced by the facility and no adverse drug reactions were observed on the residents. (V7) was terminated for suspicion of drug diversion, investigation is ongoing with (name of local police department).On 4/9/26 at 1:00 PM, V2 (Director of Nurses/DON) stated there were three residents whose medications had been tampered with, R3, R4, and R5. V2 stated she was notified on 3/27/26 by V15 (Licensed Practical Nurse/LPN) and V6 (RN/Registered Nurse) there was a card of narcotics missing. V2 stated she began an investigation, and they were able to locate the missing card of medications in the wrong section of the medication cart. V2 stated on 3/28/26 they discovered the labels had been switched on R3, R4, and R5's narcotics and the medications were replaced with Lopressor (metoprolol) and potassium. V2 stated they notified the local police department, the state police, the attorney general, and the Department of Professional Regulation. V2 stated they did drug screens on all licensed nurses except V7 (RN) who did not return to the facility and refused to participate in the investigation. V2 stated they drew potassium levels on the residents affected and they were within normal limits and monitored their blood pressures and remained within normal limits.1.R3's Resident Face Sheet with a print date of 4/9/26 documents R3 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, hemiplegia, and dependence on respirator.R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a severe cognitive impairment.R3's current Care Plan documents a Problem area with a start date of 5/30/25 of, Resident has pain/risk for pain. Contractures, Hx (history) Pelvic Mass, nonverbal, chronic pain. Interventions for this problem area include, Meds (medications) per order report to MD (Physician) if ineffective/adverse effects.R3's Medication Administration Record (MAR) dated 3/1/26 to 3/31/26 documents a physician order for oxycodone 5/325 milligrams to be administered every 6 hours as needed. This same MAR documents the medications were administered as ordered and documented as effective at relieving the pain. This same MAR documents pain assessments were done each shift and pain scale ranges from 0-4.2.R4's Resident Face Sheet with a print date of 4/9/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include pain in right ankle and joints.R4's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact.R4's current Care Plan documents a Problem area with a start date of 7/5/24 of, Resident has pain/risk for pain. Dx (diagnoses) rheumatoid arthritis, spinal stenosis, pain back and rt (right) shoulder, radiculopathy, arthropathic psoriasis, kyphosis, calciphylaxis, chronic pain. This Problem area includes the intervention of, Administer medication/patches per order report to md (physician) if ineffective/adverse effects.R4's MAR dated 3/1/26 to 3/31/26 documents a physician order for hydrocodone 10/325 milligrams administer four times a day as needed. This same MAR documents the hydrocodone was administered as ordered and the medication was effective in relieving the pain. This same MAR documents pain assessments were completed each shift, and the pain scale ranges from 0-8.On 4/11/26 at 6:48 PM, R4 denied concerns with medication administration. R4 stated her pain medication seems to run out faster than it should but denied concerns with it.3. R5's Resident Face Sheet with a print date of 4/9/26 documents R5 was admitted to the facility on [DATE] with diagnoses that include pain in right leg.R5's MDS dated [DATE] documents a BIMS score of 15, indicating R5 is cognitively intact.R5's current Care Plan documents a Problem area with a start date of 2/13/23 of, Resident has complaints of chronic pain R/T (related to) Dx (diagnoses), diabetic neuropathy, polyosteoarthritis, hx (history) Migraine, PVD (Peripheral Vascular Disease), pain legs/knees, OA (osteoarthritis) rt (right) knee. This Problem area includes the intervention of, meds (medications) per order and report to md if ineffective/adverse effects.R5's MAR dated 3/1/26 to 3/31/26 documents a physician order for hydrocodone 10/325 milligrams administer every four hours as needed. This same MAR documents the hydrocodone was administered as ordered and documents the medication was effective or somewhat effective. This same MAR documents pain assessments were completed each shift with the pain scale ranging from 0-8.On 4/11/26 at 7:04 PM, R5 denied concerns with her pain medication.On 4/11/26 at 10:16 AM, this surveyor attempted to contact V7 a voice mail was left requesting a return call. This surveyor was not able to make contact with V7.On 4/12/26 at 2:36 PM, V15 (Licensed Practical Nurse/LPN) stated she was working with V6 (Registered Nurse/RN) 3/27/26 and they did a pre-count before the next shift arrived. V15 stated she knew there had been 9 cards of narcotics delivered the night before and there were only 8 papers and cards. V15 stated they reported it to V2 (DON) and she began the investigation. V15 denied any concerns related to narcotics diversion prior to that.On 4/12/26 at 7:03 PM, V6 (RN) stated she was working with V15 on 3/27/26 and they started counting the narcotics cards and V15 stated she had received 9 cards of narcotics the previous shift, R3's oxycodone was one of them and was missing. V6 stated they called the pharmacy to verify one had been sent out and the pharmacy confirmed they had sent a new card out for R3 on 3/25/26. V6 stated she notified V2 (DON) it was missing. V6 stated V2 began an investigation and found narcotics had been replaced with other medications.On 4/11/26 at 9:47 PM, V8 (police officer) stated he was notified by V2 (DON) that narcotics were missing. V8 stated they noted the medication cards had been tampered with and believed V7 was the offender. V8 stated the facility started the investigation and V7 refused to give a drug test. V8 stated since V7 refused the drug screen the case was closed, as far as he was concerned.On 4/9/26 at 1:00 PM, V1 (Administrator) stated they did not have any other allegations of misappropriation of resident's medications. V1 stated an investigation was started immediately and all notifications were made. V1 stated they had been unable to obtain a written police report. In an email on 4/14/26 at 2:43 PM, V1 stated there were a total of 120 narcotics missing from R3, R4, and R5. The facility Abuse Prevention Program dated 11/26/25 documents Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.Misappropriation of resident property: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident consent.The facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach.Prior to the survey date, the facility took the following actions to correct the non-compliance:The facility QAPI (Quality Assurance and Performance Improvement) Ad Hoc Form dated 4/1/26 documents the following, 1. Immediate Corrective Action for those affected by the deficient practice: Suspected nurse suspended immediately pending investigation. Investigation initiated. (R3's) MD (Physician), POA (power of attorney), pharmacy, and local police notified. Nurses working during Drug test administered to nursed worked when the missing drug was noted. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur. Regional Clinical Director (V20) audited narcotics to ensure no other cards were tampered with on carts (North and Pheonix carts) and DON (V2) audited narcotics on [NAME] and Southwest halls. Licensed nurses educated on drug diversion policy, recognition of label/medication tampering, and reporting suspected diversion. DON (V2)/designee will visually audit narcotic supply to ensure there is no evidence of tampering 3 x (times)/week for 4 weeks. DON/designee will audit narcotic count sheets 2x/week for 4 weeks to ensure counts are correct. 4. Plan to monitor performance to ensure solutions are sustained. Administrator to monitor above and report findings/trends/issues to the QA (Quality Assurance) committee.

Based on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 4 (R1 and R2) residents reviewed for activities of daily living (ADL) in the sample of 14.Findings Include:1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene and has occasional urinary and bowel incontinence.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I am incontinent of bowel and toileting. I require assistance to remain dry and clean. I use briefs, pads and I require assistance to maintain application and incontinent supplies as required.On 4/9/26 at 11:17 AM, V19 (Family Member) stated R1 had to wait for up to two hours for care to be provided after having a bowel movement. On 4/15/26 at 10:55 AM, V21 (Family Member) stated she arrived to the facility on an unknown date and R1's call light was on. V21 stated R1 had a bowel movement and had feces on him. V21 stated she waited 45 minutes after arriving at R1's room and then went and found staff to clean R1 up. V21 stated on another unknown date R1 had a bowel movement and they waited an hour for assistance before she left the room to locate a staff member to clean R1 up.2. R2's Resident Face Sheet with a print date of 4/11/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, anemia, chronic kidney disease, and overactive bladder.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toilet hygiene and has frequent urinary and bowel incontinence.R2's current Care Plan documents a Problem area with a start date of 3/11/26 of, Resident admitted to (name of facility) for (skilled LTC/long term care) care [sic]. I require a Baseline Care Plan identifying care needs, risks, strengths and goals within the first 48 hours. This Problem area includes the intervention with a start date of 3/11/26 of, Bowel and Bladder: I am occasionally incontinent for urine and toileting. I am continent for bowel and toileting. I am at risk for bladder and bowel incontinence and require assistance to remain dry and clean. I use briefs and require assistance to maintain application and incontinent supplies required.On 4/9/26 at 10:25 AM, R2 stated it takes an hour or more for facility staff to answer call lights at times. R2 stated she is incontinent and had to sit in urine when it took them longer.On 4/11/26 at 8:45 PM, V14 (CNA/Certified Nursing Assistant) stated it takes 15-30 minutes to answer call lights at times. V14 stated three CNA's are not enough to meet the needs of the residents timely. V14 stated they have three CNA's and two nurses on the 12-hour night shift and one of the nurses leaves at 3 AM. When asked if residents get checked and changed timely. V14 stated they usually do but if they have call lights going off during bed checks then the call lights have to wait.On 4/12/26 at 2:36 PM, V15 (Licensed Practical Nurse/LPN) stated they have three CNA's and two nurses on the 12-hour night shift. V15 stated she is the only nurse from 3 AM to 5 AM. V15 stated V2 (Director of Nurses/DON) comes in at 5 AM since there is only one nurse working. V15 stated during that time frame she is passing medications and doing treatments and answers call lights when she can. V15 stated the CNA's are doing bed checks during that time frame and they have to prioritize which call lights to answer. V15 stated some people may have to wait longer, especially if they have been on their light a lot and the staff know they have been cared for.On 4/12/26 at 7:03 PM, when asked if she had any concerns/complaints related to call lights being answered timely and/or incontinence care being provided timely, V6 (RN/Registered Nurse) stated, At night, yes, because I don't feel like we are adequately staffed. V6 stated all the night shift CNA's are good and work timely but they can only do so much when there is only three of them.On 4/12/26 at 8:27 PM, V2 (Director of Nurses) stated they have enough staff for the census but not for the acuity of the residents. V2 stated there are residents who require assist of two staff and if someone needs help while they are assisting those residents then they have to wait.On 4/11/26 at 9:11 PM, V1 (Administrator) denied concerns and/or complaints related to timely incontinence care.The facility policy titled Toileting documents, Policy: It is the policy of (name of facility) to ensure all of our residents' toileting needs are met. Procedure.2. Check each resident every two hours and change if found incontinent.Ensure the call light is in within reach and answer ASAP (as soon as possible).

Based on interview and record review the facility failed to ensure a urinalysis was obtained timely for 1 of 3 (R1) residents reviewed for urinary tract infections in the sample of 14.Findings Include:1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include urinary tract infections.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I am incontinent of bowel and toileting. I require assistance to remain dry and clean. I use briefs, pads and I require assistance to maintain application and incontinent supplies as required.On 4/9/26 at 11:17 AM, V19 (Family Member) stated R1 received orders for a urinalysis and several days later the facility still wasn't able to obtain it. V19 stated he had R1 drink water, then helped him stand up and use the urinal and was able to obtain the urinalysis for the facility.R1's Physician Order Report dated 2/24/26 to 3/30/26 documents a physician's order with a start date of 3/27/26 of Culture, Urine; Urinalysis; Once- One Time; 05:30 AM.R1's Progress Notes document on 3/27/26 at 3:12 AM, Signee (V6 RN/Registered Nurse) attempted to obtain UA (urinalysis) via straight cath (catheter) x (times) 2 attempts and unsuccessful. Res (resident) stood up at bedside with assist from CNA's (Certified Nursing Assistants) and signee to see if he could urinate in urinal and unsuccessful. There is no further documentation related to the urinalysis until 4/1/26 at 5:57 AM when the progress note documented the urinalysis was obtained on the evening of 3/31/26 and sent to the laboratory on the morning of 4/1/26.R1's urinalysis report documents a collection date of 3/31/26 and reported on 4/2/26. The results included 2 plus blood, positive for nitrites, 2 plus leukocytes, greater than 50 white blood cells, and negative for bacteria. The culture and sensitivity report documents it was reported on 4/8/26 and documents greater than 100,000 colony forming units per milliliter of pseudomonas aeruginosa.On 4/12/26 at 7:03 PM, V6 (RN) stated she attempted to get a urinalysis on R1 on an unknown night and was unsuccessful. V6 stated she attempted to collect it via straight catheter and by having R1 urinate in a urinal with no success. V6 stated she reported it to the next shift, and she isn't sure what happened after that. V6 stated it shouldn't have taken four days to get the sample.On 4/12/26 at 8:27 PM, V2 (Director of Nurses) stated she was aware of an order for a urinalysis for R1 and that they had attempted to obtain via straight catheter with no result. V2 stated she knew the family had given them a urinal with urine in it and they educated them they couldn't use the urine since they didn't know how long it had been sitting. V2 stated they were finally able to get the sample. When asked if it was acceptable for it to take from 3/27/26 to 3/31/26 to obtain the sample, V2 stated, Really, probably not but if he is incontinent most times it is kind of hard to collect that.The facility Clinical Cultures policy dated 4/2015 documents, Policy: Cultures will be performed when necessary to determine the presence of absence of infection.Cultures are obtained as soon as practical when ordered.

Based on interview and record review the facility failed to ensure medications were crushed prior to administration for 1 of 3 (R1) residents reviewed for pharmacy services in the sample of 14.Findings Include:R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include dysphagia, oropharyngeal phase, heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing.R1's current Care Plan does not document a Problem area related to medication administration.R1's Physician Order Report dated 2/24/26 through 3/30/26 documents an order dated 3/10/26 of Diet: Regular solids with Nectar liquids, add household shakes to all meals and an order dated 2/24/26 of May crush medications- do not crush enteric or time released medication.On 4/9/26 at 11:17 AM, V19 (Family Member) stated a nurse brought in R1's medications and attempted to give it to him whole with thin liquids when it was to be administered crushed and in applesauce and R1 was on thickened liquids.On 4/15/25 at 10:55 AM, V21 (Family Member) stated R1's medications were supposed to be crushed and administered in applesauce because he had swallowing issues. V21 stated she would tell them to crush them and put them in applesauce, so he didn't choke. V21 stated on unknown day V2 (Director of Nurses) entered R1's room with a smaller pill that was whole. V21 stated she reminded V2 that R1's medications were supposed to be crushed and V2 told her he could take the one smaller pill whole. V21 stated about an hour later R1 spit something out and he thought it was a tooth, but it was the pill he had kept in his mouth that whole time.The facility Grievance/Complaint Report dated 3/19/26 documents, (V19-family member) states DON (Director of Nurses/V2) was nurse on hall 3/16/26. Came to resident room (V21-family member and V19 was in room) gave resident a pill whole with regular water stating 'He does well with one pill.' (V19) stated he takes his medicine in applesauce and is on thick liquids. DON left room and medication was still in residents' mouth after she exited room. Under Documentation of Facility Follow -Up the report documents, Yes this did happen. I did crush med et (and) put in applesauce and give to resident.On 4/12/26 at 2:36 PM, V15 (Licensed Practical Nurse) stated R1 takes his medications crushed in applesauce.On 4/12/26 at 7:03 PM, V6 (Registered Nurse) stated R1 takes his medications crushed in applesauce.On 4/11/26 at 11:04 AM, V2 (DON) stated R1 can usually take one pill at a time with water. V2 stated it was a small pill, and she gave it to him whole with the water he had in his room that was thickened. V2 stated she left his room, and (V21) came out of the room with the pill that R1 had not swallowed. V2 stated she got R1 another pill, crushed it, and administered it.On 4/11/26 at 9:11 PM, V1 (Administrator) stated V2 went in to give R1 his medications and the (V19) reminded V2, R1 was on thickened liquids. V1 stated she got the thicken liquids and administered R1's medications with the correct consistency water.The facility was unable to provide a policy related to this specific deficient practice.

Based on observation, record review, and interview the facility failed to ensure there was hot water for showers and personal care for the 21 residing on the 200 and 300 halls. The Findings Include: On 3/11/26 at 1:00 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. On 03/11/2026 at 1:12 PM, R10 who was alert and oriented, stated her biggest concern is that the facility does not have hot water. R10 stated when the CNA's (Certified Nurse Assistants) have to clean her up the water is freezing cold. R10 stated it is awful to get your butt wiped with a cold washcloth. On 3/11/26 at 1:15 PM, R23 who alert and oriented, stated that he never has hot water in his sink in his room that he uses to wash up with at night and in the morning. R23 stated that the shower room water temperature is better, but not always hot. On 3/11/2026 at 1:17 PM, the water temperature was taken at the sink in room [ROOM NUMBER] with a metal stemmed thermometer and the hot water measured 80 degrees Fahrenheit. On 03/11/2026 at 1:18 PM, the water temperature was measured with a metal stemmed thermometer in sink of room [ROOM NUMBER] and the hot water was 82.8 degrees Fahrenheit.On 3/11/26 at 1:30 PM, 300 Hall Shower room hand sink hot water temperature was taken with a metal stemmed thermometer and the hot water measured 84 Fahrenheit degrees in the sink. The hot water temperature was taken at the shower head with a metal stemmed thermometer and the hot water measured 80 degrees Fahrenheit. On 03/11/2026 at 1:35 PM, the temperature of water in sink of room [ROOM NUMBER] was measured with a metal stemmed thermometer and the hot water was 87.6 degrees Fahrenheit.On 03/11/2026 at 1:42 PM, the temperature of water in sink of room [ROOM NUMBER] was measured with a metal stemmed thermometer and the hot water measured 95 degrees Fahrenheit.On 03/11/2026 at 1:50 PM, the water temperature of 200 hall shower rooms were tested using a metal stemmed thermometer the hot water at shower head measured 95 degrees Fahrenheit. On 3/12/26 at 2:00 PM, V11 (Maintenance Director) stated that there are 3 water heaters to control the entire building. V11 stated that when, there were problems he had been checking water temperatures everyday, but has not been for quite some time. V11 stated that he is working on turning up the water heaters from 102 to 105 in an attempt to get the water to heat up. The facility Daily Census Report dated 3/10/26 documents there were 21 residents residing on the 200 and 300 halls.The Facilities Temperatures policy with a revision date of 12/2016 documents: It is the policy of (name of facility) that the facility monitor and maintain a reasonable and comfortable temperature and environment for the residents, employees and guests .3. A random sampling of water temperatures will be monitored routinely. 4. The hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times .

Based on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 10 residents residing on the 100 hall.The Findings include On 3/11/26 at 11:40AM, V30 (Family Member) stated that in the evening hours and on weekends it is very hard to get assistance from staff with call lights. V30 stated she has to walk the halls to find staff to assist R23. On 3/11/26 at 2:00 PM, during the resident council R1 who was alert to person, place and time and R5 who was alert to person, place and time both stated that evening time it is hard to get someone to answer your call light. R1 resides on the 100 hall.On 03/12/2026 at 8:54 AM, V6 (Certified Nursing Assistant/CNA) stated, that residents need to be turned/repositioned every 2 hours or as needed. V6 also stated that, or as often as I can by myself today when she was asked how often she does bed checks. V6 stated, the next CNA comes in at 10 AM and if she hasn't found help to assist the residents who require 2 people they will get to those residents then. V6 stated, they would like to have 2 CNA's on 100 hall but they normally have call-ins which then they have to try to fill that shift or work short and that is what happened today with a call in, and she is working short until someone can get here. V6 stated, she got here at 6AM and is just now able to do bed checks at 8:54AM. V6 stated, she will do all the people she can do with 1 assist then will find help with residents that are 2 assist. On 03/12/2026 at 9:07 AM, V6 (CNA) completed care for residents on the 100 hall that only required one person assistance and no other CNA's were present or scheduled on the hall at that time.On 03/12/2026 at 11:17 AM, V17 (Respiratory Therapist) stated, resident rounds are completed every 2 hours and as needed and the CNA's do the repositioning. V17 stated that respiratory therapy will help every 2 hours with bed checks if needed. V17 stated that two CNA's are assigned on the 100 hall if they are lucky, but feels there needs to be 2 due to residents mainly being dependent on staff. V17 feels that the CNA's do their best when working alone. On 3/13/2026 at 12:30 PM, V32 (Regional Director of Clinical Services) stated that they just follow the Public Health guidelines for staffing and go by their resident needs when assigning staff.According to the Daily Census Report dated 3/10/26 there are 10 residents residing on the 100 hall.

