Every finding on record at Eastview Healthcare & Senior Living

Based on observation, interview and record review the facility failed to provide supervision for a resident in a resident's room to prevent falls for one resident (R2) and failed to implement fall prevention interventions to for one resident (R3). These failures affect two of four residents (R2, R3) reviewed for falls in the sample list of 19. These failures resulted in R2 sustaining a subarachnoid hemorrhage and a compression fracture of the T12 vertebral body from falling. Findings include: 1) R2's Medication Review Report dated 6/18/26 documents diagnoses including Unspecified Dementia with Other Behavioral Disturbance, Cognitive Communication Deficit, Other Lack of Coordination and Other Reduced Mobility. R2's Care Plan dated 11/4/25 documents R2 slid out of the wheelchair while in R2's room unsupervised. The intervention put into place was to educate staff to place R2 in the common area until available to assist R2. R2's Public Health Notification Form Dated 5/26/2026 documents R2 had a fall with injury. R2's incident report dated 5/25/2026 at 5:00pm documents (R2) had an unwitnessed and unintentional change of plane. (R2) was observed in (R2's) room lying on (R2's) right side in front of (R2's) wheelchair. (R2) had full range of motion and (R2) had a hematoma 5.0 cm x 5.0 cm on the right side of (R2's) forehead. R2 was sent to the local hospital. R2 demonstrated signs of pain. R2's hospital records dated 5/25/2026 documents R2 was admitted via the emergency room with a diagnosis of Subarachnoid Hemorrhage, and Acute-Subacute Compression Fracture of T12. V7's Certified Nursing Assistant (CNA) witness statement dated 5/25/2026 at 4:50 pm documents V7's statement as V8 CNA and I were getting residents up for supper. We got another resident up first and then got (R2)'s roommate up. V8 went on down the hall to the next resident's room, while I took another resident to the dining room. I was coming back for (R2) when I was informed that (R2) fell out of (R2) wheelchair. V8's CNA's witness statement dated 5/25/2026 at 4:50pm documents We got (R2) up around 4:45pm to 4:55pm for supper in (R2)'s wheelchair. After that we got (R2)'s roommate up. I went to the next resident while V7 took (R2)'s roommate to the dining room and was coming back to get (R2) as well. The undated final Report for the incident documents that on 5/25/26 at 4:50pm, V7 and V8 were getting residents ready for the evening meal. Upon returning to (R2)'s room (R2) was observed on the floor in front of her wheelchair. The conclusion documents a therapy evaluation, enhanced supervision, and monitor effectiveness of interventions. R2's fall risk evaluation dated 11/7/2025, 1/14/2026, and 2/6/2026 document R2 at risk for falls. On 6/18/2026 at 10:40am, V2 Director of Nursing stated R2 is a high fall risk. V2 stated V2 would expect that R2 would not be left alone in R2's room. 2) On 6/16/2026 at 12:35pm R3 stated I have not been here long. I am leaving tomorrow. R3's fall risk assessment dated [DATE], 4/16/2026 and 4/25/2026 documents that R3 is at a high risk for falls. R3's care plan dated 6/1/2026 documents the fall intervention of a left side rail on 4/19/2026 and documents that R3 is at risk for falls. R3's Fall Intervention dated 4/25/2026 documents unwitnessed fall in room due to bed rail not being in proper position with an intervention of place sign to ensure bed rail is up at all times. On 6/16/2026 at 12:35pm there are no bed rails on either side of either bed in R3's room. There is no signage posted in R3's room. R3 stated I was moved into this room from another room. They did not move my bed down here that has side rails. I have not had side rails since I have been in this room. Facility census documents R3 was moved from on 5/18/2026 from R3's previous room. On 6/16/2026 at 11:30am and 3:00pm there were no bed rails noted on either of the two beds in R3's room. R3's Electronic Health Record documents R3 discharged from the facility on 6/16/2026 at 6:10pm. Facility Policy provided by V1 stated the staff and the physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.

Based on observation, interview, and record review, the facility failed to perform adequate sanitation of residents' eating utensils, cutlery, and dishware. This failure has the potential to affect all 20 residents residing in the facility.Findings include:On 6/16/26 at 1:15 PM after the lunch meal, V16, Dietary Aide performed a temperature check using the manufacturer's provided temperature gauge on the dishwasher, and performed a chemical sanitization check with manufacturer approved litmus paper. The Litmus paper was read by V16 who stated the results were between 25-50 parts per million (ppm) when compared to provided scale on the bottle. V16 confirmed the temperature was read at 118 degrees Fahrenheit (F) during the wash cycle and 120 degrees F at the rinse cycle.On 6/17/26 at 9:20 AM V15, Dietary Aide was washing breakfast dishes and looked at the temperature gauge on side of the dishwasher and stated the water temperature during the wash cycle was 118 degrees F. On 6/17/26 at 9:51 AM V10, Maintenance Director, stated the water temperature in the dishwasher should be at least 120 to 145 degrees F when washing and rinsing the dishes, but at midday, the staff have to run the dishwasher three times before using it, to get up to the temperature needed. V10 stated that maintenance is done by the company that they lease the machine through. V10 referred to the poster on the wall behind the dishwasher which documents, Typical wash and rinse temperatures for a low temp (temperature) machine 120-145 degrees F. Temperatures should coincide with Manufacturer's label on machine.On 6/17/26 at 11:10 AM V17, Dietary Manager, first stated the dietary staff test the water temperatures and chemical sanitizer levels in the dishwasher once daily. V10 then walked over and looked at the clipboard on the wall where staff record the temperatures and V17 stated well, three times a day but we haven't been logging it as you can see, we just stopped.On 6/18/26 at 11:00 AM V1, Administrator, stated the dishwasher temps were low, and the machine is not functioning properly. V1 stated the company which leases them the dishwasher was notified and will be coming to repair it, and the kitchen is now using disposable utensils until the dishwasher is fixed.The facility's document, Dishwasher Temperature /Sanitizer Log, dated June 2026 documents temperatures and sanitizer levels are checked at breakfast, lunch and supper. Directions on this document read, Record temperature or test strip results before washing dishes after each meal. Report inappropriate temperatures or test strip results to the supervisor. There are no results of temperatures or sanitizer levels documented for supper on 6/7/26 through 6/10/26 and no temperatures or sanitizer checks for any meals on 6/11/26 through 6/14/26. On 6/15/26 and 6/16/26, the temperatures and sanitizer levels are recorded for breakfast and lunch, but not supper. On 6/18/26 at 11:00 AM, V1 stated the facility does not have a policy specific to testing water temperatures and sanitizer levels in the dishwasher. V1 stated the only thing the company that leases the dishwasher to the facility told V1 was to refer to the poster behind the dishwasher.The facility's MDS (Minimum Data Set) Resident Matrix dated 6/18/26 documents 20 residents reside in the facility.

Based on observation and interview the facility failed to provide and maintain a safe, functional, and sanitary environment for three of five residents (R2, R5 and R6) reviewed for unsealed windows/environment in the sample list of 19. Findings Include:On 6/16/26 at 11:35 AM R5's window was observed with a window air conditioning unit sitting on the left side of the window opening and a piece of cardboard on the side right side which was taped loosely in place with white tape. There were openings around the cardboard where the tape was not sealed and outside light was observed through the gaps. There were dead gnats and other bugs and dirt on the sill of the window. R5 used her grabber to poke the cardboard, and it moved easily and the tape came apart. R5 stated the staff are aware her window is like this and she does not like it because she cannot see out of her window. R5 stated she asked if they could replace it with plexi-glass or something else, but stated, I still have the cardboard. On 6/16/2026 at 11:20 AM R6's window was observed with foam on both sides of the air conditioner unit secured loosely with white tape. The tape was not sealed all the way around the window, and outside light was observed through the cracks where the window was not sealed. On 6/17/2026 at 9:51 AM R2's previous room was observed with V10, Maintenance Director, and he acknowledged there were gaps where the tape was not sealed around the cardboard on each side of the window air conditioner unit and dead bugs on the window seal. There was outside light observed through the cracks where tape was not sealed. V10 stated the facility uses white tape around the air conditioning units because the board voted and does not want to use the metal tape on the new windows. V10 stated he is the president of the facility's board and stated this is acceptable. He stated the units are temporary and are removed in the winter On 6/18/2026 at 11:00 AM V1, Administrator, stated it is not acceptable to have cardboard taped around the window air conditioner units and agreed you could not see out the window with the cardboard there. She stated the windows were not adequately sealed with the tape.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for three residents (R2, R3, R6) reviewed for abuse, in a sample list of nine residents.Findings Include: 1. R3's Incident report dated 4/5/2026, documents the incident occurred in the lounge on 4/5/2026 at 6:15pm. It also documents that R3 came out of the dining room when R4 hit R3 on the left forearm. The incident reports that R3 had no redness, bruising, or swelling noted. R3 was interviewed and was documented as stating that R4 came toward R3 and hit R3's arm. The immediate action documented is that R3 and R4 were separated and assessed for injury. R3's Physician's Order Sheet documents diagnosis of: Dementia with Anxiety, Schizoaffective Disorder, Bipolar Disorder, and Repeated Falls. R3's Health status note dated 4/6/2026 documented, R3 was coming out of the dining room when another resident (R4) came at and hit R3's left forearm before staff could intervene. R3 and R4 were separated and R3 assessed for injury. No bruising, redness, or swelling noted to left forearm. R3's Care plan dated 1/8/2026 did not address interventions for the incident on 4/5/2026. R3's Minimum Data Set (MDS) dated [DATE] documents that R3 is not cognitively intact. On 6/1/2026 at 12:45pm, R3 was interviewed. R3 had no recollection of the incident on 4/5/2026. R4's Minimum Data Set (MDS) dated [DATE] documents that R4 is cognitively intact. R4's Physician Order Sheet dated 5/22/2026 documents diagnoses of: Metabolic Encephalopathy, Paranoid Schizophrenia, and Urinary Tract Infection. R4's Behavior note dated 4/4/2026, documented that R4 almost punched a Certified Nursing Assistant (CNA) in the face, missing by an inch or two. R4 stated the CNA called R4 a bastard, so R4 tried to punch the CNA and then threatened to get a knife and cut the CNA's lips off. Several witnesses stated the CNA did not call R4 a name but offered R4 a slice of pizza when R4 did that. R4 chased another CNA threatening to cut his b***s (expletive) off. R4 is currently in R4's room in R4's wheelchair. R4's Behavior note dated 4/5/2026 documents R4 was chasing another staff member yelling I hate you over and over. Staff went into the kitchen and shut the door. R4 then went into the lounge area in front of the nurse's station and spotted R3 and R4 went after R3 and hit R3 before staff could intervene. R4's Progress note dated 4/6/2026 documented, Spoke to (Emergency Room) nurse at (local hospital) and (R4) will be admitted to the behavior unit once (R4) is medically clear as (R4) also has a (urinary tract infection). Nurse stated that resident has been very aggressive while there. R4 was interviewed on 6/1/2026 at 1:35pm. R4 did not recall the incident on 4/5/2026. R4 denied hitting other residents at any time. R4 denied any thoughts to harm others. R4 denied feeling sad, or angry. R4 stated I do see Bespoke Psychiatry and that they have made medication adjustments at times. R4 stated I used to get Electroconvulsive Therapy (ECT) at Local hospital. R4 stated I feel happy and safe here. On 6/1/2026 at 1:53pm, V7 Certified Nursing Assistant (CNA), stated, R4 approached R3 in the lobby and struck R3 in the left forearm before V7 Certified Nursing Assistant (CNA) could reach R3 and R4. V7 CNA also stated that prior to the incident R4 was being aggressive with staff and had chased V8 Dietary Aide, out of the dining room. V7 CNA also stated V7 has witnessed R4 be verbally abusive before, but not physical. That was the first time. On 6/1/2026 at 2:06pm, V8 Dietary Aide (DA) state that prior to the incident R4 was throwing punches at the air, but not connecting to anything. V8 DA also stated that V8 attempted to redirect R4 and R4 started chasing V8 around, so V8 secluded V8 in the kitchen. V8 DA stated V8 has seen R4 have behaviors like this before. R4 was mad because V8 intervened. On 6/2/2026 at 3:00pm, V9 CNA stated that after supper R4 was flinging R4's arms and legs around and V9 told R4 it was inappropriate and asked R4 to stop. V9 did not see any actual contact with R3. V9 has worked at the facility for two and a half years and R4 can be physical. 2. On 6/1/2026 at 11:20 AM, R2 stated that R1 came into R2's room and hit R2 in the left upper arm. R2 stated that R2 was not hurt, and that R2 did not bruise and that R2 went and reported it to the nurse. R2 stated that R1 thought it was R1's house, and R1 could do whatever R1 wanted. R2 stated that R1 was sent to the hospital and that R1 has been mean to a lot of residents and staff. R2 stated that R2 feels safe living in the facility if R1 stays in the hospital. R2's Progress note dated 5/25/2026 documented that R2 wheeled up to the nurse's station/lobby and reported that another resident came into R2's room and made contact with R2's left arm. R2 and R1 were kept separated from each other. R2's left arm was assessed with no bruising or open areas. R2's left arm had light redness to top of arm. Full ROM (Range of Motion). The State Agency, local police department, and Medical Doctor were all notified. R2's Physician's order sheet dated 6/2026 documented diagnosis of Unspecified Dementia. R2's MDS dated [DATE] documents that R2's cognition was intact. R2's Care plan dated 9/20/2023 documented, Staff to move between Resident and any dangers. On 6/3/2026 at 11:15 AM, R1 stated that R1 never went into anyone's room and hit them in the arm and that no one has hit R1 while at the facility. R1's Behavior note dated 5/25/2026 at 5:59am documented Note Text: R1 has been up since 0130 going into other residents room being physically and verbally abusive to staff has hit this writer in the face three (3) times this shift R1 has been in the lobby taking pictures off the wall throwing them in the floor taking cushions off the couches throwing them in the floor R1 went and hid in another residents room behind the door and when staff finally found R1 she said Oh did I make you look for me. R1 went into the dining room and threw another resident playing cards into the floor, threw bibs and other essentials in floor. R1 also came behind nurses' station and dumped a water pitcher all over the medication cart. R1 is not redirectable and when asking why R1 is doing all this R1 stated, So you dumb b*****s (expletive) can pick it up. R1 is currently sitting in lobby (at) this time. R1's Behavior Note dated 5/25/2026 at 12:10 PM documents, Note Text: Another resident came to nurses' station at 9:30am and reported that this resident (R1) was in her room and that made contact with her left arm. Staff went to room and (R1) was still in other resident's room and denied hitting anyone. (R1) was asked to go with staff to front office and resident followed staff to office. Resident unable to report anything on incident and continued to deny hitting. Resident was loudly telling staff to call her mom or her aunt. Resident repeatedly verbalized phone number for her aunt. Staff called (Medical Doctor) and (Power of Attorney) and (Medical Doctor) ordered her to be sent to hospital. (Emergency Medical Transportation) arrived shortly after incident and she was transported to (local hospital) per (Power of Attorney) request. Resident cooperated with (Emergency Medical Transportation) and was loudly telling and pointing to nursing staff that they needed to call her aunt right now. Bed hold policy sent with (Emergency Medical Transportation) /resident. R1's Hospital records dated 6/1/2026, documents, Discharge Diagnosis: 1. Dementia with Behavioral Disturbance; 2. Senile Dementia with Behavioral Disturbance It also documented, Hospital Course: [AGE] year-old female patient with a past medical history of Dementia, Hypothyroidism and tremors who presents to the emergency department 5/25/26 from (facility) for recent onset of combativeness at the nursing home. R1's Physician order sheet dated 6/2026 documents an admission date of 5/20/2026. On 6/2/2026 at 2:00 PM, V3 LPN/Resident Care Coordinator (RCC), stated that R2 came to V3 at the nurse's station and said that R1 hit R2 in the arm after R2 told R1 to leave R2's room. V3 continued to state that V3 assessed R2's arm and it was slightly red and then went to R2's room and assisted R1 out of R2's room and assessed R1. On 6/2/2026 at 11:30 AM, V5 LPN stated that R1's admission was an odd admission. R1 was discharged from the hospital and went home with R1's husband and then later that evening he brought R1 to the facility. There was no information, no medication list or heads up on what R1 needed. He also stated that he did not know the extent of R1's behavior. V5 LPN stated that R1 would wander in and out of other residents' rooms and use their bathrooms. On 6/2/2026 at 2:15 PM, V6 CNA stated that V6 was here the night R1 was admitted and R1 was starting to get upset when R1's husband left. V6 continued to state that R1 was wandering in and out of other residents' rooms and even ended up in the beauty shop and would not let them in. V6 stated that R1's family brought R1 into the facility and had R1 admitted but they, the staff, were not aware of R1's needs or any of R1's behaviors. V6 CNA stated that V6 feels like the staff do not get enough information about new residents and how to take care of them, especially the ones with behaviors issues. 3. On 6/1/2026 at 11:10 AM, R6 stated that no one hit R6 while R6 has been a resident at the facility. R6's Progress note, dated 5/11/26, documented, Resident had another resident make contact to the right side of face by his ear. There is no redness or bruising and he denies pain at this time. Police, (administrator), (Power of Attorney), (Medical Doctor) all notified. R6's MDS, dated [DATE], documented that his cognition was intact. R6's Care Plan dated 3/11/2026 did not document any interventions for the risk of being abused. R6's Physician's Order Sheet dated 6/2026 documents diagnosis of Unspecified Dementia. On 6/1/2026 at 10:30 AM, R5 was asked if R5 had grabbed another resident (R6) by his face, R5 just smiled but did not answer. When asked more questions about what happened between R5 and R6, R5 was unable to answer and just smiled. R5's Progress Note dated 5/11/2026 V3 LPN/ RCC, documented, Resident made contact with another resident. (State Agency), (Medical Doctor), (administrator), (Power of Attorney), and Police notified. R5's MDS dated [DATE] documented that R5 was unable to answer the questions for the Brief Interview for Mental Status. R5's Physician's Order Sheet, dated 6/2026, documented a diagnosis of Unspecified Dementia, Severe, with Psychotic Disturbance. R5's Care Plan dated 6/14/2025 documents, Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. There was no documentation presented during this investigation. It also documents, When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. On 6/2/2026 at 11:30 AM, V5 LPN stated that R6 was coming down the hallway and R5 was blocking R6's doorway to R6's room. V5 stated that V5 heard R6 ask R5 to move out of R6's way. V5 continued to state that V5 did not see R5 smack R6 but V5 saw V6 CNA running that way and when V5 saw V6, V5 ran down the hallway and helped by deescalating R5 and help R5 down to R5's room and V6 took R6 into R6's room. V5 continued to state that V5 went and assessed R6 for injuries and there were none. V5 LPN stated that the facility has a lot of residents with behaviors, and they cycle. V5 stated that R5 is very territorial, and R5 thought R6's room was R5's and that night they moved R5 to the last room on the hallway away from R6. On 6/2/2026 at 2:15 PM, V6 CNA, stated that V6 was rounding the corner at the nurse's station and V6 saw R5 slap R6 on the side of the head. V6 continued to state that V6 ran down the hallway and so did V5 LPN. V6 moved R6 out of the way of R5 and V5 was trying to calm R5 down. V6 continued to state that R5 did not want to move, and R5 was very territorial of that part of the hallway because R5's room was right next to R6's room and they shared a bathroom. V6 continued to state that R5 was starting to get anxious prior to the incident because while they were getting resident up and ready for supper, R5 watches the staff go back and forth and that's when R5 starts to get anxious. The facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, documented, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. It continues, 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, a. facility staff; b. other residents.