Based on observation, interview and record review, the facility failed to dispose of expired stock medical equipment, expired resident and stock medications, and failed to label medications with residents' names, and document the date opened on multi-use vials of medications for 4 of 6 residents (R5, R12, R26, and R44 ) reviewed for medication storage in the sample of 26.Findings include:On 3/11/26 at 10:55 AM the facility's medication storage room was reviewed with V3, Assistant Director of Nursing. V3 opened the medication refrigerator and pulled out 5 bags that each contained a swab and a lab collection tube. Each swab documented the expiration date of 10/2024. There was one unopened vial of Daptomycin with no name on label and an expiration date of 1/12/25. There was an unopened vial of Humulin R insulin with the expiration date of 11/21/25. There were 2 boxes of Arformoterol nebulizer solution with R26's name on the labels, one box had expiration date of 1/19/26 and the other box had the expiration date of 12/1/24. There were 2 boxes of Formoterol nebulizer solution with R26's name on the label both boxes with the expiration date of 7/2025. There was also one Bisacodyl suppository with the expiration date of 1/2026, but no name on the package. On 3/11/26 at 11:35 AM the North Hall medication cart was reviewed with V3. There was an open bottle of Systane eye drops with no resident's name on the bottle or the box it was contained in. In the same medication cart, there was a 10 milliliter sodium chloride pre-filled syringe with the expiration date of 1/31/26. There was also a 20 gauge needle with the expiration date of 4/10/24.On 3/11/26 at 11:45 AM the Southwest Hall medication cart was reviewed with V3. In the top drawer of the medication cart there was an ampule of Albuterol nebulizer solution with only R12's first name written in marker on the side of the ampule, but no directions for use. There was also an opened Insulin Glargine injectable pen in a clear plastic bag with R44's name written in black marker on the pen but no label with orders for use and no date documenting when it was opened. There was an opened bottle of Lantus insulin with no label identifying who it belonged to and no documented date when it was opened.On 3/11/26 at 11:50 AM, V3 stated she does not know who the Systane eye drops belong to and she threw them in the trash. V3 stated she knows she should throw away expired medical supplies such as syringes and needles but she does not have a sharps container large enough to hold all of them. V3 stated she has told them they needed to get rid of the expired syringes and needles but they won't listen. V3 stated she only has four hours a day to do her job. V3 stated insulin pens and vials should be dated when they are opened. She stated the bags containing the swabs and lab collection tubes were used to do rapid COVID tests back in COVID times and she acknowledged they were all expired.R44's physician order dated 8/23/2025 documents she receives insulin glargine subcutaneous injection; 100 UNITS/ML (milliiters); amt (amount): 10 UNITS; subcutaneousonce a day.R12's physician order documents ipratropium-albuterol .05 mg-3 mg (milligrams)/3ml solution for nebulization three times a day with a start date of 10/12/25. R5's physician order for perforomist (formoterol fumarate) solution for nebulization 20mcg (micrograms)/2ml: amt: 2ml; inhalation with a start date of 8/01/2024 and a discontinue date of 10/21/2024.R26's physician order for arformoterol solution for nebulization; 15mcg/2mL; amt:2ml; inhalation with a start date of 03/11/2025. R26's current physicians order does not document a current order for formoterol nebulizer solution.The facility's policy, Storage of Medications, revised 5/1/18 documents all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secured closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview, and record review, the facility failed to provide restraint assessments for 2 (R3, R7) of 2 residents reviewed for physical restraints in the sample of 26. The Findings Include: 1.R3's Face Sheet documented an admission date of 2/10/2026 and included diagnoses of cerebral infarction, dependence on respirator, chronic respiratory failure with hypercapnia, and acute pulmonary disease. R3's Minimum Data Set (MDS) with assessment reference date as 2/16/2026 documents no Brief Interview for Mental Status score because resident is rarely/never understood, indicating significant cognitive impairment. This same assessment documented under Section P0-Restraints and Alarms of limb restraint is used less than daily. R3's Care Plan documented a focus area of physical restraints; resident is at risk for decline related to use of physical restraint - hand mitt right hand with an intervention of assessing and documenting the need for a restraint. R3's Physician Orders dated 2/18/2026 documented hand mitt as needed to prevent pulling/removal of tubes, release every 2 hours for 15 minutes with supervision as needed. On 03/10/2026 at 11:23 AM, R3 was observed lying in her bed while resting and hand mitten applied to right hand. R3's Progress Note on 3/11/2026 by V3 (Assistant Director of Nursing) documented R3 had been alert and oriented, mouths words. Resting via bed with head of the bed elevated.hand mitt in place. The were no restraint assessments found in R3's record.2. R7's Face Sheet documented an admission date of 12/8/2023 and included diagnoses of cerebral palsy, dependent of a respirator, contracture of muscle, multiple sites, cerebral infarction and pulmonary fibrosis. R7's Minimum Data Set (MDS) with assessment reference date as 1/26/2026 documents no Brief Interview for Mental Status score because resident is rarely/never understood, indicating significant cognitive impairment. This same assessment documented under Section P0-Restraints and Alarms of limb restraint is used less than daily. R7's Care Plan documented a focus area of physical restraints; resident is at risk for decline related to use of physical restraint - hand mitt left hand with an intervention of assessing and documenting the need for a restraint. R7's Physician Orders dated 12/4/2025 documented a hand mitt to left hand as needed related to pulling at medical devices, remove every 2 hours for 15 minutes with supervision as needed. On 3/12/2026 at 8:42 AM, R7 was observed lying on her back in her bed with hand mitt applied to her left hand. R7's Progress Note dated 3/13/2026 by V19 (Registered Nurse) documented, resting in bed with head of bed slightly elevated.left hand mitt continued. The were no restraint assessments found in R7's record.On 03/12/2026 11:17 AM, V17 (Respiratory Therapy/ RT) stated, the nursing and RT staff will apply mitts/restraints as needed per orders. V17 stated, the nursing staff is to complete all restraint assessments and not sure how often they are done. On 03/12/2026 at 11:54 AM, V2 (Director of Nursing/DON) stated, she cannot verbalize how often a physical restraints is to be assessed for residents. On 03/12/2026 at 3:16 PM, V1 (Administration) stated, it is her expectation that staff follow the restraint policy and procedure. V1 stated, V24 (MDS Coordinator) has taken over this position in the last month because the previous MDS Coordinator had not been completing the restraint assessments including the pre-assessment form, decision tree form and quarterly assessments. V1 stated, she was not able to find the required assessments required for physical restraints for R3 and R7. The facility's policy Restraints (revised May 21st ,2024) documented under Policy: It is the policy of the facility name that facilities uphold rights of all residents residing in the facility regarding the use of physical restraints. Restraints usage will always be an interdisciplinary decision, including the resident or responsible party and based on comprehensive assessment. Residents with restraints will be assessed on admission and periodically (at least quarterly) by the interdisciplinary team for application, reduction or continuation of a restraint. Restraints will not be used for convenience or discipline. A resident with capacity to make decisions has the right to request the use of a restraint. This same document under Procedure.3. The Pre-Assessment (NUR0110b) is completed as follows: a. The assessment is to be completed by a nurse of licensed physical/occupational therapist.5. The completed Pre-Restraining Assessment (NUR0110b) should be placed in the resident's medical record under the Therapy/Rehab tab. 6. After the Pre-Restraining Assessment is completed the Restraint Decision Tree (NUR0110a) should be determine if the medical symptoms and impact of function have been identified with regard to restraint.

Based on interview and record review the facility failed to ensure that residents are free from unnecessary medication 1 of 5 residents (R2) reviewed for unnecessary medications in a sample of 26. The Findings Include:R2's face sheet indicates an admission date of 11/7/24 and also includes the following diagnosis: anxiety disorder and depression. R2's current physician order sheet for March 2026 includes the following medications: lorazepam 0.5 milligram (mg) once day per gastric tube as needed for anxiety. This order has a start date of 1/09/2026 with no end date. R2's behavior tracking for the last 3 months has no behaviors listed. R2's medication administration record for the last three months list that R2 received lorazepam 1/15/26-1/20/26, 2/2/25, 2/3/26, 2/5/26, 2/9/26-2/12/26, 2/15/26-2/18/26, and 2/24/26-2/26/26.There was no documentation found in R2's record to indicate a reason for R2's Lorazepam to be extended beyond 14 days.On 3/13/2026 at 12:30 PM, V32 (Regional Director of Clinical Services) stated, that she will continue to work with the physicians to ensure that they fill out the paperwork accordingly if they do not want to reduce the medication. V32 states that she is aware they need to place an end date on PRN medications. The psychotropic medication use policy with a revision date of 12/2018 documents: It is the policy of (Facility Name) that all residents receiving psychotropic medications be monitored to ensure the least amount of medication is given to treat the diagnosis. This is accomplished through tracking behaviors and effectiveness of interventions, monitoring for side effects, reviewing data at least quarterly and dosage reduction attempt of at least one quarter annually. Procedure: 4.Residents do not receive psychotropic drugs pursuant to an PRN (as needed) order unless the medication is needed to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days. Except as provided if the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order

Based on interview, observation, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (R9) of 12 residents reviewed for position and mobility in the sample of 26. The Findings Include:R9's resident face sheet documents an admission date of 10/12/2018. This same document includes the following diagnoses: Parkinsonism, symptomatic epilepsy, partial seizures, hypotension, anemia, asthma, contracture of the right hand, and chronic pain. R9's most recent quarterly MDS (Minimum Data Set) dated 12/30/2025 documents section C, that R9 has a BIMS (Brief Interview of Mental Status) of 15, indicating that R9 is cognitively intact. Section GG documents for functional limitation in range of motion that R9 has an impairment on one side for upper extremity. Section GG for self-care documents that R9 is Dependent for toileting, lower body dressing, putting on taking off footwear, substantial / maximal assistance for shower / bathe, upper body dressing, and personal hygiene. The same section documents under mobility, R9 is partial / moderate assistance for roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair / bed transfer, toilet transfer, and tub shower transfer. Section O of this same MDS documents that R9 received 6 days of Restorative for transfers and 4 days of restorative for walking during the look back period.R9's care plan with a start date of 01/11/2024 has a problem area of activity of daily living functional status / rehabilitation. Residents needs assist for activities of daily living related to contracture of right hand and low levels physical activity. Interventions listed include assist with activity of daily living, restorative programs as indicated and ordered, and therapy as ordered.R9's progress note dated 03/12/2026 authored by V32 (Regional Director of Clinical Services) documented writer assessed residents need for splint. Resident states he has not used splint for some time. Writer referred resident to therapy for re-evaluation of splinting needs and comfort.R9's Physician Order Report dated 02/13/2026 - 03/13/2026 does not document an order for a splint. Document titled Occupational Therapy In-Service Training Sign-Off Sheet with a date of 09/18/2025 documented that R9 should wear his splint to the right hand for 4 hours daily. On the bottom of this document, it is noted that R9 needs to put splint on when he gets up in the a.m. and wear for 4 hours. On 03/10/2026 at 8:38 A.M. R9 was observed to not have a splint on right hand. On 03/11/2026 at 9:40 A.M. R9 was observed to not have a splint on to right hand. On 03/12/2026 at 10:03 A.M. R9 was observed to not have a splint on the right hand. On 03/12/2026 at 10:05 A.M. V10 (Certified Nurse Assistant/CNA) stated R9 never wears the splint. V10 stated R9 will refuse to wear it. On 03/12/2026 at 11:15 A.M. R9 stated he use to wear his brace/splint, but the staff no longer put it on him. R9 stated he thought the splint was discontinued so he had not been wearing it. R9 stated he would wear the splint if he is supposed to wear it. On 03/12/2026 at 11:52 A.M. V9 (Physical Therapy Assistant / Therapy Director) stated that R9 should have the splint on to his right hand. V9 stated she would go to the room and see if the splint is in there. V9 stated she is not sure there is an order for him to have the splint, but the staff were educated on when he is supposed to wear the splint. On 03/12/2026 at 11:55 A.M. V9 stated the splint for R9 was in his room on the dresser. V9 stated she evaluated R9 and feel that therapy will pick him back up and work on stretching his hand since she does not know how long it has been since he has had the splint on. On 03/13/2026 at 9:19 A.M. V3 (Licensed Practical Nurse / Assistant Director of Nursing) stated she is not sure how often R9 wears his splint. V3 stated that R9 will refuse care. V3 stated that she is not sure there is a place in the chart where it is documented when he refuses the splint. V3 stated there is no order in the chart for the splint / brace. On 03/13/2026 at 9:20 A.M. V26 (Certified Nurse Assistant) stated she thinks R9 wears his splint daily. V26 stated R9 had a shower this morning and that is why it is not on. V26 stated she was not aware that therapy staff took the splint yesterday and was going to evaluate it. On 03/13/2026 at 9:24 A.M. V2 (Director of Nursing) stated she was not aware that R9 did not have his splint on this week. V2 stated if it is ordered she expects the staff to put the brace on. V2 stated that if R9 is refusing to wear the splint / brace then it should be documented in the medical record. V2 stated there is no order in the medical record for the splint. V2 stated there should be an order in the record so the staff knows R9 needs to have the splint on. On 03/13/2026 at 9:40 A.M. V27 (Certified Nurse Assistant) stated she doesn't routinely work west hall, but she has occasionally. V27 stated she has never seen R9 in a splint / brace and she has never put it on him.On 03/13/2026 at 9:43 A.M. V28 (Licensed Practical Nurse) stated she has only worked for the facility for three weeks. V28 stated she was not aware that R9 had a brace / splint. V28 stated that not staff told her that he was refusing to wear it. V28 stated if she had been made aware she would have charted his refusal. On 03/13/2026 at 9:47 A.M. V9 stated she has completed the insurance verification for R9 to be evaluated by therapy on 03/16/2026. V9 stated she will be putting a new procedure in place to make sure when a resident is discharged , she will make sure the order will be in the chart and the staff will be aware. Facility policy titled Resident Mobility and Range of Motion with a revision date of 10/20/2025 documents under section titled Policy Statement .2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion.

Based on interview and record review the facility failed to ensure that meals served were served at palatable temperature for 3 of 3 (R1, R5 and R23) residents reviewed for palatability in a sample of 26. The Findings Include: During the resident council meeting held on 3/11/26 at 2:00 PM, R1 and R5 both stated that the evening meals are cold and often times they just eat it cold rather than regularly asking for it to be reheated. R1 is the resident council president and was alert to person place and time. R5 stated he attends resident council meetings regularly and was alert to person place and time. On 3/11/26 at 11:40 AM, R23 who was alert to person, place and time stated his family often brings in food for him at dinner so he doesn't have to eat cold food.On 3/12/26 at 12:45 PM, R5 stated that the cold food in the evening has been brought up in resident council meetings regularly. Review of resident council minutes for the last 6 months showed no concerns for dietary and/or cold food. Review of grievance log for last 6 months was reviewed and no grievances logged for cold food by residents or family. On 3/13/26 at 10:00 AM, V29 (Activities) stated that they have mentioned the cold food in the past during resident council meetings. V29 could not give an answer as to why those complaints had not been mentioned in the resident council minutes as they should have been. V29 stated last week she was still here for during the dinner meal and R1 and R5 both requested their meal to be reheated because they complained of it being too cold.

Based on observation, interview, and record review the facility failed to follow infection control practices for 3 (R1, R2, and R3) of 12 residents reviewed for infection control in the sample of 26. The Findings Include:Facility policy titled Cleaning of Durable Medical Equipment with a revision date of 01/18/2021 documented under section titled Policy: All Durable Medical Equipment will be disinfected with appropriate disinfectant between resident uses. Including but not limited to blood glucose monitoring machines, pulse oximeters, thermometers, etc. Under Section titled procedure, to clean, disinfect, and deodorize in one step: wipe surface with towel until completely wet. Allow to remain wet for one minute at room temperature. Wipe dry or allow to air dry.On 03/10/2026 at 11:16 AM, V3 (Licensed Practical Nurse / Assistant Director of Nursing) gathered blood glucose machine, lancet, alcohol wipe and micro kill wipe and placed on disposable tray. V3 sanitized hands and placed gloves on. V3 knocked on the door and entered R1's room. V3 explained the procedure to R1. V3 sat tray with supplies down on the bedside table and cleaned R1's first left finger. V3 picked up the blood glucose machine, inserted strip and obtained a blood sample. V3 discarded the lancet in the sharps container and wiped the blood glucose machine with a Micro-Kill wipe. V3 wiped blood glucose machine for 20 seconds then placed the blood glucose machine on a Kleenex. V3 then discarded the wipe in the trash can, removed gloves and sanitized hands. At 11:24 AM V3 gathered blood glucose machine, lancet, alcohol wipe and micro kill wipe and placed on disposable tray. V3 sanitized her hands and placed gloves on. V3 knocked on the door and entered R2's room. V3 explained the procedure to R2. V3 sat tray with supplies down on the bedside table and cleaned R2's first left finger. V3 picked up the blood glucose machine, inserted strip and obtained a blood sample. V3 discarded the lancet in the sharps container and wiped the blood glucose machine with a Micro-Kill wipe. V3 was observed cleaning the blood glucose monitor for 20 seconds and placed back on Kleenex. V3 then discarded the wipe in the trash can, removed gloves and sanitized hands. At 11:31 AM V3 gathered blood glucose machine, lancet, alcohol wipe and micro kill wipe and placed on disposable tray. V3 sanitized her hands and placed gloves on. V3 knocked on the door and entered R3's room. V3 explained the procedure to R3. V3 sat tray with supplies down on the bedside table and cleaned R3's first left finger. V3 picked up the blood glucose machine, inserted strip and obtained a blood sample. V3 discarded the lancet in the sharps container and wiped the blood glucose machine with a Micro-Kill wipe. V3 was observed cleaning the blood glucose monitor for 25 seconds and placed on a new Kleenex. V3 then discarded the wipe in the trash can, removed gloves and sanitized hands. On 03/13/2026 at 9:19 A.M. V3 (Licensed Practical Nurse / Assistant Director of Nursing) stated she was nervous having a surveyor follow her to do blood glucose testing and didn't realize she had not cleaned the blood glucose machine for a full minute. V3 stated she thought she had cleaned it longer than a minute. V3 stated she knows the policy and was just nervous and in a hurry. On 03/13/2026 at 9:24 A.M. V2 (Director of Nursing) stated it is her expectation that staff follow the policy for proper disinfecting of a blood glucose machine. V2 stated that V3 thought that she had sanitized it long enough. R1's resident face sheet documents that R1 was admitted to the facility on [DATE]. Diagnoses listed include cerebral infarction, acute and chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, chronic atrial fibrillation, low back pain, and edema. R1's Physician Order Report dated 02/13/2026 - 03/13/2026 documents an order for blood glucose to be taken prior to giving sliding scale lispro insulin before meals and at bedtime. R2's resident face sheet documents that R2 was admitted to the facility on [DATE]. Diagnoses listed include cerebral infarction, anxiety, dependence on respiratory ventilator, constipation, chronic respiratory failure, hemiplegia and hemiparesis, type 2 diabetes mellitus with hyperglycemia, and gastro-esophageal reflux disease. R2's Physician Order Report dated 02/13/2026 - 03/13/2026 documents an order for blood glucose to be taken prior to giving sliding scale lispro insulin before meals and at bed time. R3's resident face sheet documents that R3 was admitted to the facility on [DATE]. Diagnoses include kidney transplant, chronic respiratory failure type 2 diabetes mellitus with other specified complication secondary to transplant, status epilepticus, anxiety disorder, chronic kidney disease, contracture of left hand, anemia in chronic kidney disease, and end stage renal disease. R3's Physician Order Report dated 02/13/2026 - 03/13/2026 documents an order for blood glucose to be taken prior to giving sliding scale lispro insulin before meals and at bedtime.