Based on observation, interview, and record review the facility failed to implement interventions to prevent a fall for one resident (R1) who has a history of seizures and takes an anticoagulant of three residents reviewed for falls in a sample list of eight residents. This failure resulted in R1 falling from R1's bed while having a seizure and R1 sustaining a six centimeter scalp laceration requiring evacuation of a hematoma and sutures, and a subdural hematoma.R1's Care Plan updated 10/20/25 includes the following diagnoses: Epileptic Seizures, Peripheral Vascular Disease. Recent Femoral/Popliteal Bypass with Wound Dehiscence, Chronic Kidney Disease Stage III, Muscle Weakness, Difficulty Walking, Osteoarthritis, Major Depression, History of Subarachnoid Hemorrhage with Residual Hemiplegia and Hemiparesis of the Left Side.R1's Medication Administration Record (MAR) for December 2025 documents R1 has a current physician's order with the start date of 10/20/25 for Eliquis (anticoagulant) five Milligrams twice daily and Keppra (Anticonvulsant) 500 Milligrams twice daily. This MAR also documents R1 refused his morning Keppra on 12/3/25 and his evening Keppra on 12/2/25, 12/3/25, 12/7/25, 12/8/25, and 12/9/25. There is no documentation to support these refusals were reported to the physician or the Nurse Practitioner. There is no documentation to indicate new interventions were initiated to address R1's seizures. R1's Progress Note dated 12/10/25 at 6:41AM documents Certified Nurse's Assistant (CNA) noted R1 lying on floor in the prone position next to bed. This writer was summonsed to (R1's) room. (R1) was alert, Copious amount of blood noted from head. (R1) stated he thinks he had a seizure that caused him to roll out of bed onto the floor. Towel placed on the areas to head that were bleeding. Appeared to have large laceration to right orbital site and crown of skull. (R1) began to have absence Seizures lasting approximately 10-20 seconds, (R1) responded to this writer during the episode. (R1) then began to have a partial seizure that lasted approximately 20-30 seconds with no loss of consciousness. After these two seizures (R1) started to have grand mal seizures repeatedly with each one lasting approximately 5-10 seconds each. During these episodes (R1) unable to respond to verbal stimuli. Ambulance notified.R1's hospital discharge document dated 12/15/25 documents R1 sustained a six Centimeter scalp laceration requiring evacuation of a hematoma and sutures, and a subdural hematoma as a result of a ground level fall.On 12/29/25 at 3:11PM, V18 Licensed Practical Nurse (LPN) stated I was the nurse for (R1) when he had the seizures and fell. I saw the seizure activity. R1 had quite a bit of bleeding from the head wound. The CNA heard a noise from (R1's) room and went in. The bed was not in low position. We don't use fall mats because (R1) gets up on his own and we thought it would be a trip hazard. (R1) doesn't like side rails. (R1) does refuse his seizure meds at times. It's such a regular thing for him so I wouldn't notify the doctor or Nurse Practitioner.On 12/29/25 at 11:00AM, R1 was lying in bed. The bed was in low position. No rail or pads were in place. V11 Certified Nurse's Aide (CNA) was assisting R1. V11 stated before he fell, we had him in a regular bed. Now we keep the bed low. I don't think there's anything else we do. R1 stated I remember falling and going to the hospital. I think I had a seizure.On 12/30/25 at 11:30AM V6, Certified Nurse's Aide (CNA) stated When (R1) fell I was in another room, and I heard a moaning sound. I went to find (R1) lying face down on the floor with a lot of blood on his head. I called for the nurse, and she came right in. I went out and called 911. The ambulance was here pretty quick.On 12/30/25 at 1:00PM, R1 was in his bed, and the bed was in low position. No rail was present, and no pads were present.On 12/30/25 at 1:00PM, V1 Administrator verified the facility does not have a specific policy for seizure precautions.On 12/30/25 at 2:00PM, V20 Family Nurse Practitioner (FNP) stated The Nurse Practitioner should have been notified in a timely manner when (R1) was refusing his Keppra. V20 stated at a very minimum (R1's) bed should have been in low position prior to the seizure. V20 verified the refusal of the seizure medication caused the seizure which caused the fall which caused the subdural hematoma and the laceration.

Based on interview and record review the facility failed to ensure timely call light response for one of four residents (R6) reviewed for staffing in the sample list of eight residents. Findings include: On 12/29/25 at 11:17 AM R6 stated there aren't enough Certified Nursing Assistants (CNAs) on second and third shifts, R6 waits an hour for R6's call light on these shifts while needing incontinence cares, causing R6 to be left in urine/feces. R6 stated call lights are frequently brought up in resident council. The Grievance/Complaint Report dated 11/10/25 documents unidentified residents complain that third shift isn't answering call lights fast enough so residents can be changed. R6's Minimum Data Set, dated [DATE] documents R6 as cognitively intact, is dependent on staff for toileting and R6 is frequently incontinent or urine and always incontinent of bowel. On 12/29/25 at 1:06 PM, V9 Activity Director stated call lights were brought up in November's resident council meeting, but V9 could not recall which residents voiced the concerns. On 12/29/25 at 1:45 PM, V11 Certified Nursing Assistant (CNA) stated four CNAs is not enough for days/evenings, there are a lot of residents that require toileting assistance which affects call light response times. The facility's Residents Call System policy dated September 2022 documents calls for assistance should be answered as soon as possible, but no later than five minutes, with urgent requests for assistance immediately addressed.

Based on interview and record review the facility failed to provide showers as scheduled for one of four residents (R6) reviewed for staffing in the sample list of eight residents. Findings include: The facility's Shower/Tub Bath policy dated February 2018 documents the purpose of this procedure is to promote cleanliness, provide comfort and monitor skin condition. This policy documents to record if the resident refused showers/baths and notify the supervisor. On 12/29/25 at 11:17 AM, R6 stated R6 is supposed to get showers twice per week and R6 prefers to have them in the evenings after 7:00 PM. R6 stated her shower days used to be Mondays/Thursdays and then changed to Tuesdays/Fridays, and R6 goes two weeks without getting showers. R6's Grievance/Complaint Report dated 11/10/25 documents R6 stated R6 had not received a shower in two weeks. R6's Minimum Data Set, dated [DATE] documents R6 as cognitively intact and is dependent on staff for bathing. R6's active Care Plan documents R6 has activities of daily living self-care deficit related to above knee amputations and requires supervision/assistance to complete. This care plan includes an intervention that R6 will receive showers twice weekly.The facility's undated shower schedule documents R6's showers are scheduled on Tuesdays and Fridays on second shift. R6's November and December 2025 shower documentation, provided by V2 Director of Nursing, documents showers given on 11/10/25, 11/20/25, 11/25/25, 12/17/25, 12/29/25 and 12/26/25. R6's Shower/Abnormal Skin Report dated 12/2/25 documents R6 did not know that R6's shower day was changed and R6 would wait until Friday. R6's Response History for showers documents not applicable on 12/5/25. On 12/29/25 at 1:30 PM, V2 provided R6's shower documentation for November/December 2025. V2 stated that is all the documentation V2 was able to locate. V2 confirmed showers are scheduled twice per week and gaps in R6's shower documentation. V2 stated refusals would also be documented on the paper shower forms.

Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one of four residents (R2) reviewed for incontinence in the sample list of eight residents. Findings include: The facility's Perineal Care policy dated February 2018 documents for female perineal care wash/dry from front to back, washing the labia and perineum followed by the rectal area/buttocks. On 12/29/25 at 1:34 PM, R2 was lying in bed. V11 and V12 Certified Nursing Assistants applied gloves and gowns and entered R2's room. V11 pulled down R2's brief which was wet with urine and had a small amount of soft bowel movement. V11 used wash cloths to clean R2's vaginal area in a front to back motion and then turned R2 on her side to cleanse buttocks. V11 did not change gloves and applied a clean brief. V11 then turned R2 onto R2's back and cleaned R2's vaginal area again while wearing the same gloves used to wash R2's buttocks. At 1:45 PM, V11 confirmed V11 used the same contaminated gloves to wash R2's vaginal area after washing R2's buttocks. V11 confirmed V11 should have changed her gloves. R2's Minimum Data Set, dated [DATE] documents R2 has moderate cognitive impairment, R2 is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene. R2's urine culture dated 12/3/25 documents greater than 100,000 colony forming units per milliliter (CFU/ml) of Klebsiella Oxytoca ESBL (Extended Spectrum Beta Lactamase) and Escherichia Coli, (E. Coli) indicating infection. R2's Provider Note dated 12/8/2025 at 12:49 PM documents persistent UTI / ESBL to start Tobramycin 80 milligram injection three times daily for 10 days. R2's Nursing Note dated 12/27/2025 at 2:35 PM documents R2's urine culture returned with E. Coli ESBL greater than 100,000 CFU/ml. Orders were received for Meropenem intravenous three times daily for seven days and contact isolation were implemented. On 12/29/25 at 3:00 PM, V13 Resident Care Coordinator stated during female incontinence care staff should change gloves when moving from soiled to clean areas and should cleanse from front to back.

Based on observation, interview, and record review the facility failed to implement fall prevention measures for two of two residents (R2, R7) reviewed for falls on the sample list of 13. These failures resulted in R2 experiencing a displaced fracture of the right hand, and R7 a fractured nasal bone. Findings Include:Falls and Fall Risk Management policy dated March 2018 documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.1. Facility Reported Incident Final Investigation dated August 19, 2025, documents on August 11th, 2025, the Certified Nursing Assistant (CNA) reported that while giving R7 a shower, R7 lunged forward out of the chair and onto the floor. Nurse assessed immediately and R7 was sent to the emergency room (ER). Conclusion: X-Ray found nasal bone fracture.R7's undated care plan documents diagnosis of Unspecified Dementia; Bipolar; Schizoaffective Disorder; Major Depressive Disorder; and Alzheimer's. The same document documents an admission date of 6/14/2021.R7's Minimum Data Set (MDS) documents on 08/19/2025 that R7 is severely cognitively impaired. The MDS documents R7 as dependent on staff for all cares including showers. R7's record review of progress notes documents a progress note dated 8/11/2025 at12:29pm stated the CNA yelled for a nurse from the shower room. The Nurse reported to the shower room to note resident face down on the floor with a pool of blood. The CNA stated that R7 thrashed herself forward and the CNA couldn't catch R7 in time before R7 hit the floor. Support provided for R7's head and 911 called. R7 was noted to have a possible fracture to nose and swelling to left eye. Both nurses remained with resident to monitor and keep her safe from further injury until Emergency Medical Services (EMS) arrived. All parties notified.R7's progress note dated 8/11/2025 at 5:00pm which stated R7 returned from ER via stretcher and EMT's. R7 was alert and had contusions on the left side of R7's face from eyebrow down to below cheek. Report states she has nasal bone fracture.R7's care plan documents under Falls section: educate staff on keeping chair in reclined position when R7 is in chair for proper positioning and comfort due to R7's strong thrusting body movements uncontrolled. Date Initiated: 04/07/2025R7's care plan documents the resident has a nasal bone fracture related to falling out of the shower chair. Date Initiated: 08/12/2025On 8/26/25 V12 License Practical Nurse (LPN) stated on 08/11/25 that R7 was getting a shower from V11 CNA, when V11 yelled out the shower room door for a nurse. V12 stated V12 ran to the shower room and observed R7 lying face down with a pool of blood coming from under R7's face. V11 stated she assessed R7 and rolled R7 over and noted that R7 had what looked like a nasal fracture with blood coming from the nares (nostrils). V11 stated EMS (Emergency Medical Services) was called to take R7 to the local hospital. V11 stated that all staff knew R7 rocks/lunges forward when seated and usually two nursing staff give R7 a shower. V11 stated there was only one CNA (V11) in the shower room at time of fall.On 08/27/25 at 10:10am, V11 Certified Nurse's Aide, stated that R7 lunged forward from the shower chair on 08/11/25. V11 stated that a second CNA had left the shower room to get R7 some clean clothing. V11 stated that R7 has a known history of lunging forward unexpectedly from chairs. V11 stated V11 was standing to the left side and behind the shower chair and was unable to reach the shower chair as R7 lunged forward falling from the shower chair and landing on the floor. V11 then stated that V11 opened the shower room door and yelled for a nurse.On 08/26/2025 at 12:45pm, V16 (R7's family) stated she was informed of R7 falling from the shower chair in the shower room. V16 stated the hospital told her that R7 had a broken nose. V16 stated that R7 has been known to be lunging/rocking when sitting up for as long as she can remember, and the staff know this.2. Facility Reported Incident Final Investigation dated July 9th, 2025, documents on July 5th, 2025, R2 was pushing on bed during care and rolled onto her right hand. Staff stated that as he (CNA) rolled R2 over to change her, R2 put her right hand down on the mattress and R2 rolled on top of R2's right hand. R2 was transferred to the ER for evaluation and the x-ray revealed a minimally displaced fracture involving the fifth proximal phalanx. R2 returned to the facility with a soft cast in place.Review of R2's hospital records dated 7/5/25 at 11:22 PM documents This is an [AGE] year-old female NHR (Nursing Home Resident) with a history of dementia who is nonverbal at baseline brought to the ED (Emergency Department) by EMS after her right hand became caught underneath her in bed with audible pop and subsequent swelling and bruising noted to the right little finger and hand. IMPRESSION: Obliquely oriented minimally displaced fracture involving the fifth proximal phalanx.R2's undated care plan documents diagnosis of: Unspecified Dementia; Type 2 Diabetes; Hypertensive Heart Disease; Generalized Anxiety Disorder; Major Depressive Disorder; and Cognitive Communication Deficit. The same document has an admission date 09/09/2019.R2's MDS (Minimum Data Set) dated 8/8/25 documents R2 as severely cognitively impaired. The same MDS documents R2 as dependent on staff for all cares.On 8/25/25 at 11:49am, call placed to V13, R2's Family, unanswered, Voicemail left.On 8/25/25 at 11:56am, V8 LPN stated V9 CNA was providing cares for R2 by pushing R2 over onto R2's side and R2 was pushing back. When R2 relaxed R2's body moved forward on to R2's right hand and V9 heard an audible pop. V9 noted the right 5th digit was pointed in the wrong direction so V9 came and got the nurse.On 8/25/25 at 12:50pm, V9 CNA stated R2 was being combative with cares after having a bowel movement. V9 stated V9 left the room to allow R2 to calm down and returned a few minutes later. V9 stated that R2 grabbed the side of the bed and was pushing against being turned but needed cleaned up. V9 was trying to clean R2 up when R2 relaxed R2's body moved forward onto R2 right hand. V9 stated he heard a pop and looked at R2 noting R2's pinky appeared dislocated and V9 got the nurse. V9 stated there was another agency CNA in the building and V9 could have asked her for help but did not want to scare her off on her first time working in the facility by asking her to help with a difficult resident so he chose to proceed on his own.