Based on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 47 residents living in the facility.The findings include: 1.R2's Face Sheet dated 02/17/26, documents an admission date of 03/19/21 with diagnoses in part of polyosteoarthritis, morbid obesity, pain in left leg, malignant neoplasm of endometrium, chronic obstructive pulmonary disease, pressure ulcer of sacral region, pain in right knee and unspecific convulsions. R2's MDS (Minimum Data Set) dated 02/04/26 documents in Section C, a BIMS (Brief Interview for Mental Status) score of 15 which indicates R2 is cognitively intact. Section GG documents toileting as dependent and turning and repositioning as substantial/maximal assistance. Section M documents under current number of unhealed pressure ulcers/injuries at each stage as 1 unstageable. R2's Care Plan with an edited date of 02/05/26 documents a problem area of resident is incontinent of bowel and bladder, require assist for toilet use, does not ask to use toilet or bedpan, hx (history) rt (related to) nephrolithiasis with intervention of provide incontinent care as needed. Another problem area of resident need assist for activities of daily living, limited rom (range of motion) rle (Right lower extremity) with an intervention of assist as needed with ADL's (Activities of Daily Living) but encourage independence. A problem area pressure ulcer/injury hx of pressure ulcers, dx (diagnosis) PVD (peripheral vascular disease), incontinence and does not request bedpan, morbid obesity, hx of edema, hx wound sacrum, hx of area left 3rd toe, current ulcer sacrum, diarrhea with an intervention of t/r (turn and reposition) q2 (Every 2 hours) and prn (as needed). On 02/10/26 at 2:11PM, R2 stated she is to be repositioned at least every two hours and sometimes it will be longer than every two hours. R2 said that when she hits her call light or yells out it will take the staff a very long time to answer. R2 said that she feels that the facility is short of staff and could use more staff working at the facility. R2 stated that sometimes you might get help right away other times you just have to wait and see if you do get help. R2 said that when she needs a nurse that most of the time she will get one right away, but there are other times it will take them a long time to come into her room or bring her pain medications. R2 said that she feels like that staff are doing the best they can with the amount of staff they have. 2.R3's Face Sheet dated 02/17/26, documents an admission date of 08/29/25 with diagnoses in part of spondylosis cervical region, repeated falls, chronic kidney disease, muscle weakness, and disorders of bone density and structure. R3's MDS dated [DATE], documents in Section C. a BIMS score of 11 which indicates R3 has moderately impaired cognition. Section GG documents substantial/maximal assistance with toileting and transfer. R3's Care Plan with a edit date of 02/12/26 documents a problem area of ADL Functional status/rehabilitation potential impaired transfers as evidenced by res (Resident) unable to complete transfers independently related to dx: weakness and another problem area of resident is at risk for incontinent of bowel and bladder dx bph (benign prostatic hypertrophy), hx of hesitancy micturition incontinent at times with a intervention of provide assist with toilet use as needed and provide incontinent care as needed. On 02/10/26 at 12:35PM, R3 who were alert and oriented stated that he feels that facility is very short of staff. R3 stated that he thinks staff do the best they can with the number of staff they have. R3 said that he did have a fall recently he had put on his call light and was waiting on staff to answer the call light and got inpatient and fell. R3 said that he doesn't know how long his light was on for. R3 said there are days that he will wait up to 20 minutes if not longer for staff to answer his call light. R3 said he has never had an incontinent episode waiting on staff to answer his light, but he knows if he starts to feel the urge he better start hitting the light because it is going to take them a while to answer. 3.R4's Face Sheet dated 02/17/26, documents an admission date of 06/23/24 with diagnoses in part of polyosteoarthritis, lack of coordination, and muscle weakness. R4's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R4 is cognitively intact. Section GG documents R4 is dependent with toileting and partial/moderate assistance with transfers. R4's Care Plan with a edit date of 11/20/25 documents a problem area of ADL Functional status/rehabilitation potential impaired transfers as evidenced by res unable to complete transfers independently related to dx: weakness and resident is at risk for injuries r/t: h of falls secondary to dx: dizziness, hx unsteady on feet, left hemiparesis with a intervention of provide assist for toileting as needed. On 02/10/26 at 10:27AM, R4 stated that they could use some more staff at the facility. R4 said that he has trouble with getting someone to help get him dressed in the morning. R4 said that it will take them forever just to help him get some clothes on. R4 said that he puts his call light on, and it takes them forever to answer the call light. R4 said that he has had an incontinent episode while waiting on staff to answer his call light to help him. R4 said he wasn't mad just wishes the facility would get more help. 4. R5's Face Sheet dated 02/17/26, documents an admission date of 06/17/25 with diagnoses in part of cerebral infarction, facial weakness, hemiplegia and hemiparesis affecting right dominant side, lack of coordination, and muscle weakness. R5's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R5 is cognitively intact. Section GG documents substantial/maximal assistance with toileting and transfers. R5's Care Plan with an edit date of 02/12/26 documents a problems area of ADL Functional status/rehabilitation potential impaired transfers as evidenced by resident unable to complete transfers independently related to dx: weakness and urinary incontinence resident is incontinent of bowel and bladder requires assist toilet use with a intervention of provide assist with toilet use as needed and provide incontinent care as needed. On 02/10/26 at 12:38PM, R5 stated that some days they do have enough staff and other days they do not. R5 said that she had to wait over 30 minutes at times for staff to answer her call light. R5 said that she has had an incontinent episode while she was waiting on staff to answer her call light and then needed assistance with getting cleaned up as well. 5.R6's Face Sheet dated 02/17/26, documents an admission date of 12/08/25 with diagnoses in part of muscular dystrophy, muscle wasting, muscle weakness, lack of coordination, encounter for attention to tracheostomy, dependence on respirator (Ventilator) status, and non pressure chronic ulcer of left heel and buttocks. R6's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R6 is cognitively intact. Section GG documents R6 is dependent for toileting and turning and repositioning.R6's Care Plan with an edit date of 12/23/25 documents ADL Functional status/rehabilitation potential impaired mobility as evidenced by difficulty moving extremities independently related to dx: weakness and resident needs lim/ext (limited/extensive) assist for activities of daily living r/t requires assist for adls. Dx of ms (Multiple Sclerosis), contractures ble (both lower extremities) with interventions of assist as needed with ADL's., assist as needed with toileting. Another problem area of Resident has impaired gas exchange r/t COPD, acute/chronic respiratory failure, trach, vent. On 02/17/26 at 2:19PM, R6 stated that she feels the facility is short of staff. R6 said that sometimes they only have one staff member like a certified nurse assistant, working on her hallway and she doesn't feel like that is an appropriate number of staff for her hall. R6 said that there are a lot of residents on her hallway including her that have ventilators and tracheostomies which is why they really need the extra people working on the hall. R6 said that anytime she needs help with turning or repositioning or even when she has an incontinent episode, they have to have two staff to help her because of all of her hoses and tubes. R6 said that when they only have one staff member working on the hallway, she will have to wait for the staff member to go to another hall and see if they can get help to turn and reposition her or help change her. R6 said that the nurses will sometimes help but they are also short and are running around trying to get their medication pass done. R6 said that she knows sometimes they don't even have a nurse on her hall because they have to work her hall and another hall, she said that they use to have a nurse on the hall all the time, now they don't anymore. R6 said that she has waited over an hour to get assistance with repositioning and getting someone to answer her call light. On 02/10/26 at 1:41PM, V10 (Certified Nurse Assistant/CNA) stated there are some days when the facility does have enough staff and other days they don't. V10 said that she has worked several of the halls at the facility by herself and she is able to get all the resident care needs done on some of those halls, but there are other halls that she is not able to get all the care needs of the residents completed. V10 said that all she can do is try to do the best she can when she is working by herself. On 02/10/26 at 2:21PM, V8 (CNA) stated that she doesn't feel like that facility has enough staff. V8 said that yesterday she worked from 6AM to 6PM on southwest hall all by herself for over 8 hours. V8 said that she wasn't able to get all of the care done for all the residents. V8 said that most of the time they are able to get all the resident care done such as turning and repositioning, incontinent care, and showers. She said it is very hard but somehow, they manage, but then there are other days they aren't able to get all of this done. V8 said when they don't have enough staff it takes them 15 minutes or longer to answer a call light and that every resident who needs to be turned and repositioned every two hours is not getting turned every two hours, it is longer. On 02/17/26 at 12:47PM, V5 (Registered Nurse/RN) said that no she doesn't think the facility has enough staff to be able to meet the resident care needs. V5 said that most nights when she works, she is able to get most of her stuff done. She said that she is pretty fast and there are other nurses who aren't as fast as her and can't get everything done. V5 said that she doesn't think they have enough CNA staff either some nights they might have enough to be able to meet the resident care needs other nights they might not. V5 said that it also depends on the night, some nights are worse than others. On 02/17/26 at 1:16PM, V11 (CNA) said that when they have call in's they figure out a way to cover the call ins and other days they just don't cover the call in's. V11 said that he lives close and is always available to come into work, but they don't call him even when they have call off's and don't get it covered. V11 said that last week was a horrible week that they had 3 call in's almost every day and didn't get most of them covered. V11 said that usually he is able to get most of the resident care done properly when they have call offs. On 02/17/26 at 1:26PM, V9 (CNA) said that somedays are better than others with staffing. V9 said that yes, they have days they are short of staff and it is hard to get all the resident care provided to them. V9 said that last week they had several days that they were short, and she had to work by herself on west hall for 4 hours. V9 said that there were times that she wasn't able to get all the resident care done such and turning and repositioning for all of the residents who needed it between trying to feed residents breakfast and trying to get them turned and repositioned and trying to provide care to them it was around 2 and 1/2 hours to 3 hours in between turns and checking on the residents. V9 said not only do they not have enough CNA's staff sometimes, but she doesn't think that they have enough nurses for the building either. V9 said that residents will also complain that they don't think they have enough nurses. On 02/17/26 at 1:35PM, V13 (CNA) said that sometimes they don't have enough staff and sometimes they do have enough staff. V13 said that when they don't have enough staff that they are able to manage to get the care done but it is very hard. V13 said that they have to borrow staff from other hallways to be able to get a resident up or sometimes turn and reposition residents. V13 said that they might have to wait for the staff to come to help so the residents might have to wait longer. V13 said that she tried to make sure all the resident care is done, but she is sure there are times it doesn't get all done because they are short of staff. On 02/17/26 at 2:31PM, V2 (Director of Nursing) said that she doesn't feel like the facility has enough nurses or CNA staff. V2 said that they keep losing staff. V2 said that they are losing staff left and right. V2 said that even V6 (Medical Doctor) is going to talk to cooperate about it. V2 said that you have staff that work three 12 hours shifts a week and now we are shaving off 8 hours of those hours and having them leave for several hours. V2 said that she and V6 feel like this is why things are getting missed because nurses are in such a hurry to try to get stuff done and they are missing things or not getting to things until later. V2 said that she doesn't feel like the facility has enough CNA's either to be able to provide adequate care to all of the residents. V2 said that they are also in a hurry to try to get as much done as they can and they might be missing things or in a rush to get things done. V2 said that she doesn't feel that they have a safe number of staff to be able to care for the residents properly. V2 said, if something happens on 1 hall after 3am we have just one nurse and 1 respiratory therapist and 2 CNA's i don't feel like they can provide adequate care especially with a specialized hall like the trach and vent unit that requires so much specialized care. V2 said not only that but they have other halls that also have a high acuity of care needs. V2 said that she doesn't feel like the nurses are able to assess the residents in a timely manner. V2 stated the residents do get assessed but it might be a little later because the nurse is in the middle of a medication pass or taking care of another resident. V2 said that she is not saying the nurses miss change in conditions of residents just that it takes them a little longer to assess some of those residents. On 02/17/26 at 3:12PM, V6 (Medical Doctor) said that yes and no the facility has enough staff to provide adequate care. V6 said that he knows that they are pushing us to talk to the facility company about getting more staffing. V6 said that they have had talks about the care of the residents with the current staffing. V6 said that it is up to the facility company to decide on the staffing of the facility. The facility policy titled Staffing with a revision date of November 2021 documents under policy The facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements CMS (Center for Medicare and Medicaid Services), IDPH (Illinois Department of Public Health), DHS (Department of Human Services) ). Under Procedure 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met and schedules adequate staff to meet or exceed individual state requirements. The daily census report dated 02/10/26 documents total number of resident in house as 47.