Based on interview and record review, the facility failed to designate and maintain a full-time Director of Nursing (DON). This deficiency has the potential to affect all 50 residents in the facility by compromising the oversight and coordination of nursing services. Findings Include:Review of staffing schedules from 7/25/25 thru 8/25/25 confirmed that no licensed nurse was designated as Director of Nursing (DON) and no interim appointment was made.On 8/25/25 at 1:20pm, V12 Licensed Practical Nurse (LPN), confirmed there is no DON at this time and stated we haven't had a DON for a few weeks now.On 8/26/25 at 12:20pm, V1 Administrator stated, We've been trying to hire a Director of Nursing (DON), but we haven't been able to find anyone. We do have an interim DON starting soon.On 8/27/25 at 1:35pm, V2 Corporate Nurse stated the facility does not have a DON at this time, but we do have an interim DON starting soon.The Facility Census dated 8/21/25 documents there are 50 residents currently in the facility.

Based upon interview and record review, the facility failed to employee a certified dietary manager for food services. This failure has the potential to affect all 50 residents currently residing in facility.Findings include:Facility Census dated 8/21/25 documents there are 50 residents currently residing in the facility.Dietary Services food certifications reviewed on 8/21/25. Certifications include food safety for all dietary staff. Certifications do not include Dietary Manager Certification.On 8/21/25 at 1:00pm, V4 Dietary Manager (DM) stated she is not certified for dietary management.On 8/27/25 at 11:57am, V5 Registered Dietician (RD), stated she consults for facility and primarily approves menus and completes dietary recommendations for residents. V5 stated V5 is at facility on average approximately 16 hours a month. V5 confirms the facility has a newer dietary manager that is not certified at this time. On 8/27/25 at 12:50pm, V1 Administrator and V2 Regional Nurse confirmed that V4 DM is not a certified dietary manager and that V4 is not currently enrolled in any certification courses.

Based upon observation, interview and record review, the facility failed to ensure meals were palatable and at a safe and appetizing temperature. This failure has the potential to affect all 50 residents currently residing at facility. Facility Resident Census dated 8/21/25 documents that there are 50 residents currently residing in the facility.The Food Temperature Chart for August reviewed. Chart dated 8/10/25-8/16/25 documents food temperatures at meal service. Breakfast meal for dates 8/11 and 8/12 are missing documentation. Lunch meal for dates 8/10, 8/11, 8/12, and 8/13 are missing, and dinner meal for dates 8/15 and 8/16 are missing documentation. Vegetable temperatures are being documented at 200 degrees Fahrenheit (F) at time of service. Chart dated 8/17/25-8/23/25 missing documentation for the 8/17/25 dinner meal. Facility Food Temperature Chart for 8/21/25 lunch meal documented food temps as follows: meat 210 degrees F, ground meat 200 degrees F, pureed meat 192 degrees F, vegetables 185 degrees F, pureed vegetables 192 degrees F, fruit 31 degrees F, and milk 31 degrees F. No temperatures were documented for pasta.On 8/21/25, the lunch menu includes one piece of glazed meatloaf, four ounces of garlic buttered noodles, four ounces of broccoli. The recipes provided include holding temperature of food at time of service. Glazed meatloaf recipe documents to hold at 135 degrees F or above during the entire service period, noodles and broccoli are to hold at 135 degrees F for service.On 8/21/25 at 12:10pm, R5 stated very rarely do I get warm food, breakfast is always ice cold.On 8/21/25 at 12:15pm, R13's hospice aide was observed taking R13's lunch plate back to kitchen. R13 stated R13's food had just been delivered, and the food was cold. Meat temperature on the plate was 111.5 degrees Fahrenheit (F) and the pasta side temped at 98.4 degrees F.On 8/21/25 at 12:20pm, R11 stated food was cold today, the food is always cold.On 8/21/25 at 12:25pm, V4 Dietary Manager (DM) provided a test tray (photo attached) that included meat and pureed meat, noodles and vegetable. Regular texture meat temped at 194.6 degrees F, pureed meat was 120 degrees F, noodles temped at 110 degrees F and vegetable temped at 108 degrees F. The food was served on a Styrofoam plate, and a notable amount of liquid grease was pooling on the plate under the food. Regular texture meat was extremely hot to palate, flavor was palatable. Pureed meat had same flavor and was cold to palate. Noodles were cold to palate, very bland and very greasy. Vegetables were cool to the palate and had no flavor. The menu displayed on the whiteboard next to the kitchen entrance listed glazed meatloaf, garlic buttered noodles, broccoli, roll, and an apricot pie bar as mid-day meal. On 8/21/25 at 12:35pm, R12 stated the portions provided at lunch today did not reflect their normal portion sizes for protein. R12 stated they hardly get any protein and when they do its very small.On 8/21/25 at 12:45pm, V6 (R1's spouse) was at the lunch table with R1. V6 was feeding R1 pizza that V6 had brought into facility. V6 stated the food is always cold and the portion sizes are tiny. V6 stated they had pulled pork on a bun a few days ago and the portion of meat was so small that it wasn't visible on the bun until the top was removed. V6 stated that breakfast is the worst meal of the day. V6 stated the menu for breakfast never changes and consists of eggs, cereal, juice and maybe some fruit. V6 stated the eggs are always cold and the breakfast meal is always served on Styrofoam plates and bowls.On 8/25/25 at 12:02pm, V15 Dietary Aide was observed portioning out food onto resident plates for service. Resident meal cards containing diet type, restrictions, allergies and preferences listed on cards were utilized when plating food. Food observed included hamburger bun, ham salad, plain potato chips, melon, and chocolate cake. Portion sizes were not uniform, ham salad placed on bun was approximately size of half dollar, chips were placed by hand full, melon pieces varied from 3-5 pieces depending on what fit in small portion bowl, cake was cut in rectangular shape and approximately 1inch by 2inches in size. No observations were noted of food temping during service. Alternative options available included turkey burger and mashed potatoes. At 12:20pm, V4 was asked to perform temperature checks on hot food. No thermometer was available. This surveyor provided thermometer. Turkey burgers that were being held in steam table had internal temp of 117 degrees F, and mashed potatoes temped at 177 degrees F. 8/25/25 at 12:30pm, R11 stated the chips are stale, there never seems to be enough to eat, and they don't offer seconds anymore.8/25/25 at 12:35pm, V6 R1's spouse stated the chips are stale and you can't see the meat inside the bun. 8/26/25 at 1:35pm, R12 stated that often the meals provided contain meat that seems overcooked. R12 stated meat is rubbery and tough. R12 also stated that potato items such as tater tots and French fries are very undercooked.On 8/27/25 at 1:30pm, V4 Dietary Manager (DM) stated she has not been provided any education since the first day of employment and neither has the dietary aides. V4 stated that currently the left side of the oven doesn't get to temp, the flat top griddle is slow to warm and the steam table that is utilized to hold food during meal service does not regulate temperatures. V4 confirmed staff does not always check food temperatures and is unclear if they know what unsafe food temps are.Facility policy titled Food Preparation and Service dated November 2022 documents proper hot and cold temperatures are maintained during food distribution and service and any food held in the danger zone of 41 degrees F to 135 degrees F must be discarded after 4 hours. Any food held in steam table for service must be temped often.Facility policy titled Monitoring Food Temperatures dated 2020 documents all hot foods should temp no lower than 120 degrees F at point of service for palatability.

Based on interview and record review the facility failed to protect residents rights to be free from resident to resident physical abuse. This failure affects four of four residents (R3, R4, R5, R6) reviewed for abuse in the sample list of 13. Findings Include:Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.The facility reported incident final investigation dated July 25th, 2025, documents on July 18th, 2025, at 4:50pm was reported by R4 that R3 made contact with R4's right forearm. The same document documents: After a thorough investigation the facility has determined that the incident did occur.The facility reported incident final investigation dated August 13th, 2025, documents on August 7th, 2025, at 11:30pm it was reported to Nurse that R3 went into R4's room on the evening of the 6th. R3 entered R4's room through their adjoining bathrooms. R3 was going through R4's' things and R4 yelled to make R3 stop. R4 then reported on the morning of the 7th that R3 made contact with R4's hand.The facility reported incident final investigation dated July 29th, 2025, documents on July 26th, 2025, at 3:00pm it was reported to the Nurse that R3 made contact with R6's right wrist. The CNA reported to Nurse that R3 walked up to other residents playing cards. The other residents playing cards started yelling at R3 to get away. R3 then made contact with R6's right wrist.The facility reported incident final investigation dated August 12th, 2025, documents on August 6th, 2025, at 10:00am staff witnessed a resident-to-resident incident. As V12 License Practical Nurse (LPN), was doing a one-to-one with R3 when R3 made contact with the top of R6's hand. After a thorough investigation it was determined that R3 wanted the book that R6 had and R6 stopped her from taking it causing R3 to react.The facility reported incident final investigation dated July 29th, 2025, documents on July 26th, 2025, at 07:30am it was reported that R3 made contact with R5. The facility has determined that the incident did occur.On 8/25/25 at 1:20pm, V12 LPN, stated that R3 did make contact with R6 on 8/6/25 while V12 was providing one-to-one cares to R3.On 8/26/25 at 12:20pm, V1 Administrator confirmed that R3 has been investigated and had been involved in multiple incidents involving R4, R5, and R6 on various dates in which R3 has abused the other residents.On 8/26/25 at 1:04pm, V3 LPN confirmed that R3 has been investigated and known to make contact with R4, R5, and R6 on various dates.

Based on interview and record review the facility failed to ensure the right to be free from physical abuse for two (R1, R2) of three residents reviewed for physical abuse from a total sample list of three residents reviewed for abuse. Findings include: The facility provided, Abuse Policy dated 2001 documents that abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. 1.) R1's undated diagnosis sheet documents the following diagnosis sheet includes: Unspecified Dementia with Agitation and Behavioral Disturbance, Anxiety, Alzheimer's Disease, Alcohol Abuse, Psychotic Disturbance, and Mood Disturbance. R1's Minimum Data Set, dated [DATE] documents that R1 is severely cognitively impaired. R1's care plan dated 11/8/24 documents impaired cognitive function and thought processes due to Dementia. R1's 4/22/25 progress note documents an altercation between R1 and another resident (R2) documents that R1 had hold of R2's collar and was punching him in th eback of the head while yelling, He was *expletive* with me. On 5/12/25 at 9:20AM, V3 Licensed Practical Nurse stated that she had gone to the kitchen to obtain juice for another resident and As I walked into the kitchen I saw (R1) holding the back of (R2's) shirt while hitting him on the back of his head and yelling at him. 2.) R2's undated diagnosis sheet documents the following diagnosis sheet includes: Metabolic Encephalopathy, Paranoid Schizophrenia and Cerebral Infarction. R2's Minimum Data Set, dated [DATE] documents R2 as cognitively intact. R2's care plan dated 5/2/23 documents that R2 has the potential to be physically and verbally aggressive. R2' progress notes dated 3/31/25 document that R2 displayed aggressive behavior toward staff and threatened other staff with physical harm. On 5/12/25 at 1:16PM, V9 Licensed Practical Nurse stated that she saw R1 punching R2 in the back of the head in the dining room on 4/22/25 at breakfast while yelling at R2. On 5/12/25 at 10:00AM, V1 Administrator stated that they did not know what caused the altercation but that it did occur.

Based on observation, interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one (R3) of three residents reviewed for injuries of unknown origin from a total sample list of four residents. Findings include: The facility provided Abuse Policy dated 2001 documents that bruising, including those found in unusual locations such as the head, neck, lateral locations on the arm, or posterior torso and trunk, or bruises in shapes such as finger prints are to be investigated. R3's undated diagnosis sheet documents the following diagnoses include: Unspecified Disorder of Psychological Development, Schizophrenia, Major Depressive Disorder, and Peripheral Vascular Disease. R3's care plan dated 3/7/24 documents that R3 will remain free of mistreatment or improper care and statements/allegations of mistreatment will be investigated including skin checks for physical marks or injury and interview persons assigned to R3's care. R3's Minimum Data Set, dated [DATE] documents that R3 is moderately cognitively intact. The facility provided final incident report dated 3/31/25 documents a (single) bruise due to care and that R3 is on an anti-coagulant causing her to bruise easily with updated care plan interventions. R3's ordered medications were reviewed and do not include an anticoagulant medication. On 5/12/25 at 1:55PM, V8 Certified Nursing Assistant stated that she found R3's multiple bruises on 3/25/25 and reported it. V8 stated that they looked like finger prints and stated that R3 is resistive to care. On 5/12/25 at 2:00PM, V8 and V9 Certified Nursing Assistants (CNA) provided R3 perineal care. Old bruising was observed on R3's inner thighs in a fingerprint pattern. Approximately 4 bruises were noted on the bilateral thighs. V8 confirmed that these were the same bruises that she reported on 3/25/25. R3's progress note dated 3/25/2025 documents that V13, R3's Family Member stated that R3 told her that It was Him who did it but would not tell (V13) who Him was. V13 Family Member stated that R3 was very upset on Sunday. The facility provided investigation of R3's brusing does not document interviews with male CNAs who provided care for R3 days prior to the discovery of R3's bruising. On 5/12/25 at 2:00PM, V3 LPN confirmed that V10 RN, V11 and V12 CNAs, and V14 CNA are all male employees. The facility provided nursing schedule dated 3/22/25 documents V11 CNA worked from 2:00PM-10:00PM. The facility provided nursing schedule dated 3/23/25 documents V14 Licensed Practical Nurse (LPN) worked from 2:00PM-10:00PM and V11 CNA worked from 2:00PM-10:00PM. The facility provided nursing schedule dated 3/24/25 documents V10 Registered Nurse (RN) worked from 2:00PM-6:00AM, V11 CNA worked form 2:00PM-10:00PM and V12 CNA worked from 2:00AM-2:00PM. On 5/12/25 at 1:30PM, V1 Administrator stated that she didn't realize that Aspirin wasn't an anti-coagulant medication. V1 also stated that she didn't think that there weren't any men on the schedule that R3 could have been talking about. V1 stated that she thought it was from R1 resisting care that she received the fingerprint bruising, but that she did not interview any of the male caregivers in her investigation.

Based on interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 42 residents in the facility. Findings Include: The January 2024 QAA meeting attendance signature sheet does not document the facility Director of Nursing or Infection Preventionist was present for the meeting. The April 2024, July 2024, and November 2024 QAA meeting attendance signature sheets do not document the facility Director of Nursing was present for any of these meetings. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility's Quality Assessment and Assurance Committee meets at least quarterly and the required members include the facility Administrator, the Director of Nurses (DON), the Infection Preventionist (IP), the Medical Director or Designee, and two other staff members. V2 confirmed after review of the last four quarterly QAA sign in sheets, there was no DON present at any of the last four meetings and no IP present at the January 2024 meeting. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility.

Based on observation, interview and record review facility staff failed to don appropriate Personal Protective Equipment (PPE) while providing resident care and failed to prevent cross contamination during medication administration for three of three residents (R11, R26, R5) reviewed for Infection Control in a sample list of 22 residents. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: 1.) R11's undated Face Sheet documents medical diagnoses as Dementia, Alzheimer's Disease and active COVID-19. R11's Physician Order Sheet (POS) dated November 2024 documents a physician order dated 11/10/24 for R11 to be placed on Droplet and Contact Isolation for positive COVID-19 test to end on 11/20/24. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. R26's undated Face Sheet documents medical diagnoses as Alzheimer's Disease and current COVID-19 infection. R26's Physician Order Sheet (POS) dated November 2024 documents a physician order starting 11/11/24 to obtain a full set of vital signs every four hours due to COVID-19 positive. R26's Minimum Data Set (MDS) dated [DATE] documents R26 as severely cognitively impaired. On 11/13/24 at 11:10 AM V6 Certified Nurse Aide (CNA) obtained R11 and R26's blood pressure and pulse in R11 and R26's room (R11, R26 are roommates). R11 and R26's door displayed signs that indicated PPE for contact and droplet precautions is to be worn when entering R11, R26's room. R11, R26's room also had a three drawer dresser containing Personal Protective Equipment (PPE). V6 CNA was not wearing gloves nor a protective gown when obtaining R11, R26's vital signs. The front of V6 CNA's sweatshirt touched both R11, R26's bedside tables and R26's lap tray attached to the wheelchair R26 was sitting in. On 11/13/24 at 11:20 AM V6 Certified Nurse Aide (CNA) stated R11 and R26 are both COVID-19 positive and on contact and droplet isolation. V6 stated V6 should have worn a gown and gloves when obtaining R11, R26's vital signs. V6 stated V6 should have used hand hygiene between caring for COVID-19 positive residents and should have cleaned the equipment in between using it on separate COVID-19 positive residents. 2.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician Order Sheet dated November 2024 documents a physician order for Symbicort 80-4.5 micrograms (mcg). Give two puffs every morning for Chronic Obstructive Pulmonary Disorder (COPD). On 8/13/24 at 8:25 AM V7 Licensed Practical Nurse (LPN) wore gloves to administer R5's Symbicort Inhaler in R5's room. V7 LPN wore the same gloves to pick up R5's Oxygen Nasal Cannula that was laying on R5's floor. V7 LPN then proceeded to administer R5's second puff of R5's Symbicort inhaler without using hand hygiene or change gloves. On 8/13/24 at 8:40 AM V7 Licensed Practical Nurse (LPN) stated V7 should have changed gloves and used hand hygiene prior to administering R5's second puff from her Symbicort inhaler. On 8/13/24 at 1:30 PM R5 stated That nurse (V7) touched her gloves to the floor and then pushed on my inhaler right at my mouth. I didn't like that but I need my inhaler. On 8/14/24 at 12:00 PM V2 Regional Director of Operations stated nurses should perform hand hygiene before and after touching anything possibly contaminated. V2 stated V7 should have either waited to finish R5's medication administration or washed her hands and performed hand hygiene before administering R5's second puff of R5's Symbicort inhaler. 32172 3. On 11/13/24 at 12:28 PM V6 Certified Nurses Assistant (CNA) was observed in R26's room standing directly in front of R26's chair assisting her with eating the noon meal. R26 is Covid positive. The only PPE V6 was wearing was a surgical mask covering only her mouth and not her nose. V6 CNA stated she doesn't know what she is supposed to be wearing in a room with droplet precautions because she has never worked during a Covid outbreak. There was Droplet Precaution sign on R26's door with instructions on what Personal Protective Equipment (PPE) should be worn in R26's room. On 11/13/24 at 12:34 PM V7 Licensed Practical Nurse (LPN) confirmed V6 CNA should have been wearing gloves, gown, eye protection, and a N95 mask while feeding a resident with Covid On 11/13/24 at 12:38 PM V5 Infection Preventionist confirmed V6 CNA should be wearing gloves, gown, eye protection, and a N95 mask while providing care or feeding a resident with Covid. On 11/15/24 at 1:45 PM V2 Regional Administrator confirmed Certified Nurses Assistants have access to all residents in the facility and if they do not utilize the required PPE while caring for residents with Covid, the risk for potentially exposing other residents and staff throughout the facility significantly increases. The Covid-19 Control Measures policy dated May 2023 documents in the event of a facility outbreak, all health care personnel must wear an N95 mask and eye protection when caring for all residents. The undated Contact Precautions sign documents staff are to wear gloves and gowns when entering a resident's room that is on Isolation Precautions. Then undated Droplet Precautions sign documents staff are to have their mouth, nose, and eyes fully covered when entering a resident's room that is on Droplet Precautions. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility.