Based on interview and record review, the facility failed to follow physician's orders and monitor resident's declining conditions for 2 of 3 residents (R1 and R3) reviewed for resident death in a sample of 8. A. This failure resulted in worsening of R1's infection of bilateral lower leg venous wounds causing sepsis and subsequent death. B. This failure resulted in exacerbation of R3's congestive heart failure resulting in hospitalization and subsequent death. This failure resulted in an Immediate jeopardy, which was identified to have begun on:A. [DATE] when the facility failed to follow physician's orders for antibiotics for R1's infection of venous stasis ulcers. This failure resulted in R1 developing sepsis leading to R1's death on [DATE].B. [DATE] when the facility failed to complete ordered lab work and administer medications as ordered for R3. This failure resulted in worsening of R3's Congestive Heart Failure causing respiratory failure leading to R3's death on [DATE]. V1, Administrator, V2, Director of Nurses, and V30, Regional Director of Operations were notified of the Immediate Jeopardy on [DATE] at 12:25PM. The immediacy for both examples were removed on [DATE], but non-compliance remained at a Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training. Findings include:1. R1's Face Sheet documents an admission date of [DATE] and a discharge date of [DATE] with diagnoses including in part lymphedema, toxic encephalopathy, cellulitis of right lower limb, cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection, pseudomonas, muscle weakness, severe sepsis with septic shock, type 2 diabetes mellitus with diabetic neuropathy, localized edema, long term use of insulin, and urinary tract infection. R1's Minimum Date Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15, indicating R1's cognition was intact. In the same MDS it documents under Section I that R1 had an active diagnosis in the last 7 days of wound infection. Section M in the same MDS documents R1 had venous and arterial ulcers. R1's Care Plan documents R1 has a diagnosis of sepsis and history of wounds to bilateral lower extremities related to edema and a history or cellulitis, lymphedema, and current wounds with approach's dated [DATE] documenting treatment as ordered and dated [DATE] documenting medications and antibiotics per order. The same Care Plan documents R1 has a history of infection of the wounds with approach's dated [DATE] documenting R1 is to get antibiotics as ordered and to report to the physician if ineffective or any adverse effects and [DATE] documenting R1 is to have treatments per order. R1's Physician's Orders provided by the consulting wound clinic dated [DATE] documents an order for Vancomycin 1gram (gm) intravenous piggyback to be given twice a day for 14 days. Written to the side of that order is an unsigned note documenting we don't do BID (twice a day) IV (intravenous) notified (V3, consulting wound doctor). R1's Progress Note dated [DATE] at 10:58 AM, documents V13 (RN) notified V3's office that the facility would not be able to do the vancomycin order because they do not do IV medications every 12 hours because they don't have Registered Nurses (RN) on night shift to give the IV antibiotic and V3's office stated they would inform V3 that they don't have RN's on night shift to do IV antibiotics and would see what V3 wanted to do. R1's Progress Note dated [DATE] at 3:00 PM, authored by V13, documents V3 ordered the vancomycin order to be changed to vancomycin 1 gm, once a day for 14 days. R1's Progress Note dated [DATE] at 5:08 AM by V28 (LPN) documents a new order was received to increase IV vancomycin from 1gm to 1.5 gm once a day. R1's Medication Administration Record (MAR) dated [DATE] to [DATE] documents an order for Vancomycin in 0.9 % sodium chl (chloride) solution; 1 gram/250 mL (milliliters); Amount to Administer: 1 gm; intravenous once a day with a start date of [DATE] and an end date of [DATE]. This is documented as not administered on [DATE] with a corresponding note of Not Administered: Resident Unavailable and not administered on [DATE], [DATE], [DATE], and [DATE] with a note of Not Administered: On Hold. R1's MAR dated [DATE] to [DATE] documents the same Vancomycin order and documents the order is on hold on [DATE] at 5:00PM. The same Vancomycin order is documented with a start date of [DATE] and an end date of [DATE] and documents that the order was on hold from [DATE] until [DATE] at 4:00PM. The same MAR documents an order for vancomycin in 0.9 % sodium chl solution; 1.5 gram/500 mL;Amount to Administer: 1.5g; intravenous once a day with a start date of [DATE] and an end date of [DATE]. R1's Physician Orders provided by the consulting wound clinic dated [DATE] documents start Bumex 2.5 milligram (mg) once a day by mouth to be given with furosemide dose, Levaquin 750 mg once a day for 14 days, and Cipro 500 mg twice a day for 14 days. R1's MAR dated [DATE] to [DATE] does not document any orders for Bumex, Levaquin, or Cipro. R1's POS dated [DATE]-[DATE] was reviewed, and it does not document any orders for Bumex, Levaquin, or Cipro. R1's Progress Note dated [DATE] at 10:30 PM documents CNA (Certified Nursing Assistant) notified signee earlier in evening of res (R1) BLE (Bilateral Lower Extremities) having increased weeping through drsgs (dressing), explained that puddle in front of res (R1) while sitting in recliner from the weeping. CNA cleaned floor & laid down bath blanket to manage weeping until signee could perform tx (treatment). Upon entering res (R1) room, bath blanket almost completely saturated w (with) weeping from BLE after CNA had just laid down approx (approximately) 1.5 hrs (hours) prior. Res (R1) crying in pain, BLE drsgs completely saturated but intact. Admin (administered) meds (medications)- including PRN (as needed) norco. Signee then performed tx as ordered. Res (R1) continued to cry in pain while attempting to perform txs. Signee req (requested) other noc (night) shift nurse to administer prn morphine IM (intramuscular) dose. Txs finished, res (R1) tolerated better after MS (morphine) admin. BLE remain extremely red w mod (moderate) bleeding to some areas, purulent drainage noted to gauze when cleaned. Area to L (left) ankle/lower shin noted to have greenish drainage & res (R1) c/o (complained of) increased pain to specific area. RLE (right lower extremity) xeroform left in place due to skin graft started, dark black/green noted to xeroform. Mod bleeding & purulent drainage contin [sic] to areas around xeroform. Signee notified DON (Director of Nursing) of consistent worsening of BLE & worsening pain as well. Res (R1) has (Consult wound clinic name) app (appointment) this a.m. Awaiting potential N.Os (new orders). R1's physician order provided by the consulting wound clinic dated [DATE] documents Levofloxacin 750 mg once a day for 10 days and Medrol pak 4 mg oral tablets for 6 days, take 6 tabs on day 1, 5 tabs on day 2, 4 tabs on day 3, 3 tabs on day 4, 2 tabs on day 5, and 1 tab on day 6. R1's Progress Note dated [DATE] at 1:12 AM documents a new treatment order for R1's bilateral lower extremities was received via fax from V3's office. New order to change dressings to bilateral lower extremities daily and as needed. Left lower extremity: cover wound with Dakins solution-soaked gauze wet to dry dressing, cover with abdominal pad and rolled gauze then wrap with Ace bandage from foot to knee with graduated compression. Right lower extremity: leave xeroform in place to protect amniotic graft, apply abdominal pad over wound areas, cover with rolled gauze, then apply ace wraps from foot to knee with graduated compression. Treatment orders per V3 were placed into R1's electronic chart. New order for antibiotics and steroid dose pak related to bilateral lower extremity wounds received as well, levofloxacin 750 mg by mouth daily for 10 days, signee aware of resident allergy to ordered medication and unsure if R1 has taken medication in the past. A fax was sent to V3's office requesting clarification on the order due to R1's allergy, awaiting reply. Author notified dayshift nurse of possibly needing to call for new orders. Medrol dose pak was placed into R1's electronic chart. R1's Progress Note dated [DATE] at 5:49 AM by V10 (RN) documents V3's office ordered Levofloxacin for R1's lower extremity wounds and they have not replied to the fax regarding R1 being allergic to the medication. V3's office needs to clarify the antibiotic order at R1's appointment. R1's MAR for [DATE] to [DATE] and MAR for [DATE] to [DATE] did not document an order for the Levofloxacin ordered on [DATE]. R1's POS dated [DATE]-[DATE] did not document an order for the Levofloxacin that was ordered on [DATE]. R1's Physician's Orders provided by the consulting wound clinic documents an order dated [DATE] to Start Invanz 1 gram once daily for 14 days for ESBL (Extended Spectrum Beta Lactamase Producing Bacteria) in the urine. R1's MAR dated [DATE] to [DATE] did not document an order for invanz as ordered by V3 on [DATE]. R1's POS dated [DATE]-[DATE] did not document an order for invanz that was ordered on [DATE]. R1's Progress Noted date [DATE] at 5:44 PM by V6 (RN) documents received new orders from (Consultant wound clinic name) to change dressings to bilat (bilateral) lower extremities with gauze soaked with Dakins quarter strength solution. then cover with gauze and abd (abdominal) pads. then wrap legs with kerlix and ace bandages. Change dressings daily. also ordered to remove foley catheter x 1 (for 1) week and start Invanz 1 gram for 1 week r/t (related to) UTI (urinary tract infection) ESBL (Extended Spectrum Beta Lactamase Producing Bacteria) of the urine. They are faxing prescription to (pharmacy name). On [DATE] at 9:50 AM, V6 stated she doesn't remember R1 taking Levofloxacin or Invanz, but she remembers her taking Medrol dose pack. V6 stated she remembers seeing order sheets for R1 that were sent from (consulting wound clinic) but she doesn't know where they came from. V6 stated she worked night shift on [DATE] and she charted a note about the order for Invanz for R1, but she did it for the day shift nurse but doesn't remember who it was, and she doesn't know where they got it from, stated it was written down on a piece of paper. V6 stated she called the pharmacy to see if they had received R1's Invanz order yet and they hadn't so she was going to see if it came in the next night, and it didn't. V6 stated she wasn't following it anymore after that and she doesn't know who was supposed to follow up on it, but she did not follow up on it. V6 stated she said something to the Assistant Director of Nursing (ADON) about it and she thought she was going to take care of it. R1's Progress Notes dated [DATE] at 1:23 PM by V15 (RN) documents Called Pharmacy and spoke with (name) re: (regarding) Invanz order and that (consulting wound clinic) was supposed to fax over order for it. (Name) states they rec'd (received) no order for medication. R1's Progress Note dated [DATE] at 2:12 AM by V10 (RN) documents foley catheter removed tonight x 1 week r/t (related to) ESBL (Extended Spectrum Beta Lactamase Producing Bacteria). Will monitor for output/any issues. Need to clarify abx (antibiotics) order with (consulting wound clinic name) Monday r/t receiving no orders/pharmacy unaware of any new orders. Res (resident) resting quietly in bed at this time. Call light within reach. R1's Progress Note dated [DATE] at 1:00 AM by V10 documents foley (urinary) catheter remains out r/t ESBL of urine. Call (consulting wound clinic name) later today to clarify foley (urinary catheter) is supposed to be out for 1 week & also clarify abx order. Res not c/o (complaining of) any difficulties voiding, no dysuria (painful urination). PRN (as needed) morphine injection admin (administered) tonight prior to BLE tx (treatment). Res (R1) grimacing & holding on to the chair while changing BLE drsgs. Reordered morphine r/t used the rest of vial. Res (R1) now resting in bed. Will continue to monitor needs & safety. Call light within reach at this time. R1's Progress note dated [DATE] at 12:33 AM by V15 documents Still awaiting ABT (antibiotic) order to be clarified. Dressings d/I (dry and intact) at this time. Foley remains out@ (at) this time, voiding w/o (without) difficulty. Pain meds cont (continue) as ordered. R1's Progress Note dated [DATE] at 9:11 AM by V2 (Assistant Director of Nursing) documents Resident (R1) out of facility to appointment at (consulting wound clinic), this facility transport to appointment, Dressing changes to be done at appointment today. R1's Progress Note dated [DATE] at 9:41 AM by V11 (Licensed Practical Nurse/LPN) documents Spoke to (consulting wound clinic) in (town) aware we have not received atb (antibiotic) order spoke with (name) and will send script to us today provided fax number. Called (pharmacy) related need Norco refilled spoke with (name) and will send out medication. Next apt (appointment) in (town) at 10 am tomo (tomorrow) transportation aware of apt. Resident (R1) aware of all and questions asnswered [sic]. On [DATE] at 1:41 PM, V11 stated she called the consulting wound clinic for R1 on [DATE] at 9:41 AM and told them they didn't have the order for Invanz for R1 and they told her they would fax it that day. V11 stated she doesn't remember if she followed up on it or who she passed the follow up along to, stated she didn't chart anything else so she must have not done anything else with it. R1's Physician Order Report dated [DATE]-[DATE] documents treatment orders as follows; change dressings to bilateral lower extremities daily and as needed, cover with Dakin's solution soaked gauze wet to dry dressing, cover with abdominal pads, wrap with kerlix and then ace wraps from foot to knee once a day with a start date of [DATE] and an end date of [DATE] and change dressing to bilateral lower extremities daily and prn, cover with Dakin's solution soaked gauze wet to dry dressing, cover with abdominal pads, wrap with kerlix then ace wraps from foot to knee with a start date of [DATE] and an end date of [DATE]. R1's Medication Administration Record (MAR) dated [DATE]-[DATE] documents the following treatment orders to R1's bilateral lower extremities:A treatment order of cleanse bilateral lower legs with Vashe. Pat dry. Apply exufiber to the affected areas with wounds. Cover with ABD (abdominal pads, thick absorbent pad) pads and secure with roll gauze daily and as needed until wounds are healed with a start date of [DATE] and an end date of [DATE]. This treatment was documented as not administered with a corresponding note of Not Administered: other comment: cleaned with wound cleanser, wrapped w (with) abds (abdominal pads) and kerlix and not administered on [DATE] with a note of Not administered: drug/item unavailable comment: cleaned legs with wound cleanser, wrapped with abs (abdominal pads) and kerlix. Dakins, Vashe, and exufiber unavailab [sic]. An order of Change drsgs (dressings) to BLE (bilateral lower extremities) daily & prn (as needed). BLE cover with Dakins-solution soaked gauze W/D (wet to dry) drsg (dressing). Cover with ABD's. Wrap with kerlix & then ACE wraps from foot to knee with a start date of [DATE] and an end date of [DATE]. This treatment is documented as not being administered on [DATE] with a note of Not Administered: Drug/Item Unavailable Comment: DAKINS and KERLIX unavailable. removed old dressing, cleaned with wound cleanser and rewrapped w/ace, not administered on [DATE] and [DATE] with a note of Not Administered: Drug/Item Unavailable, not administered on [DATE] with a note of Not Administered: Other Comment: cleaned with wound cleanser, wrapped w (with) ABD's and kerlix, and not administered on [DATE] with a note of Not Administered: Drug/Item Unavailable Comment: cleaned legs with wound cleanser, wrapped with ABD and kerlix. Dakins, Vashe, and exufiber unavailab [sic]. An order for Dakin's solution 0.25%, once a day, apply to wet-to-dry dressings to bilateral lower extremities daily with a start date of [DATE] and an end date of [DATE]. This treatment is documented as not administered on [DATE] with a note of Not Administered: Drug/Item unavailable and not administered on [DATE] with a note of Not Administered: Drug/Item Unavailable Comment: cleaned legs with wound cleanser, wrapped with abs [sic] and kerlix. Dakin's, Vashe, and exufiber unavailab [sic]. R1's MAR dated [DATE]-[DATE] documents the following treatment orders to R1's bilateral lower extremities:A treatment order of Change drsgs to BLE daily & prn. BLE cover with Dakins-solution soaked gauze W/D drsg Cover with ABD's. Wrap with kerlix & then ACE wraps from foot to knee with a start date of [DATE] and an end date of [DATE]. This treatment is documented as not administered on [DATE] with a corresponding note of Not Administered: Other Comment: placed gauze soaked in Vershe [sic] on right leg and half of left leg, wrapped w (with) ABD's, kerlix, ace wraps. An order for Dakin's solution 0.25%, once a day, apply to wet-to-dry dressings to bilateral lower extremities daily with a start date of [DATE] and an end date of [DATE]. This treatment is documented as not administered on [DATE] with a corresponding note of Not Administered: Other Comment: placed gauze soaked in Vershe [sic] on right leg and half of left leg, wrapped w (with) ABD's, kerlix, ace wraps. A treatment order of Cleanse bilateral lower legs with Vashe. Pat dry. Apply exufiber to the affected areas with wounds. Cover with ABD pads and secure with roll gauze daily and as needed until wounds are healed with a start date of [DATE] and an end date of [DATE]. This treatment was documented as not administered on [DATE] with a corresponding note of Not Administered: Other Comment: placed gauze soaked in Vershe [sic] on right leg and half of left leg, wrapped w abds, kerlix, ace wraps. R1's Progress Note dated [DATE] at 5:05 PM by V12 (LPN) documents Res returned to facility at this time from app (appointment) @ (Consulting wound clinic) via facility transport. Facility transport driver, (Name) stating that res (R1) c/o (complained of) dizziness when first transporting to app & again when arriving to app. W/C (wheelchair) had to be used to transfer res (R1) into facility, BP (blood pressure) checked & (name) stated that it was extremely low, approx. (approximately) 70s/40s & that staff gave her juice & she felt better. Paperwork from app received w (with) N.Os. (new orders) Ertapenem (Invanz) 1G (gram) IM (intramuscular) once daily x14 days & Dakins Solution 0.25% wet to dry drsgs to BLE once daily. Awaiting delivery of meds from pharm. R1's Progress Note dated [DATE] at 5:50 PM by V12 documents When attempting to insert (consulting wound clinic name) N.O (new order) for Invanz solution, alerted of potential allergic rx (prescription) due to hx (history) of allergy to several similar abx (antibiotics) in past. Notifying oncoming shift of issue & to contact (consulting wound clinic name) to clarify if still wanting to be admin (administered) & just monitor res (R1) closely or change to diff (different) abx (antibiotic). R1's Progress Note dated [DATE] at 9:59 AM by V17 (RN) documents Saw NP (nurse practitioner) today. BLE weeping new dressing change today. Need clarification on ATB, rather or not one ordered or how long the FC (urinary catheter) is to be out. Resident (R1) sitting up in chair C/O great deal of pain. Pain meds (medication) given. Continue to monitor. R1's Progress Note dated [DATE] at 2:11 AM by V12 documents 0200 (2:00 AM) CNA notified signee at this time of res (R1) being in floor. CNA explaining that had just spoken to res (R1) @ 0130 (1:30 AM) about going to bed due to sleeping in recliner, res (R1) agreed & CNA assisted res (R1) up from recliner to ambulate to bed w wheeled walker & res (R1) stated she did not need anymore assistance. CNA then walking back up hall doing bed check when noticed res sitting in floor in front of recliner. Res (R1) A&O (alert and orientated) according to CNA, no visible injuries, res (R1) denied pain. Upon observation, res (R1) sitting in floor directly in front of recliner, feet out in front w (with) legs extended. Res (R1) A&O, verbal w SOB (shortness of breath), difficult to understand at times due to mumbling. Res (R1) denied pain & denied hitting head when asked. Res (R1) explained that fall occurred while attempting to transfer to bed after CNA had assisted res (R1) up to wheeled walker. Res (R1) denying slipping/tripping on anything, agreed that BLE had just given out. BLE wrapped w TXs (treatments) per norm, not suspected to cause fall due to being intact. Glasses on. Wheeled walker in front of res (R1), room free of clutter, well-lit. VS (vital signs): T (temperature) 98.4 BP (blood pressure) 166/90 P (pulse) 91 R (respirations) 24 SpO2 (oxygen saturation) 98% on RA (room air). Res (R1) agreed able to stand w assistance, denying pain again, no dizziness as well. Assisted res (R1) up from floor x4 max assist, transferred to bed. Gait steady but weak w transfer. Res (R1) assisted into bed comfortably, bipap in place w ordered settings. BP retaken- 100/53 P 84. Signee clarified w res (R1) that did not hit head & was not having any pain r/t fall- res (R1) agreed, stating, 'No, just my legs of course,' referring to BLE wounds. Res (R1) resting comfortably in bed, C/L (call light) within reach. Educated to use C/L when needing assistance due to increased weakness, res (R1) stated understanding. Continuing to monitor throughout rounds & notify oncoming shift to monitor for potential visible injuries arising. R1's Progress Note dated [DATE] at 9:15 AM by V13 (RN) documents Another staff member notified this nurse that something was wrong with this resident (R1). This nurse entered the resident's (R1's) room and observed that the resident (R1) was very pale in color. She said she felt weak and dizzy and didn't feel right. This nurse took the resident's (R1) vital signs. T 96.2 P 40 manually counting R 22 BP 88/62 with manual cuff 02 sat 91 % on room air. Resident (R1) was sitting-on recliner bent over her knees. R1's Progress Note dated [DATE] at 10:05 AM by V13 documents Resident (R1) left the facility via ambulance to go to (local hospital) ER (emergency room). R1's Progress Note dated [DATE] at 4:03 PM by V7 (Former Director of Nursing) documents Called (local hospital) ED (emergency department) for an update. Was informed that she is getting admitted to (different local hospital) in (town name) with a diagnosis of hypotension and sepsis. (family member name) at facility at this time and informed. R1's Progress Note dated [DATE] at 6:00 PM by V13 documents R1 is being transferred to a different hospital in a different town to be admitted to the intensive care unit with septic shock, dehydration, and acute pyelonephritis. R1's Hospitalist Discharge Summary from the local hospital documents that R1 was admitted to the hospital on [DATE] with admitting diagnoses including Septic shock secondary to bilateral leg wound infection, Bacterial cellulitis due to Pseudomonas and MRSA (Methicillin Resistant Staphylococcus Aureus), Acute toxic metabolic encephalopathy, Hypoalbuminemia, Acute kidney injury superimposed on CKD (Chronic Kidney Disease), Pseudomonas UTI (Urinary Tract Infection), and Generalized weakness. This Discharge Summary documents that R1 was discharged on [DATE]. R1's Discharge Procedure Orders document that R1's discharge diagnoses are Bacterial Cellulitis and Septic Shock and was discharged back to the nursing home. R1's discharge orders from the hospital include the following: Wound Care- Cleanse both lower legs wounds with Vashe (hypochlorous acid wound solution) and pad dry and apply exufiber (highly absorbent, sterile gelling fiber dressing) to the affected areas with wounds and cover with ABD (Abdominal Dressing) pads and secure with roll gauze daily and as needed until the wounds healed completely, Cipro (antibiotic) 750 mg (milligrams) 1 tablet by mouth every 12 hours for 7 days, and Zyvox (antibiotic) 600 mg 1 tablet by mouth every 12 hours for 7 days. R1's Progress Note dated [DATE] at 5:23 PM by V13 documents Resident (R1) returned to the facility from (local hospital name) via (ambulance name). Resident (R1) is alert to person, place, situation, but not necessarily to time. Resident (R1) made the statement 'At least I am home now.' Resident is on 2L (liters) o2 (oxygen) via nasal cannula. Resident was transferred from the stretcher to the bed via ambulance staff x2 and facility x3. admission vital signs T 97.7 P 75 R 20 BP 123/61 o2 99% on 2L. Resident's (R1's) abdominal folds are red and excoriated. Buttocks are red, blanchable, no open areas. Resident (R1) continues to have existing wounds to bilateral lower extremities. The area of wounds on the right leg measures 14cm (centimeters) in height starting at the ankle and going up the calf and encompasses the entire circumference of the calf. The area of wounds on the left leg measures 17cm (centimeters) in height from the ankle and goes up the calf and encompasses the entire circumference of the calf. Heels are firm and intact. R1's Progress Note dated [DATE] at 1:31 PM by V2 documents Patient up per w/c (wheelchair) in room, short of breath, complaining of increased pain to BLE & generalized pitting edema to BIL (bilateral) Hands & BLE. V/S (vital signs) stable. Patient stated 'just don't feel right.' 1pm (Doctor) notified of patient condition with new orders may send to ER (emergency room) to eval (evaluate) & treat. 1:05 pm POA (Power of Attorney) notified of patient condition & new orders received. 1:15 pm (local ambulance company) notified for transport. 1:28 pm (local ambulance company) here, patient assisted to stretcher & bed hold sent with patient with paperwork. 1:33 pm resident (R1) out of facility to (local hospital) ER via stretcher with (local ambulance company). R1's Progress Note dated [DATE] at 6:23 PM by V10 (RN) documents Signee called (local hospital) ER for update regarding res (R1) transfer. Nurse stated they transferred her to (different local hospital name) r/t (related to) septic shock. R1's Progress Note dated [DATE] at 3:51 PM by V20 (RN) documents (local hospital name) Nurse calls this facility to inform resident expired. R1's Hospitalist Discharge Summary from the local hospital documents that R1 was admitted to the hospital on [DATE] and discharged on [DATE] with final diagnoses including Septic shock secondary to skin and soft tissue infection (cellulitis) of bilateral lower extremities including infected venous ulcers, AKI (Acute Kidney Injury)/ATN (Acute Tubular Necrosis) with metabolic acidosis, Acute toxic metabolic encephalopathy, and Acute on chronic hypercapnic respiratory failure. This Discharge Summary documents a discharge destination of deceased in the hospital. The Hospital Course documents that R1 had VRE (Vancomycin-Resistant Enterococci) and MRSA (Methicillin-resistant Staphylococcus aureus) and bilateral lower extremity venous insufficiency/lymphedema and admitted overnight from an outside hospital with bilateral lower extremity wounds. R1 was admitted to ICU (Intensive Care Unit), started full aggressive medical care but with no improvement and continued clinical deterioration. R1's current clinical condition, risks, benefits and alternatives were discussed with R1's mother and daughter, and both understand R1 's continued suffering, repeated admissions, nonhealing extensive venous ulcers, poor baseline, functional status bed-bound at a nursing home and wanted to transition her to comfort measures. R1 passed away shortly after. R1's State of Illinois Certificate of Death Worksheet documents R1's date of death as [DATE], and cause of death documented as 1. Septic shock, 2. Skin and soft tissue infections, and 3. Methicillin-resistant staphylococcus aureus. R1's hospital records from the local hospital document under Microbiology-Lab Results dated [DATE] at 2:12 PM, under culture wound and gram stain, heavy pseudomonas aeruginosa with the source being ankle wound. On [DATE] at 11:46 AM, V10 (RN) stated she works night shift, so she never communicated with the consulting wound clinic directly regarding R1, so anytime she needed an order clarified with them she passed it along to the day shift nurse. On [DATE] at 1:45PM, V5 (CNA) stated she noticed R1's dressing was not getting changed often because the date on them would be old and the dressing would be unraveled and look very gross with drainage seeping through it, so she would tell the nurse working and they would tell her they would get to it as soon as they could. V5 stated it would eventually get changed because she would see it the next time she worked. On [DATE] at 1:13 PM, V6 (RN) stated there were several times she was unable to complete dressing changes on R1 per the order due to not having the correct supplies. V6 stated she would always do something if she didn't have the correct supplies, but it just might not be what the order says. V6 stated R1 was going to (outside wound clinic provider) to get dressing changes and when she came back with new a new order for Dakin's solution they tried to order it from the pharmacy, but they were supposed to order it through where they order other supplies not the pharmacy, so it took a while for them to get it. V6 stated they were out of Dakin's solution a lot of the time. V6 stated R1 came back from the hospital with orders for Vashe and exufiber at one point and the facility didn't have either one. V6 stated she told V7 (Former DON), and she never saw the supplies show up. V6 stated they would also not have kerlix gauze wrap at times. V6 stated she never saw that the facility had exufiber for R1's wounds and maybe just one small bottle of Vashe that only did maybe two treatments but the rest of the times she did not use it for her treatments because she couldn't find any. On [DATE] at 3:04 PM, V12 (LPN) stated she took care of R1 and there were times they did not have the Dakin's solution or other supplies like they wouldn't have kerlix to wrap her legs with. V12 stated she always did something with her dressing but didn't always do what is ordered because of not having the correct supplies. V12 stated even when she didn't have the supplies, she still checked off she did the dressing per order in the MAR. V12 stated she works night shift, so she couldn't communicate with the office where R1 went for wound care. V12 stated when R1 was ordered Levaquin she never got it, but they started the Medrol dose pack because the day shift nurses told her they couldn't get clarification on the Levaquin.V12 stated it was difficult for her and she feels like she was constantly [NAME] her wheels since she worked nights and the office was closed when she was working so she couldn't communicate with them herself. V12 stated she doesn't remember R1 ever getting Invanz. V12 stated there was several times that R1 did not get her dressings changed when they were supposed to be and she would do it when she found it wasn't completed, V12 stated this happened at least twice a week. V12 stated R1's dressing change took a while to do because they were so extensive, and the day shift nurses would always say they didn't have time to do it. On [DATE] at 5:14 PM, V17 (RN) stated she did dressing changes on R1 and sometimes they wouldn't have Dakins solution so she would use normal saline wound cleanser and sometimes they wouldn't have other supplies either. V17 stated she would still change R1's dressing but she would just use what they had. V17 stated since she works night shift she never dealt with any orders from the wound clinic. On [DATE] at 11:29 AM, V20 (RN) stated he did dressing changes on R1 and he can for sure say they didn't have Dakin's solution most of the time and when they were out of Dakin's solution he doesn't remember what he would use but he did the best he could with what supplies they had on hand. On [DATE] at 2:03 PM, V21 (Family Member) stated she felt like the communicati[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide Heat, Ventilation, and Air Conditioning (HVAC) systems to maintain a comfortable temperature and failed to maintain flooring that was clean and free from damage. This failure resulted in R1 and R6 experiencing difficulty breathing and R5 and R7 experiencing difficulty sleeping, resulting in significant discomfort. This failure has the potential to affect all 58 residents residing in the facility.Findings include:1. On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. R1's Resident Face Sheet documented an admission date of 12/12/24 and included diagnoses of morbid obesity, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and congestive heart failure. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact.On 7/30/25 at 10:33 AM, R1 was sitting on the side of her bed in her room wearing an oxygen nasal cannula connected to an oxygen condenser set at 3 liters per minute. The thermometer measured the ambient air temperature of R1's room to be 85.6 degrees Fahrenheit (F). R1's Packaged Terminal Air Conditioner (PTAC) unit was on but was not blowing out cold air. R1 said it was so hot in her room she was having difficulty sleeping. R1 stated we just sleep covered in sweat. R1 said due to the heat she was having increased difficulty breathing. R1 stated I'm on oxygen with COPD (Chronic Obstructive Pulmonary Disease). I can't hardly breathe with this heat. I'm struggling.R6's Resident Face Sheet documented an admission date of 1/30/23 and included diagnoses of morbid obesity, chronic obstructive pulmonary disease, and chronic respiratory disease. R6's MDS dated [DATE] documented a BIMS score of 14, indicating R6 was cognitively intact.On 7/30/25 at 10:59 AM, R6 was sitting in the dining room in her wheelchair wearing an oxygen nasal cannula connected to an oxygen concentrator set at 2 liters per minute. R6 stated It's so hot in here, and it has been like this for weeks. The heat makes it hard for me to breathe in here. The thermometer measured the ambient air temperature of the dining room to be 82.3 degrees F. Several residents were sitting in the dining room participating in a dice game activity and all said they were hot and uncomfortable.R5's Resident Face Sheet documented an admission date of 2/4/25 and included diagnoses of morbid obesity, hypertension, and edema. R5's MDS dated [DATE] documented a BIMS score of 14, indicating R5 was cognitively intact.On 7/30/25 at 10:40 AM, R5 stated it has been so hot in here for the past 3 to 4 weeks since the air conditioning stopped working. It's hard to sleep when it's this hot. I toss and turn all night sweating. This morning trying to get dressed I was already wet with sweat before I could get my clothes on. The thermometer measured the ambient air temperature in R5's room to be 83.6 degrees F.On 7/30/25 at 11:55 AM, the thermometer measured the ambient air temperature of R5's room at 86.1 degrees F. R7's Resident Face Sheet documented an admission date of 7/10/25 and included diagnoses of pneumonitis, atrial fibrillation, and insomnia. R7's MDS dated [DATE] documented a BIMS score of 13, indicating R7 was cognitively intact.On 7/30/25 at 10:52 AM, R7 stated It's plenty hot in here. The main problem is it's hard to sleep at night. It's uncomfortable day and night. The thermometer measured the ambient air temperature in R7's room to be 82.6 degrees F.On 7/30/25 at 11:43 AM, staff were passing noon time meal trays to several residents sitting in the dining room. The thermometer measured the ambient air temperature of the dining room to be 84.5 degrees F.On 7/30/25 at 11:49 AM, the Heating, Ventilation, and Air Conditioning (HVAC) unit farthest from the nurse's station on 300 hall was running but putting out a very small amount of cold air and was dripping condensation onto the floor and had ceiling tiles with greenish brown discoloration surrounding it.On 7/30/25 at 11:51 AM, the HVAC unit closest to the nurse's station on 300 hall was not working.On 7/30/25 at 11:53 AM, the HVAC unit above the nurse's station was not working and had 7 ceiling tiles with greenish brown discoloration.On 7/30/25 at 11:56 AM, the HVAC unit closest to the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:57 AM, the HVAC unit farthest from the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:59 AM, the HVAC unit closest to the nurse's station on 400 hall was not working.On 7/30/25 at 12:01 PM, the HVAC unit farthest from the nurse's station on 400 hall was blowing out a small amount of cold air. On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had asked corporate for 33 PTAC units to replace the older PTAC units in resident rooms and corporate had only sent him 4 PTAC units. V4 said several of the PTAC units in resident rooms had been replaced during the winter of 2024 but the PTAC units that were not replaced could not keep up with cooling resident rooms. V4 said the facility did have portable air conditioners but if too many were plugged in it would pop the breaker and everything plugged into that electrical line would lose power. V4 verified most of the HVAC systems in the facility were not functioning or not functioning well. V4 said he had contacted the HVAC company to come to the facility and fix the HVAC units but was told they would not come to the facility until the facility paid the bill from the last time the HVAC company had been at the facility.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said the air conditioning is a reoccurring theme every summer. V1 said he had done everything he could do but did not have the authority to change the HVAC units. V1 said in December of 2024 he had replaced all the PTAC units in resident rooms that needed changed but the PTAC units that needed replaced now are the older ones that were about 2 years old and are starting to fail. V1 said they needed to be replaced but corporate had only sent the facility 4 new PTAC units. V1 said he had emailed and called corporate several times about the HVAC systems and PTAC units not working but corporate still had not fixed them.On 8/1/25 at 12:14 PM, V7 (Medical Director) said he was aware the facility has had trouble with the HVAC system. V7 said with the temperatures being over 81 degrees F, it would not cause the residents to go into true respiratory failure but it would be more difficult to breathe with the high heat and high humidity. V7 said the combination of comorbidities and being elderly put the residents at high risk for dehydration, heat exhaustion, and heat stroke. V7 stated (V1) is passionate about it and has been trying to get it fixed. V7 said some of the resident rooms were very hot and that was not good. V7 said the last few days had been very hot.On 8/6/25 at 11:40 AM, V6 (Licensed Practical Nurse/ LPN) said the air conditioning had not been working all summer. V6 said over the weekend (8/2/25 and 8/3/25), the HVAC units on the 400 hall were blowing out hot air and they could not shut them off. V6 stated it was miserable in here.The facility's undated Extreme Weather- Heat or Cold policy documented in part . The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate the risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. Individuals are prone to heat illness when they remain in hot or humid weather for an extended period. If the facility reaches a heat index/ apparent temperature of 80 (degrees) Fahrenheit implement the following actions and/ or treatments. Move individual(s) to cool area. Utilize electric fans circulate air. Notify Director to ensure measures for air condition repair and resident care are being followed.The facility's December 2016 Hot Weather Plan documented in part .1. Monitoring: a. in the event of a loss of air conditioning, hallway temperatures will be monitored and recorded every hour on the Temperature Monitor Log. d. The administrator or DON should contact the Regional [NAME] President and Regional Nurse Consultant. f. Nursing will assure that each Resident's room has an operational fan. 3. Maintenance Department Response: a. Maintenance staff will be available 24 hours a day during any heat emergencies. Various heating and cooling companies will be utilized as necessary. b. Administrator, Maintenance Supervisor or designee will determine if any of the above providers should be called out. 6. Other: The Department of Health and Senior Services must be notified during serious heat emergencies. This would be defined as. when persistent heat related issues cannot be resolved by the Administrator and/ or Maintenance.On 8/12/25 at 11:40 AM, the website Weather Underground (https://www.wunderground.com/history/monthly/us/il/salem/KMWA/date/2025-7) historical data documents a maximum temperature of 91 degrees F on 7/30/25 with a maximum humidity of 100%.On 8/12/25 at 12:52 PM, the website https://southernillinoisnow.com/2025/07/28/more-than-130-million-people-brace-for-sweltering-conditions-across-most-of-the-us/ documented on 7/28/25 at 6:37 AM a report documenting in part .Extreme heat is also expected to continue on Monday and Tuesday in the Midwest, where over the weekend temperatures felt between 97 to 111 degrees from [NAME], Nebraska, up into Minneapolis . Looking ahead to the work week, potentially life-threatening heat and humidity are expected to continue across the eastern half of the country through Wednesday. Major cities including St. Louis, Memphis, [NAME], [NAME], [NAME], and [NAME], Mississippi, are all likely all see actual temperatures in the upper 90s to low 100s. A prolonged heat wave is forecast for those regions as an abundance of tropical moisture settling in is expected to drive the feels-like temperatures up to between 105 to 115 degrees over multiple consecutive days .2. On 8/1/25 at 10:14 AM, V8 (Family Member/Power of Attorney/POA) said she comes to visit R2 every Sunday, and the dining room floor is always dirty and in bad shape when she is in the facility.On 8/1/25 at 1:10 PM, the dining room floor appeared to be dirty with several tiles with blackish brown discoloration. The tiles lining the area where the flooring changes to tile were cracking and uneven with black discoloration on them from wall to wall. Several tiles by the sliding glass door were bubbled and had a blackish brown discoloration. Several tiles located around the kitchen entrance had a large amount of blackish brown discoloration with bubbling and cracking.On 8/1/25 at 1:35 PM, V10 (Housekeeping Supervisor) said the discoloration on the tiles was glue. V10 said the facility had tried to scrape it off but had not been successful. V10 said there was nothing housekeeping could do about the bubbling and cracking tiles.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had the dining room floor professionally stripped and waxed and was told there was nothing more they could do for the floor. V1 said corporate was aware of the dining room flooring.On 8/7/25 at 10:20 AM, V4 (Maintenance Director) said he had started replacing bubbling tiles. V4 said the dining room floor had several layers of tile and as the tile below broke down it would cause the top tiles to bubble and crack. V4 said the only way to keep the top tiles from bubbling and cracking would be to replace the flooring. V4 said he had stripped the floors and had removed a large about of the discoloration. V4 said he was going to put 3 layers of wax on the floor to avoid discoloration but as the lower tiles broke down it would cause the glue to seep up between the top tiles and collect dirt and debris causing the discoloration.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility.