Based on observation, interview, and record review the facility failed to employ a full time Director of Nurses and failed to provide eight consecutive hours of Registered Nurse coverage for four of fourteen days reviewed. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/24 through 11/14/24 document four days (11/5/24, 11/8/24, 11/9/24, 11/10/24) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility currently has no Director of Nurses (DON) employed by the facility and the previous DON's last day was 9/18/24. V2 also confirmed there were four days since 11/1/24 that the facility did not have the required eight consecutive hours of Registered Nurse (RN) coverage. From 11/12/24 through 11/15/24 there was no DON observed working in the facility. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility.

Based on observation, interview and record review the facility failed to provide timely incontinence care and incontinence care in accordance with facility standards for two of two residents (R22 and R10) reviewed for incontinence care in a sample list of 22 residents. Findings Include: The facility policy titled Perineal Cleansing reviewed 12/17 documents staff should wash pubic area including upper inner aspect of both thighs and frontal portion of perineum prior to washing resident buttocks and to dry areas thoroughly after cleansing. The basic infection control concept for perineal care is to wash from the cleanest to the dirtiest and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. 1.) R22's undated Face Sheet documents medical diagnoses as Dementia, Cognitive Communication Disorder, Acute Kidney Failure and Diabetes Mellitus Type II. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as severely cognitively impaired. This same MDS documents R22 as dependent on staff for toileting, bathing, dressing, transfers and requires maximum assistance for personal hygiene. R22's Care Plan intervention dated 7/22/24 documents R22 requires extensive assistance of two staff for toileting. On 11/12/24 observations were made every 15 minutes of R22 sitting her wheelchair from 10:30 AM through 1:00 PM without staff offering or assisting R22 with incontinence care. On 11/13/24 from 11:00 AM through 3:00 PM R22 sat in her wheelchair without staff offering nor assisting R22 with incontinence care. At 2:00 PM R22 was sitting at the end of her hallway in her wheelchair. R22's pants were saturated with urine from front perineal area up to her upper hip area. R22's mechanical lift sling was saturated with urine. R22 had two softball sized urine puddles on the floor underneath her wheelchair. V5 Licensed Practical Nurse (LPN)/Resident Care Coordinator (RCC) stated R22 is fully saturated with urine and should be provided incontinence care. On 11/13/24 at 3:00 PM V9 and V12 Certified Nurse Aide (CNA's) provided incontinence care for R22. R22's seat of her wheelchair was wet with urine. R22's pants and mechanical lift sling were saturated with urine. R22's incontinence brief was grossly saturated with foul smelling urine. On 11/13/24 at 3:30 PM V9 and V12 Certified Nurse Aide (CNA's) stated neither V9 nor V12 had offered or assisted R22 with incontinence care since they started their shift. V9 CNA stated I came in early today at 11:00 AM and haven't had time to do anything with (R22). (R22) should have been checked before lunch but I just didn't get to her. 2.) R10's undated Face Sheet documents medical diagnoses as Dementia and History of Urinary Tract Infections (UTI). R10's Minimum Data Sheet (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 is dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 11/13/24 at 1:35 PM V6 and V10 Certified Nurse Aides (CNA) provided incontinence care for R10. V6 CNA cleansed R10's buttocks, assisted R10 to her back and then cleansed her front perineal area. V6 did not dry R10's buttocks nor front perineal area after cleansing with no rinse cleanser. V6 did not change gloves or use hand hygiene throughout entire process. V6 did not provide barrier cream to R10's buttocks. R10's incontinence brief was thoroughly saturated, light brown in color and had a strong urine smell. On 11/13/24 at 1:50 PM V6 Certified Nurse Aide (CNA) stated V6 should have used hand hygiene, applied barrier cream and cleansed R10's front perineal area prior to cleansing R10's buttocks. V6 CNA confirmed R10's incontinence brief was saturated with urine. V6 CNA stated (R10's) incontinence brief was so wet and heavy because she hasn't been changed (provided incontinence care) since before lunch around 11:00 AM. (R10) has had a UTI before so we (staff) probably shouldn't wait so long with (R10) because sitting in urine can cause UTI's. On 11/14/24 at 12:45 PM V2 Regional Director of Operations stated residents who are incontinent and rely on staff to provide cares should be provided incontinence care every two hours. V2 stated staff should change their gloves when their gloves become contaminated. V2 stated staff should follow the incontinence care policy by cleansing the front perineal area prior to cleansing the back perineal area. V2 stated improper incontinence care and residents sitting in urine for long periods of time could cause a resident to get a UTI.

Based on observation, interview, and record review, the facility failed to identify specific medical conditions or symptoms necessitating the use of physical restraints, failed to assess safe use of restraints, and failed to release a physical restraint every two hours per plan of care. This failure affects two residents (R24, R28) of two reviewed for restraints in the sample list of 22. Findings Include: The facility policy titled Physical Restraint/Enabler Policy revised 7/24/18 documents physical restraints are any manual method or physical or mechanical device, equipment or material attached, or adjacent to the resident's body which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, Geri-chair with tray table, arm restraints, leg restraints, personal alarms and hand mitts. Allow a two-finger width between the resident's body and the physical restraint. Release the physical restraint at a minimum of every two hours. During this period the resident shall be ambulated (if applicable), repositioned, toileted or changed, and/or skin care and nursing care provided, as appropriate. 1.) R24's undated Face Sheet documents medical diagnoses as Dementia, Insomnia and Hypertension. This same face sheet documents R24 admitted to facility on 10/24/24. R24's Physician Order Sheet (POS) dated November 2024 documents a physician order starting 10/31/24 to apply a self releasing seat belt when R24 is up in her wheelchair. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is severely cognitively impaired. This same MDS documents R24 is dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R24's Care Plan intervention dated 11/13/24 instructs staff to apply self releasing seat belt due to R24 leaning forward. This same care plan documents an intervention dated 11/13/24 to Release device and assist to reposition at least every two hours and PRN for restlessness. R24's Physical Restraint/Enabler assessment dated [DATE] documents R24's physical restraint is treating the conditions of leaning forward, attempting to stand and proper body positioning. This same assessment documents R24 is ambulatory, has no weight bearing restrictions, and has no Musculoskeletal or Neurological Disorder that interferes with ambulation. On 11/12/24 at 12:00 PM R24 sitting at her dining room table eating lunch with seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. On 11/12/4 at 1:30 PM R24 was sitting in her wheelchair with a seatbelt attached laying on R24's Left Knee between her mid thigh and knee. R24 was sitting in her wheelchair with her legs crossed. R24's buttocks and legs were entirely to the side of the raised pommel. On 11/13/24 at 8:30 AM R24 sitting at her dining room table eating breakfast with seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. On 11/13/24 at 3:45 PM V5 Licensed Practical Nurse (LPN)/Resident Care Coordinator (RCC) asked R24 to remove her seatbelt. R24 looked at V5 and smiled. R24 did not attempt to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. On 11/14/24 at 11:55 PM R24 was sitting at her dining room table eating lunch with a seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. On 11/13/24 at 2:00 PM V6 Certified Nurse Aide (CNA) stated R24's seatbelt has not been released since before breakfast when R24 was assisted out of bed. V6 stated V6 did offer toileting to R24 before lunch and R24 declined. V6 stated R24's seatbelt is so loose R24 can reposition herself without staff having to do it for R24. On 11/14/24 at 4:00 PM V5 LPN/RCC asked R24 to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. R24 looked at V5 and smiled. R24 did not attempt to remove her seatbelt. V5 removed R24's personal alarm which sounded and then reconnected R24's personal alarm again. R24 stood up with her seatbelt in connected. R24 felt her seatbelt with her Right hand and then immediately sat back down. V3 Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) approached R24 at this time and asked R24 to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. R24 looked at V3 and smiled. R24 did not attempt to remove her seatbelt. V3 MDS/LPN stated R24 should not have a personal alarm in her wheelchair. V3 MDS/LPN stated We (facility) aren't supposed to have that many restraints. (R24) can stand and take a few steps but we (facility) are afraid she will fall so that is why she has the seatbelt and pommel cushion. V3 stated R24 would scoot her buttocks forward in her wheelchair under the seat belt to attempt to stand so the pommel cushion was placed in R24's wheelchair to prevent her from standing. On 11/14/24 at 12:46 PM V2 Regional Director of Operations stated any resident utilizing a physical restraint should have a medical diagnosis documented as the primary reason for use. V2 stated any resident who is using a physical restraint should have that restraint released every two hours for repositioning. V2 stated R24's seatbelt restraint should not be so loose. V2 stated R24's seatbelt restraint being so loose could cause a safety hazard. 35347 2. R28's diagnosis list (printed 11/14/2024) documents diagnoses including: Severe Dementia, Cognitive Communication Deficit, Anxiety Disorder, Osteoarthritis, Depression, and Post Traumatic Stress Disorder. R28's quarterly assessment (9/21/2024) documents R28 has severe cognitive impairment, does not have impaired upper or lower extremity range of motion, and does not use any type of physical restraint. R28's Physician Orders (11/14/2024) document: lap tray when up in reclining chair and release every two hours and when one-to-one with staff. The same record does not document any specific medical need for R28's lap tray restraint. On 11/12/2024 at 11:31 AM R28 was seated in a wheelchair in R28's room with a lap tray positioned in front of R28 with a belt attaching the tray to the wheelchair. R28 appeared to be actively attempting to remove the tray and twisting the tray upwards and side to side. On 11/12/2024 at 11:34 AM V13 (Certified Nurse Aide) reported the facility uses the lap tray when R28 is up in the wheelchair to keep R28 from trying to get out of the wheelchair. V13 reported staff recently removed R28's lap tray but R28 attempted to get out of the wheelchair three to four times so staff replaced the tray. On 11/12/2024 at 1:20 PM R28 was seated in R28's wheelchair in R28's room and was moving the lap tray around in upwards and side to side motions. R28's progress notes (10/31/2024) document attempted to remove lap tray. Resident did go three days without attempting to stand by self. On 11/4/24 resident was noted to be in room and had stood up. On 11/5/2024 resident was attempting to stand up again in dining room. Lap tray was re-applied for resident safety. He is able to move lap tray around and in different angles. On 11/14/2024 at 11:40 AM V3 (Minimum Data Set Coordinator) reported R28 is not able to remove the lap tray independently and the facility recently tried a trial removal of the lap tray but R28 tried to get up from R28's wheelchair so the tray was replaced. On 11/14/2024 at 2:50 PM V22 (Certified Nurse Aide) reported R28 attempts to get up from R28's wheelchair. V22 reported R28 is able to remove R28's socks without the tray in place but unable to do so with the tray present on R28's wheelchair. V22 reported the lap tray is used to keep R28 from attempting to get up from the wheelchair. V22 reported the pieces of pool noodles were recently placed on R28's lap tray because he was getting bilateral skin tears from the tray.

Based on record review and interview, the facility failed to provide treatment and services to prevent the development and worsening of a residents pressure ulcer. These failures affect one (R1) of three residents reviewed for pressure ulcers in the sample list of five. These failures resulted in R1's facility acquired pressure ulcer worsening. Findings include: R1's undated Face Sheet document R1's diagnoses as Alzheimer's Disease, Fracture of unspecified part of neck of unspecified femur, subsequent encounter for closed fracture with routine healing, methicillin resistant staphylococcus aureus infection as the cause of disease classified elsewhere. R1's March 2023 Weekly Wound Tracking documents on 3/9/23 R1's Stage Four pressure ulcer measured 0.5 cm by 0.2 cm by 0.1 cm. There are no documented measurements/assessments after 3/9/23 until 3/31/23 when R1's ulcer was larger and measured 2.5 cm by 2.5 cm by 0.8 cm. R1's Treatment Administration Record (TAR) dated March 2023, documents no treatments being completed on the following dates: 3/1/23 day and evening shifts, 3/3/23 day shift, 3/4/23 day shift, 3/5/23 evening shift, 3/9/23 evening shift, 3/10/23 day shift, 3/11/23 day shift, 3/12/23 day shift, 3/21/23 day shift, 3/25/23 evening shift, 3/27/23 evening shift, 3/29/23 day shift, and 3/30/23 day shift. On 12/12/23 at 12:06 PM, V13 Licensed Practical Nurse (LPN) stated that V13 found R1 lying in urine and feces all the time, R1's bed and R1 herself would be soaked. V13 stated R1 was only repositioned when the nurses did it because the Certified Nursing Assistant's (CNA) never did it. On 12/12/23 at 2:08 PM, V14 LPN stated V14 worked at the facility R1 was at before they both came to this facility. V14 stated R1's wound got worse and worse at this facility. V14 stated R1 should have been repositioned but don't think the CNA's did it at all or very often and she would frequently have to remind them to do it. V14 stated she did find R1 lying in urine and feces. On 12/12/23 at 2:37 PM, V21 Medical Doctor (MD) stated if treatments were not documented as being completed and the (R1's) wounds were not treated then yes the wounds will get worse. V21 stated wound assessments should be completed every time the dressing is changed with measurements and wound descriptions. On 12/13/23 at 1:43 PM V15 Corporate Nurse stated the nurses should follow the facility's policy when a pressure ulcer is identified and wound assessments should include size, drainage, and depth. V15 confirmed wounds should be assessed upon identification, the stage of the ulcer should be included, and R1's initial wound assessment does not identify the stage. V15 stated barrier cream can be applied by the CNA's and applications are not recorded. V15 stated daily skin checks are documented on the Treatment Administration Record (TAR). V15 reviewed R1's July 2022 TAR and confirmed it does not document daily skin checks were completed or barrier cream application. At 1:53 PM V15 provided R1's July 2022 wound log and confirmed the log does not identify the stage of the wound prior to 7/28/22. V15 stated the nurses don't always have to stage the wound. R1's medical record documents the following related to pressure ulcer history: R1's Care Plan dated 7/13/22 documents R1 has incontinence and includes interventions for use of incontinence briefs, change as needed, assess skin with each incontinence episode, and apply barrier cream as needed. This Care Plan documents to provide scheduled toileting assistance upon rising, before/after meals, and before bed. This Care Plan documents R1 is at high risk for developing pressure ulcers due to thin skin, poor safety awareness, and Alzheimer's Disease. This care plan documents interventions for daily skin checks, document any new skin conditions and to apply barrier cream to perineal area with each incontinence episode and as needed, and assist R1 to turn and reposition per schedule or at least every 2 hours. R1's July 2022 Treatment Administration Record (TAR) does not document R1's care plan interventions for daily skin checks and barrier cream application were implemented after admission on 7/13/23. R1's Admission assessment dated [DATE], documents R1 admitted with redness to R1's sacrum. This assessment does not document R1 had any open wounds upon admission. R1's Admission Minimum Data Set (MDS) dated [DATE] documents R1 has short/long term memory impairment and R1 is dependent on two or more staff for assistance with bed mobility, transfers, and toileting. This MDS documents R1 is at risk for developing pressure ulcers and did not have pressure ulcers when R1 admitted to the facility. R1's Newly Acquired Skin Conditions form dated 7/26/22, documents R1 has a pressure area of the coccyx that measures 6 centimeters (cm) by 5 cm. R1's Nursing Note dated 7/26/22 documents R1 has an open area to R1's coccyx and a calcium alginate treatment was applied. R1's July 2022 Weekly Wound Tracking report documents R1's ulcer began on 7/26/22 and the wound was pink with minimal drainage and the wound was classified as a Stage Four on 8/19/22. There is no documentation in R1's medical record of the stage of this pressure ulcer prior to 7/28/22. R1's Wound Evaluation & Management Summary dated 7/28/22, recorded by V20 Wound Physician, documents R1 has a full thickness pressure ulcer of the sacrum that was unstageable due to necrosis (dead tissue.) This wound measured 5.5 cm by 4.5 cm by 0.1 cm deep and 20% of the wound was necrotic tissue which was subsequently debrided. The facility's Aseptic Wound and Skin Treatment Procedure dated Reviewed 1/18, documents the purpose of this policy is to prevent contamination of a wound, to promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and promote resident comfort.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident for two residents (R23, R46) of 16 residents reviewed for abuse on the sample list of 29. This failure resulted in R23 requiring emergency services for lacerations to the bridge and left side of the nose. This past noncompliance occurred from 9/12/23 to 9/19/23. Findings include: The facility's final report to Illinois Department of Public Health dated 9/18/23 documents on 9/12/23 at 2:00 PM, R46 was standing in the hallway at the end of the hall near R23's room. R23 wheeled himself to the door and then stood up and went at R46 screaming for R23 to not go in his room. R46 reacted by hitting R23 in the nose and R23 hit him back. R23 and R46 were immediately separated and assessed. R46 had no injuries but R23 had a laceration on the bridge of the nose. Both were sent to the emergency room . R23's Hospital records dated 9/12/23 document R23 has a one centimeter laceration to the bridge and side of the nose. This record indicates the lacerations are caused from a resident to resident altercation that occurred in the facility. On 10/24/23 at 1:01 PM, V16 Housekeeper stated on 9/12/23 she witnessed the incident between R23 and R46. V16 stated: R23 was in his room and R46 was out in the hallway. R23 thought R46 was going to go into his room. R46 was just by the door. Then R23 started yelling at R46. V16 stated she got in between them and was really scared. V16 stated they were punching each other in the face. V16 stated several Certified Nursing Assistants came and separated them. R23 had to go to the hospital for a laceration on the nose. On 10/23/23 at 1:45 PM, V1 Administrator stated on 9/12/23, R23 and R46 were in a resident to resident altercation in which they struck each other. Prior to the survey date of 10/24/23 the facility took the following actions to correct the noncompliance. The facility submitted a plan of correction with a completion date of 9/19/23. A follow-up survey dated 10/17/23 was conducted and found the facility to be in compliance by taking the following actions: 1. V1 Administrator in-serviced all staff on the facility's Abuse Prevention Policy and Responding to Anger and Aggression in Dementia. 2. Care plans were updated with new resident centered behavior interventions. 3. The Interdisciplinary team reviewed residents whom displayed aggressive behaviors daily during their morning Quality Assurance meetings and implemented additional interventions based on the root cause or trigger of the behavior. 4. V1 Administrator is taking responsibility for implementing and communicating interventions and ensuring they are being followed. 5. Residents who are currently on a behavior management program or are having increased behaviors have been reviewed during weekly Psychotropic/Behavior Quality Assurance meetings with the Quality Assurance Team to ensure that current behavior interventions are effective and if non-effective new interventions were developed and implemented based on the root cause of the behavior. 6. V1 Administrator has been responsible to ensure that any new interventions will be communicated to the staff and IDT will monitor to ensure interventions are being followed. 7. The facility's Quality Assurance Committee has monitored compliance through the daily and weekly internal Quality Assurance process.

Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse resulting in R1 striking R2 who sustained a lip laceration and broken tooth requiring further evaluation at the hospital. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four. Findings include: The facility Abuse Prevention Program policy (5/2021) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The same policy documents: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. R1's care plan dated 8/21/2023 documents Physical aggression: R1 is/has potential to be physically aggressive with staff and other residents r/t Dementia. R2's Medical Diagnosis list (8/22/2023) documents R2's diagnoses include: Parkinson's Disease (neurodegenerative disorder), Lewy Body Dementia (neurocognitive disorder), Psychotic Disorder, Bipolar Disorder, Cerebral Infarction (stroke), Depression, and Anxiety Disorder. R2's Minimum Data Set (5/10/2023) documents R2 has moderately impaired cognition. The facility abuse investigation file (8/4/2023) documents on 7/29/2023 V3 (Registered Nurse) overheard R2 yelling from R2's room and when V3 responded, R2 was screaming at R1 to get out of R2's room, R2's mouth was bleeding, and R2 reported R1 had struck R2. The same record documents R2 was sent to the hospital for further evaluation and treatment. R2's hospital report (8/21/2023) documents R2 sustained a lip laceration and broken tooth from being struck by R1. On 8/21/2023 at 1:25PM, V3 reported hearing a commotion and finding R1 and R2 had got into an altercation and V3 concluded R1 had punched R2 in the face.