Based on interview and record review, the facility failed to safely transport 1 (R1) of 3 residents reviewed for accidents. This failure resulted in R1 receiving a fracture to R1's fifth and sixth cervical vertebrae and right radius. This past noncompliance occurred between 1/29/2024 - 2/01/2024. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE], with diagnoses of Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified fracture of the lower end of right radius, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, Morbid (severe) obesity due to excess calories, and Type 2 diabetes mellitus with diabetic nephropathy. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section GG, Functional Abilities and Goals, R1 is dependent with substantial assistance with activities of daily living. The facility's investigation report, dated 1/29/2024, documents at 4:10 PM on 1/29/24, V1 (Administrator) was notified by V3 (Transportation CNA) that while on the way to an appointment, a vehicle pulled out in front of them from the shoulder of the road. When V3 applied the brakes to avoid a collision, R1 fell forward and bumped her face on the floor of the van. R1 was immediately sent to the emergency room (ER) for evaluation. Investigation initiated immediately. Power of Attorney (POA) and V9 (Primary Physician) both notified immediately after the fall. On 1/29/24, R1 was immediately seen after the fall at an out of state emergency room . R1 was discharged from the ER the same day with all scans and x-rays negative for any fractures. POA and MD notified. Neurological checks continued. At 8:50 AM on 1/30/24, facility received a call from ER stating possible C5/C6 fracture. R1 immediately sent to local hospital for further evaluation by emergency medical services (EMS) with a C Collar applied. POA and MD notified. While at the local hospital, an MRI (Magnetic Resonance Imaging) was completed and confirmed C5/C6 fracture. The local hospital transferred R1 to another out of state hospital for further evaluation. R1 returned to this facility with a (specialized collar) from the out of state hospital. POA and MD notified. On 2/2/24, R1 complained of increased pain to the right forearm. V9 notified. X-rays ordered. POA notified. On 2/3/24 at 10:16 AM, R1 requested to go to the hospital secondary to pain. V9 and POA notified. R1 left facility and was transferred to the local hospital. R1 returned from the local hospital same day at 4:10 PM with a right arm splint and orders to follow up with Ortho. X-rays showing right radial fracture. V9 and POA notified. On 2/3/24 at 10:30 PM, R1 requested to go to the hospital secondary to increase left knee pain. V9 and POA notified. R1 states she was sitting in the chair with all straps fastened. R1 states they were on the interstate headed to her appointment when a car pulled out in front of them. R1 states V3 hit the brakes to avoid an accident and she fell forward to the floor. R1 states it all happened so fast, but she believes it was a white car. R1 states she then went to the ER and had all different scans and x-rays completed. R1 states she does not want anyone to get in trouble and it was an accident. R1's hospital x-ray report, dated 1/30/2024, documents acute nondisplaced fracture of the right C6 superior articular faucet extending superiorly to the right C5 pedicle and right C5 lamina. R1's hospital x-ray report, dated 2/03/2024, documents no acute fractures in the pelvis or left hip, and documents that R1 has an acute intra-articular right distal radial fracture. On 2/21/2024, at 9:10 AM, V1 (Administrator) stated he was notified by V3 (CNA) regarding the auto incident that occurred on 1/29/2024 while transporting R1 to an appointment. V1 stated V3 stated a car pulled out in front of him and he immediately applied the brakes to avoid a collision. V1 stated V3 stated R1's chair tipped over causing R1 to bump her face on the floor of the van. V1 stated R1 was immediately taken to a local hospital emergency room for further evaluation. V1 stated R1 was returned from the emergency room that same day with all scans and x-rays negative for any fractures. V1 stated the facility received a phone call the next day, 1/30/2024, from the local emergency room that R1 has possible C5/C6 neck fracture. V1 stated R1 was immediately sent to the local emergency room for an evaluation and a C-collar was applied. V1 stated while at the emergency room it was confirmed R1 did have a C5/C6 fracture. V1 stated R1 returned from local hospital with a cervical collar in place. V1 stated on 2/2/2024, R1 complained of increased pain to her right arm and x-rays were ordered, but R1 was sent out to the hospital before local x-ray company made it to the facility. V1 stated that R1 requested to go out to the hospital on 2/3/2024 in the morning related to pain. V1 stated R1 was sent out to the local emergency room and returned the same day with a right arm splint and to follow-up with ortho. V1 stated x-rays showed a right arm fracture. V1 stated later that evening R1 requested to go back to the hospital related to increased left leg pain. V1 stated on 2/4/2024, the facility received report that R1 had been transferred to an outside hospital with electrolyte and hemoglobin imbalances, and continues to remain at the outside hospital at this time. On 2/21/2024, at 1:30 PM, V6 (Maintenance) stated he gave an in-service on van safety and resident transport to all the employees that transport residents. V6 stated V3 (Transportation CNA) transported R1 using a (specialized wheelchair) when he took her to her appointment on 1/29/2024. V6 stated after R1's auto incident, he checked the van over and found no mechanical problems noted. On 2/21/2024, at 2:10 PM, V3 (Transportation CNA) stated he transported R1 to her appointment on 1/29/2024 and they left around 1:00 PM. V3 stated before they left, he loaded R1 into the van with a (specialized wheelchair). V3 stated he fastened and locked all four wheels and placed one seat belt over R1's left side. V3 stated he was traveling around 15 -20 miles per hour (mph) in the far-right lane and he was going down a hill when a white, four door, car pulled out in front of him. V3 stated he slammed on his brakes to avoid a collision and when he did, R1 slid out from underneath the seat belt and the (specialized wheelchair) tipped over on the left side to the floor. V3 stated he immediately pulled over and assessed R1 for any injuries. V3 stated R1 was alert and answered questions appropriately. V3 stated R1 stated that her chin was hurting. V3 stated he saw a penny size red mark on her chin at that time. V3 stated he helped get R1 get positioned properly back into the (specialized wheelchair) and checked all fasteners and made sure all the wheels were locked in place. V3 stated he called V1 (Administrator) and V2 (Director of Nursing), and they advised him to take R1 to the emergency room . V3 stated he transported R1 to the emergency room where she got evaluated. V3 stated they spent about 2 1/2 hours there; CT (Computed Tomography) scans and x-rays were taken. V3 stated at that time, R1 did not have any new problems noted and he transported her back to the facility. V3 stated he has been transporting residents since last June 2023, and he usually has 2-4 appointments a week. V3 stated he has had no other auto incidents where residents have gotten hurt. V3 stated he has only transported a resident in a (specialized wheelchair) 2-3 times. V3 stated he does not like to transport residents in (specialized wheelchairs). V3 stated any little bump in the road, the (specialized wheelchair) will move easily. V3 stated R1 has bad knees and prefers to transport using a (specialized wheelchair) rather than her wheelchair. V3 stated R1's appointments usually take 2 hours at times and it is more comfortable for her to transport using a (specialized wheelchair). V3 stated he has been trained on van safety and transport of residents, and it is now recommended no residents be transported in (specialized wheelchairs) any further. On 2/22/2024, at 10:57 AM, R1 was observed lying in her bed with a C-collar in place to her neck. R1's right forearm was observed to have yellow-greenish colored bruising noted. R1's left leg was elevated slightly on a pillow. R1 was alert and oriented to person, place, and time. R1 stated she did not want to talk about the van incident at this time. On 2/21/2024, at 9:00 AM, V1 (Administrator) stated the facility had a Quality Assurance (QA) meeting on 1/31/2024 to discuss. V1 stated the following people attended the QA meeting: V1 (Administrator), V2 (Director of Nursing), V14 (Assistant Director of Nursing), V15 (Regional). V1 stated the measures put in place to ensure the deficient practice does not recur are: All transportation staff will be educated to pull over to a safe area and call EMS after an incident. All transportation staff will be in-serviced on proper procedure for install of wheelchair. No (specialized wheelchairs) will be used on the transportation van/bus. A wheelchair audit will be completed for all residents. On 2/21/2024, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date of 2/26/24, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 1/31/2024. In attendance - V1, V2, V14, V15 (Regional). Immediate corrective action for those affected by deficient practice: R1 sent to the emergency room and treated at the emergency room . Transportation vehicle checked to ensure all safety mechanisms properly functioning. An in-service for all transportation staff on van/bus safety and resident transport was given by V6 (Maintenance) on 2/01/2024. In attendance were: V1 (Administrator), V3 (Transportation CNA), and V16 (Activity Director). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents that utilize the transportation vehicle have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: All transportation staff were educated to pull over to a safe area and call EMS after an incident. All transportation staff will be in-serviced on proper procedure for install of wheelchair. No (specialized wheelchairs) will be used on the transportation van/bus. The facilities Transportation Policy was updated to reflect the changes. A wheelchair audit will be completed for all residents. All in-service education completed on 2/1/24. 4. Plan to monitor performance to ensure solutions are sustained: Facility Administrator responsible for ensuring ongoing compliance. Facility Administrator responsible for reporting to QA committee.

Based on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one resident of four residents (R3) reviewed for abuse in the sample of 4. This failure resulted in R3, during care on 7/6/23, experiencing physical pain and emotional distress with continued feelings of intimidation, fear, sadness, anxiety and helplessness. Findings include: R3's Face Sheet documented an admitted [DATE], and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. R3's Minimum Data Set, dated dated [DATE], documented R3 has no deficits in cognition, is totally dependent on at least two staff for transfers, bed mobility, dressing, eating, and toileting. Nurses Note, dated 7/6/23 at 11:54am, authored by V4, Registered Nurse, documented, Resident accused CNA (Certified Nursing Assistant) of being rough while completing care. Is cursing and yelling at staff. Attempted to console and allowed resident to vent. Administrator and Director of Nurses notified. There was no documentation in the record to indicate R3 was assessed for injuries by nursing staff, or that R3's Physician had been contacted. On 8/23/23 at 12:05pm, R3 was alert and oriented to person, place, and time. R3 denied she has ever been physically or verbally abused at the facility, stating, I'm not going to let anybody abuse me, and stated, Some of the staff are always rude, like they're having a bad day. R3 stated staff have not said anything racist to her, but she has heard from staff that V6 has made racist comments to them. R3 stated she does not like V6 because, She's (V6) probably bipolar. R3 stated she does not think V6 likes R3. R3 stated there was an incident in July 2023 where V6, Rolled me (R3) over and she wasn't very gentle about it and hurt me, but I can't say it was intentional. R3 stated V6 does not take care of her anymore, since July 2023. R3 stated she did not ask to not have care from V6, and thinks maybe V6 does not want to take care of her anymore. On 8/24/23 at 10:15am, R3 was tearful, and stated she had been reluctant to speak to the Surveyor on 8/23/23. R3 stated on 7/6/23, V5 and V6 were providing incontinence care prior to showering. R3 stated upon entering the room, V6 seemed to be short with her. R3 stated as V6 was rolling her to her side, R3's flaccid left arm was caught under her body, and due to Neuropathy, she was in extreme pain. R3 stated she yelled for V6 to stop because she was hurting R3, but V6 did not stop. R3 stated she was hollering and V6 was hollering right back at her. R3 stated when the mechanical lift sling was placed under her, V6 stormed out of the room and into the hall, yelling, I can't do this anymore, and making statements about how uncooperative R3 is. R3 stated R3, Felt like (expletive) and started crying because she thought R3 and V6 were friends. R3 stated she feels very scared and vulnerable because she can't move or take care of herself and is completely dependent on staff. R3 stated sometimes V6 is the only CNA working on the Phoenix Unit, and she is afraid if V6 is mad at R3, she might not go tell other staff she needs help or would not go in R3's room if there was an emergency. R3 stated she worries that V6's feelings about her will poison other staff's opinion of R3. R3 stated she had not wanted to tell the Surveyor this because she fears staff retaliation. R3 stated she has a history of experiencing domestic violence, including a former partner shooting her in the neck, causing her to be quadriplegic. R3 stated, I already have problems with being scared, especially at night, and I startle easy with an extreme reaction to noise. R3 stated other staff members have said things to her such as,This (Phoenix) is (V6's) hall, which R3 has interpreted to mean it's V6's hall, not R3's hall. On 8/23/23 at 10:55am, V7, Certified Nursing Assistant (CNA), stated she usually works on the Phoenix Unit, but at times will float to other halls. V7 stated she has witnessed V6, CNA, make racial slurs about R3 behind R3's back, including using the N word. V7 stated she reported this a few weeks ago to V2, Director of Nursing, and V3, Assistant Director of Nurses. V7 stated for a few days afterward, V6 worked on a different hall, but V6 is now working on the Phoenix Unit again. V7 stated as far as she knows,V2 and V3 didn't do any kind of investigation or say anything to V6 because V6 is continuing the behavior. On 8/23/23 at 11:35am, V3, Assistant Director of Nurses, stated on 7/18/23 or 7/19/23, V7 reported V6 was making racial slurs about R3 behind R3's back. V3 stated she did not investigate it, did not inform V1, Administrator, and did not question V6 or R3. V3 stated the decision to move V6 to a different hall for a few days had already been made based on programmatic needs. V3 stated V6 is again back on the Phoenix Unit, but V6 does not provide care for R3, because,(R3) doesn't like her. V3 stated R3 has previously told V3 that V6 is, A b***h. V3 stated when R3 made this statement, V3 did not ask R3 to elaborate. V3 stated there are other staff R3 does not like, for example new staff or younger in age staff. V3 stated R3 has never reported any abuse allegations toward any staff to V3. On 8/23/23 at 12:30pm, V4 stated on 7/6/23, she responded to R3's room to assist V5, CNA, in completing care for R3, after V6 had left the room. V4 stated R3 was crying and upset, and V4 stated V5 reported to V4 he had observed that V6, Had been rough with (R3) during care that day. V4 stated she immediately reported this to V1 and V2. V4 stated she did not know if they started an abuse investigation, but V6 was allowed to work the remainder of her shift that day. V4 stated V6 will now not go into R3's room, and V6 at times is the only CNA on Phoenix, and has to go get CNA staff from other halls if R3 turns on her call light or needs care. V4 stated she has not heard V6 make any racial statements. V4 stated she is concerned about whether or not R3 is getting proper care under these circumstances. On 8/23/23 at 12:45pm, V5 stated on 7/6/23, he was assisting V6 in caring for R3. They provided incontinence care, and V5 stated R3 always wants a certain perineal spray cleanser to be used, so staff always use the spray per R3's wishes. V5 stated R3 requested the spray be used, and V6 seemed upset and told R3 she wasn't getting the spray that day, but provided no rationale. V5 stated V6 then rolled R3 toward the side of the bed while V5 placed the mechanical lift sling under R3.V5 stated R3 has a lot of nerve pain and staff have to be extra careful when repositioning her, but V6 was not being careful, and R3 began yelling that she was in pain, and asked V6 to stop, but V6 continued rolling R3 over. V5 stated R3 was yelling, crying, and cursing, and V6 was being equally loud toward R3.V5 stated he is not sure if V6 was trying to hurt R3, or if it was accidental. V5 stated he told V6 to leave the room, V4 came in the room, and when R3 was comfortably positioned, V5 reported the incident to V4. V5 stated he then assisted R3 with showering, and R3 was crying as V5 tried to console R3. V5 stated he assured R3 the incident would be reported, so after the shower, V5 reported the incident to V1 and V2. V5 stated he is not sure if an investigation was started, but V6 worked the remainder of her shift. V5 stated since the incident, V6 has refused to take care of R3, so CNAs from other halls have been providing care. V5 stated he has not heard V6 make racial statements, but V6 has told V5, I don't hate her (R3), but I just don't care about her. On 8/23/23 at 2:05pm, V6 stated she works the 6am to 6pm shift, always on the Phoenix Unit. V6 stated she has been employed at the facility since February 2023, but had previously worked at the facility for a total of eleven years. V6 stated she has never been accused to any type of resident abuse and denied ever having abused any resident. When asked about the 7/6/23 incident, V6 stated R3 is,Hard to handle, and verbally abuses staff. V6 stated on that date, she and V5 were providing incontinence care for R3 before showering her. V6 denied there was an issue with perineal spray, and denied telling R3 she couldn't have it. V6 stated she was rolling R3 toward her as V5 was putting the lift sling under R3, when R3 suddenly started yelling,Get off me and stop hitting me. V6 stated she believed R3 was saying that because R3 had told another staff member who no longer works at the facility that R3 was trying to get V6 fired. V6 stated she did not say anything to R3, and did not yell back at her. V6 stated she told V5 she was going to leave the room so that R3 could calm down. V6 stated R3 was not crying and did not say anything about being in pain. V6 stated later that day, V2 and V3 told V6 they decided V6 should work a different hall for an undetermined amount of time to give V6 a break from R3, and to give R3 some time to cool off, because It seemed like there was a personality conflict. V6 stated she worked the rest of her shift that day, and then had a few days off. V6 stated she worked on another hall for a few days when she returned, but had to return to the Phoenix Unit because, All the residents there were upset and crying because I wasn't taking care of them anymore. V6 stated, She (R3) must have called (V10, Ombudsman) because she showed up last week and asked me a bunch of questions. V6 stated V10 felt it would be for the best if V6 did not work with R3, so administrative staff told V6 when R3 turns on her light or needs care, other CNA and/or nursing staff are to be summoned to provide the care. V6 stated if staff to resident abuse is witnessed or suspected, it should be immediately reported to V1, V2, or V3, and if they are unavailable it should be reported to the Charge Nurse. V6 stated if a resident is angry and upset with a staff member, the staff member should remove herself and get another staff member to approach the resident. V6 stated she has never witnessed any staff make racist comments about residents, and stated she has never made racist comments about residents. On 8/23/23 at 3:05pm, V10 stated on 7/7/23, R3 reported to her the incident with V6 that occurred on 7/6/23. V10 stated R3 reported V6, Was rolling her over and using more force than what was required. V10 stated R3 did not identify the incident as abuse, but R3 stated she did think V6's actions were intentional. V10 stated she discussed the incident with V1 and V2, who stated V6 had a few days off, and when she returned would not be back on the Phoenix Unit for an undetermined amount of time. V10 stated R3 called V10 on 8/11/23 to report V6 was working on the Phoenix Unit again. On 8/23/23 at 3:42pm, V2 stated on 7/6/23, V4 reported R3 said V6 was rough rolling her over, and R3 wanted to speak to V2. V2 said R3 stated her arm got caught under her as V6 was rolling R3 to the side during care. V2 stated R3 said she did not think V6 was intentionally trying to hurt R3. V2 stated V1 was off that day, but she communicated about the incident with him by phone. V2 stated there have been no previous complaints from residents about V6, and that V6 is a good employee. V2 stated she determined, Nothing inappropriate happened, I felt it was a personality conflict, and that was the end of it. V2 denied any staff had approached V2 about V6 making racial comments about residents. V2 stated V6 was again assigned to the Phoenix Unit with the understanding V6 would not go into R3's room and would have other staff provide her care. On 8/23/23 at 4:07pm, V1 stated he acts as the facility's Abuse Coordinator. V1 stated in his absence, V2 acts as the Abuse Coordinator. V1 stated the facility's Abuse Policy states abuse is to be immediately reported to him, and if he is unavailable, it is to be reported to V2 or the Charge Nurse, who will immediately report it to him. V1 stated he is to then come immediately to the facility and begin an investigation.V1 stated the accused employee is to be walked out immediately, and is to remain off until the investigation is completed. V1 stated he was off on 7/6/23 when V2 called and told him that (R3) said (V6) was rough with her during rolling her side to side, that (V2) talked to (R3), (R3) said it wasn't abuse, and that was the end of it. V1 stated V2 said V6 denied being rough with R3. V1 stated when he returned to work, he spoke with R3 and R3, Apologized for lashing out at (V6) and said she wanted (V6) to start taking care of her again. V1 stated since the Surveyor arrived on 8/23/23 asking questions about staff to resident abuse, he decided to start asking staff if they had witnessed abuse, and V2 had, immediately before this interview, told him staff have said V6 has made racial slurs about people of color, but has not made them in front of residents. V1 stated he does not feel this is abuse, but he will be filling out a disciplinary action form on V6. V1 stated V6 takes care of several residents of color, but he does not feel that is a potential problem. V1 stated V10 is in the building a lot, but he does not recall her speaking to him about R3. V1 stated if V10 had reported abuse, he would have immediately followed up on it. V1 stated there have been no previous allegations of abuse against V6. V1 stated V6 is again working on the Phoenix Unit, but other staff are to be taking care of R3, because V6 is, Scared to go back in there for fear (R3) will accuse her of something. The Surveyor informed V1 there had been allegations V6 made racist comments about R3, and hurt R3 physically and emotionally during care on 7/6/23. V1 stated he would begin an immediate investigation, and would call V6 at home to advise her she would be off until the investigation was completed. An 8/23/23 Long Term Care Facility Serious Injury Incident and Communicable Disease Report documented, Alleged abuse-involving (R3). Staff involved: (V6). At 4:45pm, (V1) was notified of an allegation of verbal and physical abuse. Investigation initiated immediately.(V6) suspended immediately. Law enforcement notified. Final reportable will be sent within five business days. On 8/24/23 at 8:10am, V2 stated V1 still acts as the Abuse Coordinator even when off, and is to be immediately notified of abuse, but V2 is to communicate with him and start an immediate investigation and walk out accused staff. V2 stated the residents nurse is to do head to toe skin check to check for signs of injury. V2 acknowledged there was no documentation in V4's Nurses Note to indicate an assessment for injuries was done, and V2 stated, (R3) gets a daily skin check anyway. V2 stated the 7/6/23 skin check was not timestamped, so there is no way to know if it was done before or after the above referenced incident. V2 stated she did not contact R3's Physician about the allegations of staff to resident abuse. . On 8/24/23 at 8:30am, V4 stated nursing staff should do a full body assessment on the resident after an abuse allegation has been made. V4 stated she doesn't remember if she assessed R3. V4 stated V2 did not instruct her to do one, nor is she aware of V2 doing one. V4 stated she did not contact R3's Physician. 8/24/23 9:20am, V11, Social Services Designee, stated she has been in the position since May 2023. V11 stated R3 is Quadriplegic as a result of a gunshot wound she sustained during a domestic dispute. V11 stated R3 has recently stated she will accept pastoral counseling for help in dealing with her issues. On 8/24/23 at 11:50am, V1 was told about R3's allegation of physical and verbal abuse and verbalization of fearing staff retaliation. V1 stated the initial notification of staff to resident abuse had been submitted to the Illinois Department of Public Health and the investigation was ongoing. The facility's undated Resident Rights Policy documented, Your facility must provide services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone-physically, verbally, mentally, financially, or sexually. Your facility may not threaten or punish you in any way for asserting your rights or presenting grievances. The facility's Abuse Prevention Program Policy, dated 9/29/22, documented, Abuse is the willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and servicesthat are necessary to attain or maintain physical, mental, and psychological well-being. The facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. 5. Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the Administrator. Upon learning of the report, the Administrator shall initiate an incident investigation. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the Administrator. Employees of the facility who have been accused of abuse will be removed from resident contact immediately until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. 8. External Reporting of Potential Abuse: In response to allegations of abuse, are reported immediately, but not two hours later than the allegation is made, to the Administrator and other officials (including the State Survey Agency). The allegation shall be either called or faxed to the Regional Public Health Office. The Administrator or designee will also also inform the resident or resident's representative and attending physician of the report of an occurrence of potential mistreatment and that an investigation is being conducted. The facility shall immediately contact local law enforcement authorities in the following situations: 1. Physical abuse involving physical injury inflicted on a resident by a staff member or visitor.

Based on interview and record review, the facility failed to notify a resident's Primary Care Physician of a worsening wound, failed to ensure ordered weekly wound care physician visits were done, and failed to notify the resident's Primary Care Physician of the lack of a wound care physician for 1 of 3 residents (R1) residents reviewed for pressure wounds in the sample of three. These failures resulted in R1's wound worsening to a Stage 4 that developed an infection requiring hospitalization , Intravenous (IV) antibiotic therapy, and surgical debridement. Findings include: R1's Face Sheet documented an admitted [DATE], and Diagnoses including Hemiplegia/Hemiparesis following a Subarachnoid Hemorrhage affecting the non-dominant left side, Aphasia, Morbid Obesity, a pressure ulcer to the sacrum, and Diabetes Type 2. R1's Minimum Data Set, dated dated [DATE], documented R1 was totally dependent on at least two staff for transfers, toileting, and bed mobility, had an indwelling urinary catheter, a gastrostomy tube with enteral feedings, a tracheostomy with mechanical ventilation, and a Brief Interview for Mental Status Score of Zero, indicating R1 had severe deficits in cognitive functioning. R1's Care Plan, with a start date of 5/1/23, documented a problem area, Resident is at risk of skin breakdown or pressure ulcers, with a corresponding intervention, Report changes to MD (Medical Doctor) and obtain treatments as ordered as indicated. R1's Braden Scale for Predicting Pressure Sore Risk, dated 6/19/23, documented R1 was at moderate risk for the development of pressure ulcers. R1's June 2023 Physicians Order Sheet documented an order, Cleanse coccyx wound with wound cleanser, apply (trade name alginate dressing) and cover with bordered gauze dressing daily. R1's Nursing Wound Assessments documented the following (all the following measurements are in centimeters): 5/1/23: Initial wound observation: (Wound location) Coccyx, two open areas, (area) measures 2 by 4 with a depth of 0.1, light clear serous drainage, well defined edges, with 100 percent of the wound covered by granulation tissue, (stage not documented). 5/10/23: (Wound measures) 6.2 by 6.5 by 0.1, moderate serous drainage, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue. Wound status: Stable. 5/15/23: 4.5 by 5.6 by 0.1, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue. moderate serous clear drainage. Wound status: Improving. 5/22/23: 4.3 by 5.5 by 0.1, stage 3, 30 percent epitheliazation tissue, 70 percent granulation tissue, moderate serous clear drainage. Wound status: Improving. 5/30/23: 4.3 by 5.5 by 0.1, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue, moderate serous amber clear drainage. Wound status: Declining. 6/5/23: 4.5 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/12/23: 4.3 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/19/23: 4.3 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/26/23: 4.3 by 5.4 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. Physician Wound Evaluation and Management Summaries, authored by V5 (Wound Care Physician), documented the following: 5/10/25: At the request of the referring provider (V7, R1's Primary Care Physician), a thorough wound care assessment and evaluation was performed today. Stage 3 pressure wound to the sacrum for at least 45 days duration. Wound size (in centimeters) 6.2 by 6.5 by 0.1. (Follow up) in seven days. 5/15/23: Stage 3 pressure wound to the sacrum. Wound size: 4.5 by 4.6 by 0.1. Wound progress: Improved. Follow up .within seven days. 5/22/23: Stage 3 pressure wound to the sacrum. 4.3 by 5.5 by 0.1. Wound progress: Improved evidenced by decreased surface area, increased epitheliazation. Follow up .within seven days. 5/29/23: The patients visit has been rescheduled. No nurse available for rounds. There was no further documentation by V5 in the record. R1's TAR (Treatment Administration Record) for May and June 2023 documented from 5/1/23 to 5/9/23, the coccyx wound was treated every 48 hours with moistened (trade name collagen matrix) covered with a (trade name foam dressing). From 5/10/23 to 6/19/23, the wound was treated daily with calcium alginate with a trade name bordered gauze dressing. From 6/20/23 to 6/28/23, which included the day R1 was sent to the hospital, the area was treated daily with hydrogel followed by (trade name calcium alginate) covered with (trade name bordered gauze dressing). Nursing Progress Notes for R1 documented the following: 6/20/23 at 3:45pm: Wound Doctor attempted to be contacted multiple times the last few days .regarding residents worsening wound to coccyx. Wound Nurse finally contacted (V6-Physician/Medical Director) for further instruction, (new treatment order obtained.) 6/26/23 at 5:36pm: Wound Nurse assessed and completed residents prescribed treatment order with no issues .Wound edges look to be rejuvinating much better than previous treatment that was prescribed. Wound Nurse attempted to contact Wound Doctor once again regarding (the) center area of the wound that is still not appearing to improve Still no answer. 6/28/23 at 8:10am: Night nurse reported .this resident had 104 (degrees Fahrenheit) fever .rechecked at 7:30, still 103.8. Urine in (indwelling catheter) bag noted to be dark and cloudy with small clots observed. (V7) notified at 7:38am and orders are given to send to the hospital. A Hospital Admission Record for R1, dated 6/28/23, documented, admitted (to the ICU (Intensive Care Unit)) with Urosepsis .(Admission) white blood cell count 18.6 (cells per microliter)(reference range: Normal 5-10). Culture from sacrum: Light Proteus miralibis, light polymorphonuclear cells, heavy gram-positive cocci, moderate gram variable bacilli. Assessment: Septic shock secondary to sacral wound. Cefipime 2000 milligrams in 0.9 percent sodium chloride in 50 milliliter IV piggyback given. A Hospital Encounter note dated 6/30/23 documented, Debridement of infected, necrotic, stage 4 sacral wound .necrotic tissue (present) all the way to the coccyx, fascia, and muscle .Possible need for multiple serial debridements. On 7/13/23 at 7:35am, V4 (R1's Power of Attorney) stated R1 was admitted to the facility on [DATE]. V4 stated R1 was admitted to the facility with a coccyx wound. V4 stated on 6/28/23, R1 developed a temperature of 103 degrees Fahrenheit, and was sent to the hospital, where it was discovered R1 had a Urinary Tract Infection and R1's coccyx wound was so deep the bone was exposed, and the wound was infected. V4 stated R1 will need multiple surgical interventions to close the wound. V4 stated R1 will also have to be on intravenous antibiotics, for weeks. On 7/13/23 at 2:30pm, V6 (Physician/Medical Director) stated staff had contacted him once in the past few weeks to report R1's pressure ulcer was not improving and they had been unable to reach V5. V6 stated he did not evaluate R1, but did give orders to change the treatment. V6 stated he had heard nothing further about R1. On 7/13/23 at 2:50pm, V2 (Director of Nursing) stated R1 was admitted with she believed three pressure areas to the sacrum, two of which have healed. V2 stated R1 was getting daily skin checks documented with a check off on the Treatment Administration Record (TAR), with a documented full evaluation of the skin done weekly. V2 stated R1's wound care treatment was being done daily with a check off on the TAR. V2 stated V5 was to see all residents with wounds every Monday. V2 stated over the course of several weeks in April and May 2023, V5 became less and less available and difficult to reach. V2 stated V5 last saw R1 on 5/22/23. V2 stated she is not sure why any of V5's notes would read, No nurse available to round, as any of the nurses may round with V5. V2 stated V3 (Licensed Practical Nurse/Wound Care Nurse), tried contacting V5 on multiple occasions after 5/22/23. V2 stated V3 was measuring and staging V5's residents wounds weekly, and was continuing to treat the wound according to V5's 5/22/23 orders. V2 stated about two weeks ago, V2 reached out to V5's contractual employer to ask that they send a different provider, and a Wound Care Nurse Practitioner started at the facility on Monday, 7/10/23. V2 stated on 6/28/23, R1 developed a 103 degree fever and was sent to the hospital for Urosepsis. V2 stated at the time of hospitalization , R1 did not have a wound infection. On 7/14/23 at 9:40am, V3 stated R1 was admitted with an area to the coccyx, primarily covered with granulation tissue, with two small unhealed areas within it. V3 stated the coccyx was being treated daily, with V3 doing the treatment on Mondays and Fridays and floor nurses doing the treatment on the remaining days. V3 stated R1 was being seen weekly by V5. V3 stated one area resolved, but V3 did not believe the other area was improving with the treatment V5 prescribed. V3 stated she brought this to V5's attention every time he rounded, but V5 still would not change the treatment orders. V3 stated V5 last evaluated R1 on 5/22/23, and did not show up or call to cancel the following week. V3 stated she kept calling V5, as well as his contractual employer, and about three weeks after 5/22/23, the employer told V3 that V5, was on an extended medical leave and was not available. V3 stated at that point, she called V7 to ask if V7 could evaluate the wound, but V7 did not return V3's call. V3 stated on 6/20/23, she contacted V6 to report the wound was declining, and V6 did not evaluate the wound, but did prescribe new treatment orders. V3 stated she last observed and treated the wound on 6/26/23, and she felt the wound was improving. V3 stated around that time, V2 called V5's employer and asked they send a different provider since V5 was not dependable. V3 stated she heard on the morning of 6/29/23 that R1 had been sent to the hospital on 6/28/23 and, (V1, Administrator) and (V2) said they heard from the hospital that when they got (R1), the wound looked really bad, the wound was infected, bone was exposed, (R1) would have to be on IV antibiotics for four weeks, and she would need to have surgery on the wound. V3 stated she was very surprised to hear this report. V3 stated R1 is the only resident whose wound deteriorated while the facility was without a wound care provider. V3 stated on 7/10/23, V5's employer sent a new mid-level wound care provider, who followed up on all V5's residents, and will see them weekly every Monday. On 7/14/23 at 12:45pm, V1 stated he heard from a nursing staff member, he could not remember which one, a nurse at the hospital where R1 was, called voicing concerns about the appearance of the wound and questioning the quality of wound care she was receiving at the facility. V1 stated the last staff member to provide R1's wound care prior to her hospitalization was V8 (Licensed Practical Nurse/LPN) on 6/27/23. On 7/14/23 at 12:50pm, V8 (Licensed Practical Nurse/LPN) stated she did not specifically recall doing R1's dressing change on 6/27/23, but if it had showed signs of infection or if the bone was exposed she most certainly would have contacted V7. V8 stated she and V3 had discussed the wound several times, and she was aware V3 had been trying to get a hold of V5. On 7/14/23 at 1:20pm, V9 (Registered Nurse) stated she had discussed R1 with hospital staff during transfer report, but nothing was said about her wound being infected. On 7/14/23 at 1:30pm, V2 stated she,Heard in passing at the 6/29/23 Department Head Meeting, that hospital staff called to voice concern about the condition of the wound and the quality of wound care she received at the facility, but she did know who took the call, and she did not follow up with the hospital. On 7/14/23 at 1:45pm, V10 (Hospital Nursing House Supervisor) stated R1 was admitted on [DATE] with an admitting diagnosis of Sepsis due to Urinary Tract Infection versus Osteomyelitis from an infected sacral wound. V10 stated on admission, staff noted the wound was unstageable with necrotic tissue present. V10 stated R1 was on IV antibiotics throughout her stay. V10 stated during the hospitalization the wound had to be surgically debrided. V10 stated R1 was discharged from the hospital on 7/7/23 to a hospital in Missouri, where R1 will get more surgical intervention for the wound. V10 stated R1's hospital chart contained no documentation to indicate their staff talked to the facility about R1's wound specifically. On 7/14/23 at 2:00 pm, V7 (R1's Primary Care Physician) stated she was aware R1 had been sent to the hospital due to Urosepsis and an infected pressure ulcer. V7 stated she had no idea V5 had not been visiting the facility due to being on an extended medical leave. V7 stated the facility did not call to tell her R1 was not being seen, nor that R1's pressure area had worsened. V7 stated she is always available by phone, and additionally she is in the facility rounding every week and nobody said anything to her about this issue. V7 stated had she been aware, she would have evaluated the wound herself. V7 stated R1 has multiple serious health concerns which complicated her care. V7 stated she had counted on the facility to ensure R1's wound was being treated by a specialist. A Wound Management Program Policy dated 1/20/23 documented, It is the policy of (the facility) to manage resident skin integrity through prevention, assessment, and implementation of evaluation and interventions .Physician orders should be obtained and followed for each resident. The facility will assess residents weekly for current skin conditions .Physician .(will be) called weekly .with an update of the current wound condition. These calls are documented in the nursing notes.

Based on observation, interview, and record review, the facility failed to implement a pain management program to promote comfort with wound care for 1 of 1 resident (R56) reviewed for pain in the sample of 38. This failure resulted in R56 experiencing significant pain while being provided wound care, as evidence by expressions of persistent pain, grimacing, moaning, and flushed face. Upon interview, R56 describes the pain present during wound care as a 9 out of 10, on a scale with 10 being the worst pain. Findings Include: Review of R56's active Physician Orders for January 2022 documents an order with a most recent start date of 12/7/21 which states, Pain Scale 0-10. Give Pain PRN (as needed) meds per scale of S/S (signs and symptoms) pain. Additional Physician Orders located on the same document documents an order with a start date of 12/9/21 which states, [MEDICATION(S)] Concentrate - Schedule II solution; 100 mg/5 mL (20 mg/mL); amt. (amount) 0.25 mL; DX. (diagnosis) pain. Every 2 hours PRN (as needed). Review of R56's Plan of Care documents a problem start date of 12/7/21 for the area of Pressure Ulcer. This problem area includes an approach for this area as, Prevent or treat pain during dressing changes and debridement. R56's Plan of Care also includes a problem start date of 12/7/21 for the area of Pain. The problem area documents the notation, Resident has complaints of chronic pain R/T (related to) DX., pressure ulcer sacral region, unstageable, pain in right shoulder, bicipital tendinitis, right shoulder etc. (etcetera). Approaches listed for this area include but are not limited to, Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors. Monitor and record any non-verbal signs of pain: (e.g. (example given) crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc Review of R56's Wound Evaluation & Management Summary, dated 1/5/22, documents the following wounds in which wound care services were observed being completed: 1.) Stage 4 pressure wound coccyx full thickness. The wound is documenting as measuring 11.5 centimeters (cm) (length) x 15 cm (width) x 3 cm (depth), with 3 cm undermining at the 7 o'clock position. 2.) Unstageable DTI (Deep Tissue Injury) of the left heel partial thickness. The wound is documented as measuring 5 cm (length) x 5 cm (width) x no measurable depth. 3.) Unstageable DTI of the right heel partial thickness. The wound is documented as measuring 6 cm (length) x 5 cm (width) x no measurable depth. An additional wound treatment was also observed to R56's right outer calf which is not listed on the Wound Evaluation & Management Summary. On 1/06/22 at 11:07 AM, wound care was observed being provided by V3 (Assistant Director Of Nursing) with V8 (Certified Nurse Assistant) assisting. During care, R56 was observed as demonstrating extensive grimacing, repeatedly saying ouch, and becoming flushed in the face while care was being provided. V3 and V8 both provided verbal reassurance to R56 by stating they were sorry . trying to be gentle and hurrying. Upon completion of care, V3 states R56 usually doesn't experience pain unless you're messing with her. When asked if R56 ever receives pain medication prior to having R56's wound care, V3 acknowledges V3 should have checked about R56 having some pain medication prior to providing the care. On 1/06/22 at 11:34 AM, V16 (Licensed Practical Nurse) states V16 was working as R56's nurse that day. V16 reports R56 had not had any of R56's as needed pain medication that morning prior to wound care being provided. V16's interview is confirmed by review of R56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication is not documented as being given at all on 1/6/22, and last given on 1/5/22 at 11:55 AM. On 1/06/22 at 12:56 PM, R56 was observed lying in bed. R56 is alert and oriented to person, place, and time. R56 stated yes when asked if R56 recalls R56's wound care being completed this morning. R56 shakes R56's head yes when asked if R56 experiences pain when they are completing R56's wound care. R56 was asked to rate the pain R56 had during wound care on a scale of 1 to 10, with 10 being the worst pain. R56 is observed as becoming wide eyed and states 9! R56 was asked to describe R56's pain level now, which R56 states is a 3. R56 states yes when asked if R56 would like to have R56's as needed pain medication prior to wound care in an effort to help with the pain R56 experiences. R56 acknowledges the pain medication is effective when given. On 1/07/22 at 10:35 AM, V15 (Physician) confirms V15 provides wound evaluation and care for R56. V15 states if R56 was experiencing pain during wound care, as needed pain medication orders in place should be implemented to promote comfort. Review of the facility policy titled, Pain Prevention & Treatment, with an effective date of October 2017, states this policy is To assess for, reduce the incidence of and the severity of pain to help the resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and non-pharmacological interventions to manage pain and / or try to prevent the pain consistent with the resident's goals. This policy goes on to say, Certain medical conditions may be painful such as pressure ulcers Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: .Skin / Wound Conditions: Pressure, venous, or arterial ulcers.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 7. This failure resulted in R2 being hit and choked by V11 (Certified Nursing Assistant/CNA) resulting in bruises on R2's arm, chin, and neck. Findings Include: R2's face sheet, dated 7/13/2021, documents R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's facility progress notes, dated 7/11/21 at 3:06 PM, documents a dark purple bruise that measures 4.7 cm x 3.8 cm (centimeters) on inner aspect of right upper arm, with another 4.0 cm x 2.4 cm bruise beneath it. R2's progress note documents R2's right side of face from cheek to jaw red and swollen with yellow discoloration to right side of chin with pain noted as well as yellow discoloration noted to left frontal aspect of neck. Administrator notified. R2's progress notes do not document any assessments of R2 from 7/6/21 until 7/11/21. R2's facility progress notes, dated 7/12/2021 at 9:51 AM with V1's (Administrator) signature, states a full body assessment was completed on R2 with a bruise measuring 4 cm x 4 cm to her inner right arm with no other areas noted. The progress note documents R2's neck, face, and chin were free from any areas. R2's progress notes document a separate assessment signed by V9 (LPN) on 7/12/2021 at 5:38 PM, that states, Discoloration remains to right upper inner arm and left neck and right chin. Right cheek remains slightly swollen. Voices kind of sore today. R2's facility Serious Injury Incident Report, dated 7/12/2021 at 8:00 AM, documents, Resident (R2) reported a staff member had pinched her and hit her sometime last week. Resident could not recall when or who the staff member was. Full body assessment revealed a 2 cm x 2 cm bruise to inside of arm. No other injuries noted. Law enforcement notified of incident, full investigation and final report to follow. POA (power of attorney) and Doctor informed of allegation. The report documents NA next to witness name and does not document the date and/or time the local law enforcement, power of attorney, and/or physician were notified. R2's facility Serious Injury Incident Report, dated 7/14/2021, documents, .7/12/2021 resident (R2) reported to me that a staff member had punched her (R2) in the face and choked her when they were performing morning care and getting her up for breakfast. Resident could not provide a time-line of when the incident occurred. Resident stated it was a blonde girl who was very skinny. Investigation began immediately with interviews of staff and resident. Full body assessment performed revealing a 3 cm by 3 cm bruise to upper right arm, slight yellow area and minimal swelling to residents left jaw line. Resident states her jaw is a little sore when someone touches it. During staff interview it was reported that on Friday morning V11 (Certified Nursing Assistant/CNA) and V8 (CNA) were attempting to get resident up for a shower before breakfast when resident became verbally and physically abusive towards staff. Staff informed resident it was time to get up for a shower and breakfast, resident agreed and was compliant with care. Staff got resident dressed, resident was placed on the (mechanical lift) pad and resident was handed her brush to brush her hair. Resident swung the brush and hit V11 in the right arm, V11 reacted and hit the resident in the upper right arm and grabbed her chin, turned residents head toward herself and stated, I am done being hit by you and walked out of the room. V8 provided the statement and was witness to it. V11 was immediately removed from the building, suspended, and asked to provide a statement. V11's statement reads they were providing care and getting resident on the (mechanical lift) pad when resident struck her with the brush in the arm. V11 grabbed residents arm and held it down and removed the brush from her hand and left the room. Resident was reinterviewed and confirmed the incident as reported by V8 but claimed the staff member was a skinny blonde headed lady. V8 fit the description so was suspended pending investigation results. Resident was shown pictures of the two staff members, Resident pointed to the picture of V11 and mimicked hitting herself in the jaw. When asked if that was the one who hit her resident stated, yes when asked about the other picture the resident stated no. All other residents in the building were interviewed and denied witnessing or being abused in any way, all staff was interviewed and denied witnessing abuse. POA (Power of Attorney) was informed of incident and investigation at 0934 (9:34 AM) on 7/12/2021, doctor was also informed immediately following the call to the POA at 0934 on 7/12/2021. Law enforcement was called, and investigation began on 7/12/2021 at 1000 (10:00 AM) Based off the interview of the resident and staff member (V8) abuse is confirmed to have occurred by V11 (CNA). V11 was informed of investigation outcome and the termination of her employment at 1000 on 7/13/2021 V8 informed of investigation outcome and is allowed to return to work on her next scheduled day, V8 will be coached for delay in reporting abuse upon return to work. All staff will be in-serviced, and resident/staff follow up will continue. Law enforcement notified of investigation outcome. On 7/12/2021 at 10:10 AM, R2 stated she had a bruise to her right upper arm and her right lower cheek. R2 stated her right lower cheek continues to be very sore and swollen. R2 stated a skinny lady with long blonde hair hit her on the right jaw and upper arm. R2 stated the occurrence happened last Tuesday in her room in the early morning. On 7/13/2021 at 12:50 PM, R2 stated a person with long blonde hair hit, punched, and choked her. R2 stated she did not know who it was, and could not recall the date it occurred. R2 stated she was in bed when they came in and asked her if she was ready to get up. R2 stated when the aggressor started choking her, she (R2) punched them in the chest and they stopped. R2 stated she reported it to the front desk. R2 was observed to have a purple and yellow bruise on the inner aspect of her upper right arm, with a second bruise of the same color just behind the first one. R2 stated her chin hurts so bad and showed this surveyor an area on the right side of her chin that R2 said hurt to touch. R2 stated her cheek felt swollen. A faint purple/blue bruise was noted on R2's chin. R2 also had a faint yellow linear bruise around the base of her neck on the left side that extended down towards R2's chest. On 7/13/2021 at 10:28 AM, V7 (Certified Nursing Assistant, CNA) stated on 7/11/2021, she observed a bruise to R2's right inner arm. V7 stated she asked R2 how she got the bruise, and R2 told her one of the staff (unknown) punched and choked her, and her jaw also hurt. V7 stated she asked R2 when it happened, and R2 told her the other day. V7 stated she assumed it occurred on 7/9/2021, because she (V7) was working on a different hall, and when she went to say hello to R2 a few times throughout the day, R2 was in bed with her curtains drawn. V7 (CNA) stated V8 (CNA) and V11 (CNA) were working on R2's hall on 7/9/2021. V7 stated she asked R2 if the nurse was aware, and R2 shrugged. V7 stated she completed R2's care, and then reported the allegation to V24 (RN/Registered Nurse). On 7/13/2021 at 11:54 AM, V20 (LPN/Licensed Practical Nurse) stated on 7/10/2021 (unknown time), V8 (CNA/Certified Nursing Assistant) reported to V20, while assisting R2 with morning care on 7/09/2021, R2 hit V11(CNA). V8 reported to V20 that V11(CNA) then hit R2. V20 stated V11 was not working on 7/10/2021 when V8 reported the allegation of abuse to her. V20 stated she reported the allegation to V1 (Administrator), but did not ask R2 what had occurred, or get a written statement from V8. V20 stated she assessed R2, and did not see any bruising at that time. When asked where she had documented the allegation of abuse, assessment of R2, and notification of the allegation to V1, V20 stated she had not documented it. V20 stated V11 was scheduled off work on 7/10 and 7/11/21, and V11 was told she had been suspended when she returned to work on 7/12/2021. V20 stated V8 worked on 7/10 and 7/11/21 and was suspended on 7/12/21, pending the outcome of the investigation. On 7/13/2021 at 12:20 PM, V9 (LPN) stated V24 (RN) reported to her on 7/11/21, R2 had been punched, hit, and choked. V9 stated V24 notified V1 (Administrator) of the allegation on Sunday 7/11/2021. V9 stated V24 asked V9 to get measurements of the bruising on R2. V9 stated R2 had a yellow bruise on her right arm, a small bruise on her right chin, yellow discoloration on her left lower neck/clavicle area, and R2's right cheek was swollen. On 7/13/2021 at 2:20 PM, V24 (RN) stated on 7/11/21, R2 was sitting at the nurses station and she noticed bruising to R2's upper arm. V24 stated the bruises looked pretty significant. V24 stated R2 told her the blonde girl came into her room, held her down, choked her, and punched her in the face. V24 stated she notified V1 (Administrator) of the allegation. When asked if V1 asked her any questions related to the allegation, V24 stated V1 told her he would be in touch with her on Monday 7/12/2021, and she still hadn't heard from him. When asked if she had any idea who R2 could be talking about, V24 stated the only person she could think of that fit that description would be V11. V24 stated she did not remember V7 reporting the allegation to her, but V25 (Activity Aide) had confirmed R2 told her about the allegation. On 7/13/2021 at 2:56 PM, V25 (Activity Aide) stated she was doing an activity with R2 on 7/11/2021, and noticed a bruise on R2's arm, and when she asked R2 how she got the bruise, R2 stated she didn't know. V25 stated then R2 told her she was told she couldn't tell what happened. V25 stated she asked R2 who told her she couldn't tell. V25 stated R2 told her a blonde headed girl had hit R2, and pulled R2's hair, and did not want R2 to tell anyone. V25 stated she took R2 to the nurse's station and reported the allegation to V24 (RN). On 7/14/2021 at 9:10 AM, V8 (CNA) stated she was working with V11 (CNA) on 7/9/2021. V8 stated it was R2's shower day, and R2 was being her normal self and yelling. V8 stated they (V8 and V11) got R2 on the mechanical lift and R2 hit V11 in the arm. V8 stated V11 then hit R2 in the arm, grabbed R2 by the throat, pushed R2 down, and got in R2's face. V8 stated she couldn't remember if V11 said anything to R2. V8 stated they unhooked R2 from the mechanical lift, V11 left the room, and did not provide care to R2 the rest of the day. V8 stated she did not report the incident because she was in shock, but she should have. V8 stated she came to work on 7/10/2021 and reported the incident to V20 (LPN), who reported it to V1 (Administrator). V8 stated V1 called her on the morning of 7/12/2021 and asked her to come to the facility and talk about the allegation. V8 stated she worked on 7/11/2021 and 7/12/2021, but V11 did not. V8 stated V1 did not speak with her related to the allegations until 7/12/2021. V8 stated the incident occurred before breakfast (approximately 6:30 or 7:00 AM). On 7/14/21 at 2:24 PM, V1 (Administrator) stated he was notified by V20 (LPN) of the allegation of physical abuse of R2 by V11 on Saturday 7/10/2021. The facility Abuse Prevention Program, dated 12/16/16, documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Under Internal Reporting Requirements and Identification of Allegations the policy documents, Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observed, hear about, or suspect immediately to the administrator Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation. Under Protection of Residents the policy documents, Employees of the facility who have been accused of abuse, neglect, or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse, neglect, or misappropriation shall not complete the shift as a direct care provider to residents.

Based on observation, interview, and record review, the facility failed to provide resident care in a timely and dignified manner for 3 (R4, R6, R2) of 5 residents reviewed for resident care in the sample of 10. The failure resulted in psychosocial harm as evidenced by R4 experiencing expressions of embarrassment, negative statements, tearfulness, and reports of crying, along with R6 experiencing tearfulness. Findings Include: 1. On 5/27/21 at 11:05 AM, R4 states she is continent of urine and bowel, but due to lack of timeliness in assistance being provided to the restroom, she has experienced episodes of incontinence. R4 states she requires staff assistance with transferring and finds although she illuminates her call light as soon as she has the indications she will need to use the restroom, the untimeliness of staff response, along with her consumption in taking a water pill make it so she cannot wait for long periods of time. R4 states her most recent incontinent episode at the time of this interview was on 5/26/21, and then a couple weeks prior to that. R4 states she finds the incontinence embarrassing. R4 recalls an incident when she states she was apologetic to staff by saying Sorry, I couldn't hold it any longer and dirtied the bed. R4 states the staff responded by stating, I know, I can smell it. R4 then stated, Things like that just don't make a person feel good. R4 states she waits anywhere from 15 minutes to over an hour for her call light to be answered. R4 states she presented her concerns to V2 who told her to remember she isn't the only one here. During this interview, R4 was alert and oriented to person, place, and time. On 5/28/21 at 7:55 AM, R4 states yesterday evening she had an episode in which she urinated in her clothes waiting for her call light to be answered. R4 states she kept seeing staff walk by her room and was trying to holler at them too, even though her light was on to let them know she couldn't hold it, but states they kept telling her she would have to wait a minute. R4 states after urinating and being left sitting in her wet clothes, she used her cell phone and called the nurses station and talked with V10 (Licensed Practical Nurse) to let her know she needed help. R4 states at that point, she broke down and began crying because she is frustrated, mad, and embarrassed that a grown woman has to sit there and pee her pants! R4 states she is working hard with therapy to try and be able to transition back home, and to soil her clothes makes her feel like she is going backwards. R4 is observed as again becoming tearful and raising her voice during this time. On 5/28/21 at 12:07 PM, V10 confirms she did work on 5/27/21, and received a phone call around 7 PM from R4 stating she was upset, had wet herself, and was wanting to be put to bed. V10 states staff were on the hallway where R4 resides tending to other residents. V10 states she told the staff members R4 needed assistance and she would help if needed. V10 states she was getting ready to leave for the day though, so she just went and checked on R4 to let her know she had spoken with staff and they would be heading her way. V10 states the facility needs more staff to meet resident care needs. 2. On 5/28/21 at 12:15 PM , R6 describes an episode of experiencing rough care as, Leaves me on the bedpan for long time. Other night for 2 hours. When asked if R6 turns on R6's call light when done R6 states, Yes. When asked how R6 determined the time frame of 2 hours, R6 states, Clock, and a clock is observed on a wall within viewing distance of the bed. R6 states, Yes when asked if R6 has been left on the bedpan for an unacceptable amount of time more than once. When asked does this upset you, R6 states, Yes. It uncomfortable. R6 also states Yes when asked if it interrupts R6's sleep. R6 states V3 (Certified Nurse Assistant) was the staff member who responded to R6 light and removed the bedpan. During this interview, R6 was observed as being alert and oriented to person, place and time. On 5/28/21 at 1:25 PM, V3 states the facility does not have enough staff to meet resident needs. V3 states call lights are not answered in a timely manner, nor are residents changed and/or repositioned as they should be. V3 states an incident occurred a few nights ago where she responded to R6's call light and when she entered R6's room, she noted R6 face to be red with R6 on the verge of tears. V3 states she asked R6 what was wrong in which R6 responded bedpan. V3 states she asked R6, you want on the bedpan? V3 states R6 stated, off! V3 states, I wasn't trying to be an a-hole. I didn't know she was on there. I don't know who put her on there. V3 states she asked R6 how long R6 had been on there and states R6 said, Awhile! V3 states she removed the bedpan and continued working. V3 confirms R6 is cognitively intact and utilizes the call light. V3 states that R6 just has trouble getting out what R6 wants to say. 3. On 5/27/21 at 11:29 AM, R2 states the facility does not have enough staff to respond to call lights in a timely manner. R2 states she would say on average it takes about 20 minutes for her call light to be answered. During this interview. R2 was alert and oriented to person, place, and time. On 5/27/21 at 8:48 AM, V2 (Director of Nursing) states current staffing levels at the facility probably don't meet resident needs. V2 states the facility has attempted to hire more staff, along with utilize agency staff, but states they receive little to no applicants, and agency staff don't always show up to work. V2 states resident needs aren't met by evidence of call light timeliness could be improved. V2 states she has received complaints specifically from R4 regarding her call light not being answered in a timely manner. V2 also states resident showers may not be given on their scheduled days as staffing may not be available for showers on those days but will be given on a later day to fulfill the twice weekly showering requirement. At 2:52 PM on the same day, V2 states staffing levels are based off facility census versus resident acuity. On 5/28/21 at 8:24 AM, V6 (Certified Nurse Assistant) states there are days the facility does not have enough staff to meet resident needs. V6 states staff just Have to do what we can. V6 states, Things cannot get done the way they need to be done. V6 goes on to state this statement includes call lights not being answered in a timely manner and residents not being taken to the toilet in a timely manner. V6 states she is aware of instances in which normally continent residents experienced incontinent episodes due to not being taken to the toilet timely. V6 states there are times showers are unable to be completed on designated shower days due to not being enough staff. V6 states staff will attempt to make up the showers on another day or give resident's bed baths. On 5/28/21 at 10:20 AM, V12 (Licensed Practical Nurse) states with the current facility staffing levels, staff are unable to meet resident needs. V12 states she works night shift and had notified V2 of her staffing level concerns recently via phone when V2 has told her to call people in. V12 states, there was no one to call in though, and management didn't come in to help. V12 states resident call lights are not answered in a timely manner, nor are residents turned and repositioned as they should be. On 5/28/21 at 11:31 AM, V14 (Licensed Practical Nurse) states the facility needs more staff, and should the facility be adequately staffed, the quality of care provided to the residents would be improved. On 5/28/21 at 3:00 PM, V2 states her expectation would be for call lights to be answered within 5-7 minutes. V2 states once a resident is done on the bedpan and turns on their call light for service, the expectation response time by staff for bedpan removal would also be 5-7 minutes. V2 acknowledges being left on the bedpan for an extended period can result in pain and discomfort. On 6/1/21 at 10:15 AM, V1 (Administrator) states the facility is staffed as best as they can get it right now. V1 states he has received resident complaints regarding call lights not being answered in a timely manner. V1 states his expectation is for call lights to be answered in less than 5 minutes. Review of the facility policy titled Answering the Call Light, with a revision date of July 2014, states: The purpose of this procedure is to respond to the resident's requests and needs The policy goes on state . 8. Answer the resident's call as soon as possible. 9. Be courteous in answering the resident's call. Steps in the procedure include, 3. Listen to the resident's request. 4. Do what the resident asks of you if permitted. 5. If you have promised the resident you will return with an item or information, do so promptly. 6. If assistance is needed when you enter the room, summon help by using the call signal. In an article titled Nursing Bedpan Management, with an update date of July 31, 2020, and found at https://www.ncbi.nlm.nih.gov/books/NBK 8/ states, The important features of bedpan are not only to provide a functional use for the patient, but comfort and privacy. If a bed pan is to be used, it should be for a short duration. there are countless cases of pressure sores, ulcers and [CONDITION(S)] from patients being left too long on the bed pan.

Based on observation, interview, and record review, the facility failed to prevent staff to resident abuse for 3 (R4, R5, and R6) of 6 residents reviewed for abuse in the sample of 10. This failure resulted in psychosocial harm as evidence by observed tearfulness along with feelings of fear for R6. Findings Include: 1. On 5/27/21 at 11:41 AM, R6 is alert and oriented to person place and time. R6 understands speech and responds appropriately, but has difficulty speaking and expressing thoughts. An interview with R6 transpired which included the following information: Are you happy with your care at the facility? No Is anyone at the facility mean to you? Yes Do they work during the day or night? Night What is their name? No response Is it Susie? No Is it (V3 first name)? Yes Is it Lisa? No Is she the only person who is mean to you? Yes How is she mean? She yells at me. Rude. Says WHAT DO YOU WANT NOW! I'M THE ONLY ONE HERE! Inaudible vocalization continued. R6 became tearful during this time. Do you feel what she says is abuse? Yes Did she speak to you this way only one time? No What night did this occur? Most nights. She's not nice. Do you feel fearful of her or afraid she would hurt you? Yes Has she ever physically assaulted you assaulted you in any manner? No Have you told anyone about the trouble you've had with (V3 first name)? No Is it ok that I speak with the facility about the trouble you've had with (V3 first name)? Don't use my name. Can I use your name in my investigation findings? No. Are you afraid they would treat you differently then? Yes. Review of R6's Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status Score of 14, indicating she is cognitively intact. Review of R6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 5/27/21 at 12:50 PM, R5 states she has had many problems with a night shift aide named (V3's first name). R5 states she has expressed her concerns to V1 (Administrator) and V2 (Director of Nursing) regarding staff attitudes in general, in which they said they would address the staff, but states she learned, you just have to have thick skin in the nursing home. R5 describes V3 as making you feel as though you are a bother. R5 states she is very rude and handles her rough. R5 states when she turns on her call light for assistance, V3 will respond by coming in her room stating, What do you want this time? R5 also describes an incident in which she wanted to utilize the bedpan differently than how V3 had placed it for comfort reasons. R5 states when she requested to have the bedpan position changed, V3 stated in a very hateful tone, Well don't fart in my face! R5 states at times she feels the way V3 has spoken to her is in an abusive manner. R5 states she often wondered if it was only her V3 treated this way, or if there were others too. R5 states she is relieved now though because V3 is leaving from the facility so she is someone else's problem now. R5 states while some other aides can have poor attitudes, V3 is the only one she would consider being abusive at times. R5 states there is no specific dates she can pinpoint the abuse as occurring as V3 is unpleasant more often than not. R5 is alert and oriented to person, place, and time during this interview. Review of R5's Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating she is cognitively intact. 3. On 5/28/21 at 1:00 PM, R10 states she has had problems with V3 (Certified Nurse Assistant) and expressed concern to V10 (Licensed Practical Nurse) with the way she hears V3 speaking to other residents. R10 describes V3 as having a horrible attitude and states she will get loud with you. R10 states in expressing her concerns to V10 she hoped something would be done with V3. R10 states V3 works night shift and she overhears V3 speaking so loudly to residents during the night saying things like, I get tired of this all the time! I already know what you want! R10 states the manner in which she hears V3 speaking to residents she would consider abusive. R10 states, Nobody deserves to be talked to like that. R10 is alert and oriented to person, place, and time during this interview. On 5/28/21 at 12:07 PM, V10 verifies she has received a complaint from R10, along with R4 regarding V3, but states she took them more as they just didn't get along with her, not as being abusive in nature. 4. On 5/27/21 at 11:05 AM, R4 describes V3 as, She has no business working in a nursing home! R4 states she hears V3 speaking to residents in a tone that is not friendly and is rude. R4 states that she has also observed V3 handle residents roughly. R4 is alert and oriented to person, place, and time during this interview. On 5/28/21 at 1:25 PM, V3 verifies she works as a Certified Nurse Assistant on night shift at the facility. V3 states she is a loud person and maybe someone has misinterpreted her but denies any allegations of abuse. V3 states she was notified of an allegation of abuse made against her on 5/27/21 by V2 (Director of Nursing) and suspended pending investigation outcome. V3 verifies she has been trained in abuse. On 5/27/21 at 8:48 AM, V2 states V3 is the only Certified Nurse Assistant working at the facility that has that first name, and verifies she works night shift. V2 states she has received no allegations of abuse against V3. V2 was notified of the allegations made, in which she states V3 will be suspended and an investigation initiated. On 6/1/21 at 10:15 AM, V1 confirms V3 is the only employee in the facility with that first name. V1 states he has received no allegations of abuse or complaints regarding V3, but confirms an investigation is currently being conducted due to the allegations made and conveyed during this survey with the final investigative results still pending. On 6/2/21 at 9:50 AM, V1 states during his investigation he has substantiated verbal abuse occurred by V3 against R4 and R5, as well as R6, expressing feelings of intimidation by V3. V1 states V3 was terminated from the facility on 6/1/21 at 10:00 AM. A facility policy titled Staff Obligations to Prevent & Report Abuse, Neglect & Theft Acknowledgement. with a revision date of 2/16/11. states, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The same policy goes on to state that, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's final Incident Report of Abuse. dated 6/2/21 as reported by V1. documents R4, R5, and R6 were investigated for abuse by V3. The Detailed Incident Summary documents in part, It was reported by three residents that they feel intimidated by V3 and not turn on their call lights while she is here because of her poor attitude. One resident reported V3 turns off her call light, leaves her room without providing care. One other resident reported that V3 told her, 'I am tired of this crap and am about done with it all.' One resident reported by one resident that V3 stated, 'I will just turn your O2 (oxygen) off if you don't calm down.' Resident stated she thinks V3 was joking, but she did not appreciate the comment and does not feel safe with V3. During facility and IDPH surveyor investigation mental and verbal abuse was founded in the remarks made by V3,CNA to numerous different residents resulting in residents being intimidated, not feeling safe, and not believing V3 to provide the proper care that is required. As a result V3's employment was terminated on 6/1/21.

Based on record review and interview, the Facility failed to thoroughly assess for contributing factors and implement interventions based on the identified contributing factors for 2 (R7, R11) of 3 resident's reviewed for incidents and accidents in the sample of 18. This failure resulted in R7 falling out of her wheelchair and sustaining fractures involving the lateral aspect of the superior pubic rami and the medial aspect of the inferior pubic rami. Findings include: 1. A review of R7's Facility Incident Investigation documents the following: 9/24/12, 12:15 AM, "the nurse was sitting at the nurses station, heard a noise and then heard her yell for help. She went to the room to find R7 lying on the floor crying in pain. They kept her on the floor until the ambulance arrived. This resident is alert to herself. She is confused to time and place. She has Alzheimer's. She is independent with ambulation and going to the bathroom. She ambulates freely about the facility. She is Diabetic. She went to the hospital and was diagnosed with [REDACTED]. R7 was admitted for surgery". E2, Director of Nursing, stated during an interview on 3/6/13 at 1:50 PM that R7 was independent in her activities of daily living, ambulation and toileting prior to her fall on 9/24/12. E2 said that when R7 came back to the Facility following surgery and hospitalization for the left hip fracture, she could no longer ambulate. E2 said that a pommel cushion to prevent abduction; an alarm to notify staff when R7 would gets out of bed; and a tabletop placed over her wheelchair; were all ordered on [DATE], upon R7's return from the hospital. R7's Facility Incident Investigation documents that on 10/17/12, at 3:50 PM, "R7 was found lying on right side on floor, noted spilled water pitcher, had just returned from therapy. No injury". The investigation does not state when R7 was last observed, when she was last taken to the toilet, when she last had a drink, or if she was lying in her bed or sitting in her wheelchair prior to being found on the floor. The corrective action for this fall documents "resident to be sitting in hallway when up in chair unless with staff or family". Facility Incident Investigation for R7, dated 10/20/13, at 4:15 PM, documents "Resident found on floor lying on right side. Shoes on, floor dry, complaining of left hip pain. Recent hip fracture, attending therapy at this time. Resident returned from therapy and set her in room without tabletop on wheelchair. No injury". The Investigation does not document when R7 was last seen prior to her fall, or when she was last toileted prior to the fall. The corrective action for this fall documents "to have personal alarm and lap tray on when not at nurses station, resting or in therapy". R7's Facility Incident Investigation, dated 1/4/13 at 6:15, documents "Resident's husband took tray off of wheelchair for supper and left without putting tray back on, and resident got out of wheelchair and fell ". The investigation does not document when R7 was last observed by staff or last toileted prior to her fall. This investigation documents that R7 sustained acute non-displaced fractures at the superior ramus of the right pubic bone, inferior ramus of the right pubic bone and medial aspect of the superior ramus of the left pubic bone. R7 was sent to the emergency room and returned a short time later with an order for [REDACTED]. The corrective action for this fall documents "staff to take lap tray off for meals with supervision and to be put back on after eating". Radiology Report for R7, dated 1/25/13, documents "Follow-up for fractures. Fractures are noted involving the lateral aspect of the superior pubic rami and the medial aspect of the inferior pubic rami". Facility Incident Investigation for R7, dated 2/8/13 at 6:25, documents "resident found sitting on floor on buttocks with legs out in front, sitting by geriatric chair. No injuries noted. No injury noted" The investigation does not document when R7 was last observed by staff, when R7 was last toileted or if the lap tray was in place. The documented corrective action for this incident is "resident to be up in wheelchair with table top, release every 2 hours for 10 minutes with supervision". E2 stated in an interview on 3/6/13 at 1:50 PM, that R7's fall on 2/8/13 occurred over a weekend. E2 said that R7 had an intravenous access site on her foot which infiltrated and caused edema. E2 said that nursing staff needed to elevate R7's foot so they placed her into a geriatric chair without the lap tray and she fell out. R7's plan of care, with an original date of 10/9/12 documents a problem of "Potential for injury from falls related to minimal difficulty with hearing, usually understood, vision impaired, wears glasses, short and long term memory deficit, cognitive skills for daily decision making moderately impaired, inattention, disorganized". The Goal for this Problem documents "Resident will have no falls or injury related to falls". Approaches for this Problem include: "High back wheelchair with pommel cushion and table top, release every 2 hours for 10 minutes with supervision. Personal alarm in bed". R7's Minimum Data Set (MDS), dated [DATE], documents that she has short and long term memory problems; requires the extensive assistance of 1 person for transfers; does not ambulate and is at high risk for falls. 2. A review of R11's current medical record and admission records indicate R11 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R11's Fall Risk Evaluation from 8/22/12 and 11/5/12 and an undated evaluation find R11 rated at High Risk for falls. Review of R11's incident reports indicate R11 has had 9 falls from 9/2/12 to 2/18/13. The incident reports for each fall were reviewed and found incomplete. The falls root cause was repeatedly "Due to resident action or internal risk factors", the interventions after falls on 9/26/12, 11/6/12, 12/4/12, 12/29/12 and 2/18/13 were to remind the resident or council the resident. None of the interventions from the falls above were facility / staff actions or changes that could be made to assist R11 to reduce the risk to fall. There were no interventions gleaned from the facts ascertained from the investigations and/or incident report investigations. Interview with E2 (Director of Nursing) on 3/6/13 at 4:45pm found that the incident investigations did not lead to effective interventions.