Based on interview and record review the facility failed to protect residents' rights to be free from physical abuse by another resident and failed to implement interventions to prevent reoccurring physical abuse for four of four residents (R1,R2,R3,R9) reviewed for abuse in the sample list of nine residents. These failures resulted in R1 physically abusing R2, R3 and R9. The Immediate Jeopardy began on 2/11/23 when R1 (who has a history of physical abuse towards other residents) slapped R3 on her arm. R1 was placed on one on one supervision when out of bed. On 4/15/23 R1 was unsupervised, wandered into R2's room and physically assaulted R2. On 4/24/23 R1 was unsupervised and put his hands around R9's throat. V1 Administrator was notified of the Immediate Jeopardy on 4/28/23 at 11:00 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/28/23 but non-compliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Physician Order Sheet (POS) dated April 2023 documents R1 is diagnosed with Dementia with other Behavioral Disturbances, [NAME] Disease, Schizophrenia and Psychotic Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. The same MDS documents R1 has hallucinations, delusions, and wanders. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has hallucinations, physical behavior symptoms directed towards others such as hitting, kicking, pushing, scratching. The same MDS documents R1 wanders daily and significantly intrudes on the privacy of others. R1's Psychosocial Evaluation dated 3/30/23 documents R1 demonstrates poor safety awareness, poor judgment, wanders, enters other's bedrooms uninvited, is socially inappropriate, gets angry and aggressive, anxious, agitated, is physically aggressive and physically abusive. R1's Care Plan dated April 2023 documents R1 wanders aimlessly throughout the facility and significantly intrudes on others privacy. Staff are to monitor R1's location every 15 minutes and provide one-on-one supervision when R1 is out of bed ambulating in facility. The same Care Plan documents R1 uses psychotropic medications related to behaviors such as wandering and violent aggression towards staff and others. R1's behavior management program includes one on one staff supervision due to wandering and aggressive behavior when awake and out of bed. The facility's Final Report dated 2/11/23 documents on 2/11/23 at 10:40 AM R1 entered the dining room during a group activity and sat down on another resident's walker. V5 Activity Aide asked R1 to move off of the walker and R1 began hitting V5 and also struck R3 who was sitting nearby. R3 stated she was just sitting there and R1 struck her on the arm really hard. In order to keep both R1 and other residents safe, R1 was placed on one-on-one supervision when out of bed. On 4/27/23 at 10:00 AM R3 stated she remembers R1 hitting her on the arm during an activity in the dining room. R3 stated R1 hit her pretty hard and it hurt. R3's Minimum Data Set, dated dated dated [DATE] documents R3 is cognitively intact. The facility's Final Report dated 4/21/23 documents on 4/15/23 R1 entered R2's room unsupervised and when asked to leave, R1 began repeatedly hitting R2 in the neck and hit her with a belt. The Behavior Note dated 4/15/23 at 12:25 PM documents R1 entered R2's room and repeatedly struck R2 in the throat with his fist and then preceded to hit R2 with a belt in the chest. On 4/25/23 at 2:40 PM V4 Licensed Practical Nurse (LPN) stated R1 is independently ambulatory, severely cognitively impaired, impulsive, physically aggressive, combative with care, has a history of physical aggression with other residents, is very quick and almost walk/runs down the halls, is strong and could hurt other residents. V4 stated she was the nurse on 4/15/23 when R2 came out of her room and up to the nurses station. V4 stated R2 was very upset and said that R1 had wandered into her room and as R2 was telling him to leave, R1 started to repeatedly hit R2 in the upper chest/neck area. R2 also stated R1 had his belt in his hand and swung the belt at R2. V4 LPN stated R2 is cognitively intact and was visibly shaken with the incident. V4 LPN stated staff are supposed to provide one-on-one supervision for R1 when he is out of bed, but there is often not enough staff to do so. V4 LPN stated on 4/15/23 R1 was not being monitored one-on-one but really needed to be so that he wouldn't hurt anyone else. On 4/26/23 at 1:30 PM R2 stated R1 was in her room, and R2 got out of the chair to tell R1 to get out. That is when R1 began hitting R2 on her neck/chest. R2 stated it hurt very bad and R1 is a very strong man. R2 stated R1 had his belt off and it was in his hand, and he swung it at R2 but it did not make contact. R2 said she screamed out and went down the hallway to get help. Staff then went to get R1 out of R2's room. R2 stated she sat down in a chair by the nurses station and was very shaken by the altercation. R2 stated she is very scared of R1 and does not want him near her. R2 stated she has still seen R1 walking around the facility unsupervised since the incident. R2's Brief Interview for Mental Status (BIMS) Evaluation dated 4/17/23 documents R2 has a moderate cognitive impairment. The facility's Incident Report Form dated 4/25/23 documents on the evening of 4/24/23 R1 was in the hallway and grabbed R9 around the neck. On 4/25/23 at 2:40 PM V4 Licensed Practical Nurse stated she worked the evening of 4/24/23 and was at the nurses station when she heard R9 scream out. R9 was in the hallway coming towards the nurses station. V4 approached her to find out why she screamed and V9 repeated over and over that the man (R1) put his hands around her neck and she doesn't know why he did that. V4 stated R9 was visibly upset by what happened and she was very confused as to why R1 would do that. V4 LPN stated R1 was not being supervised one on one during the shift because they did not have enough staff to watch him at all times and get their work done. On 4/26/23 at 1:20 PM R9 stated she does not remember the man putting his hands around her throat but if he did, she would not like it. R9's MDS dated [DATE] documents R9 is moderately cognitively impaired. On 4/27/23 at 3:30 PM V1 Administrator confirmed R1 was not being supervised one on one during any of the three abuse incidents involving R1. V1 confirmed R1 should have been being monitored one on one due to his history of physical aggression towards others. On 5/2/23 at 2:20 PM V23 Medical Director confirmed R1 is a cognitively impaired resident who has a history of physical aggression towards others. R1 is ambulatory on his own, wanders, and should have been monitored closely by staff. R1 should not have been allowed unsupervised access to other residents. The facility should have followed their intervention of one-on-one supervision for R1 to keep him and other resident's safe and free from abuse. The facility Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of residents to be free from abuse. Residents who allegedly mistreat or abuse another resident will be removed from contact with that resident during the investigation and the accused resident's condition will be evaluated to determine the most suitable care approaches to implement considering the safety of everyone involved. The Immediate Jeopardy that began on 2/11/23 was removed on 4/28/23 when the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was transferred to a mental health facility on 4/26/23. 2. Facility staff reviewed related policies regarding Abuse Prevention Program- completed on 4/28/23 by V23 Regional Clinical Director. 3. Staff were in-serviced regarding Abuse Policy, Identifying residents at-risk for abuse, Implementing person-centered interventions and identifying behavior triggers- completed on 4/28/23 by V23 Regional Clinical Director. 4. Staff were in-serviced regarding one to one monitoring for residents who are at risk for harming others- completed on 4/28/23 by Regional Clinical Director. 5. Staff were in-serviced regarding Department Directors to assist with providing one to one supervision if nursing department cannot- completed on 4/28/23 by V23 Regional Clinical Director. 6. All staff were in-serviced regarding Abuse Policy, one on one monitoring- completed on 4/28/23 by V23 Regional Clinical Director. 7. Residents involved in physical abuse allegations were reviewed for targeted behaviors and personalized interventions were put in place- completed on 4/28/23 by Regional Clinical Director. 8. All residents at risk for abuse and aggressive behaviors were identified and personalized interventions put in place- completed on 4/28/23 by V23 Regional Clinical Director. 9. Interdisciplinary Team was in-serviced to review residents for changes in behaviors, investigate potential triggers, and ensure person centered interventions are developed and communicated to staff- completed on 4/28/23 by Regional Clinical Director. 10. All identified residents with identified behaviors will be reviewed in a weekly behavior Quality Assurance meeting- ongoing for completion. 11. Residents with aggressive behaviors will be discussed in morning meeting and a root cause analysis will be completed to determine potential triggers- ongoing for completion.

Based on interview and record review the facility failed to provide proper footwear and adequate assistance for R4, resulting in R4's fall with serious injury. R4 sustained nasal fractures that required emergency medical care at the hospital. R4 is one of three residents reviewed for falls on the sample list of 9. Findings include: R4's current diagnoses sheet documents the following diagnoses: Vascular Dementia, Unspecified Severity with Agitation, Cognitive Communication Deficit and Unsteadiness on Feet. R4's Minimum data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment requires extensive physical staff assistance with dressing. The same MDS documents R4 requires limited physical staff assistance with walking in room and in corridors. R4's Fall Risk assessment dated [DATE] documents R4's score of 12 points. The same fall risk assessment documents 10 or more points indicates resident is at high risk for falls. R4's Health Status Note dated 3/9/2023 at 7:55 PM documents the following: Note Text: CNA summoned writer to East hallway. res (resident/R4) noted sitting on floor in front of CNA, blood noted to facial area, res (R4) eased back onto pillow, area cleansed. 0.9 cm (centimeter) vertical laceration noted to medial bridge of nose, area approximated and 1 (one) steri-strip applied; swelling noted to nasal area; 6.5 cm x 4 cm (length by width) hematoma noted mid-forehead. Neuros (neurological assessment) initiated and WNL (within normal limits) for res (R4), EMS (Emergency Medical Service) notified at 20:06 (8:06 PM), responded at 20:10 (8:10 PM) and departed facility with res (R4) at 2015 (8:15 PM) in route to (local hospital) ER (emergency room ). R4's Hospital ED (emergency department) Course/Medical Decision Making record dated 3/9/23 documents the following: Diagnostic Studies/Procedures: Exam (examination), CT (computed tomography) of Head after fall. Impression: Acute Fracture of both nasal bones. R4's IDPH (Illinois Department of Public Health), Final Report dated 3/17/23 documents the following: It was reported that (R4) and independent walker (MDS above documents R4 requires physical staff assistance) had a fall that occurred 03/9/23, in the hallway that resulted in a nasal fracture. The same report documents an investigation was conducted, which resulted in the following determination: Conclusion: The IDT team (Interdisciplinary Team) performed a root cause analysis and has placed appropriate interventions in place. The resident was noted to (sic) not have been wearing the proper footwear at the time of the incident. Staff educated to ensure (R4) wears shoes or slipper socks while ambulating. (R4) also continues to work with therapy for muscle strengthening. On 4/25/23 at 2:40 PM, V4 (Licensed Practical Nurse) LPN confirmed R4 fell forward on 03/9/23 and fractured her nose. V4 stated she asked the (V8), CNA who was there, what happened, and at first (V8) denied knowing what (R4) tripped over but eventually admitted to (V4) that she (V8) was walking behind (R4) and hugging (R4) from behind when she (R4) tripped over V8's foot and they both fell to the ground. (V8) yelled for help. (V4) LPN stated (R4's) face was bloody, her nose and mouth were bleeding, (R4) had a goose egg on her forehead, and a small laceration to her nose. On 4/26/23 at 1:45 PM, V8, Certified Nursing Assistant (CNA) stated The evening (R4) fell , I was (assigned to) her (R4's) CNA after 2:00 PM. I (V8, CNA) noticed that she was sleeping when I first came in. She did not have socks or shoes on. I didn't get her up for supper or I would have put shoes or non-skid socks on her (R4). I don't know who got her (R4) up (ready for supper). We (staff unidentified) all know that all residents are supposed to have them (shoes or non-slip socks) on, if they can walk. After supper (R4) was sleeping on the couch, again without socks or shoes. When she (R4) woke up, I (V8, CNA) should have put shoes or socks on her. I don't know why I didn't. She walks on her own all the time. I walked with her, on the side of her (R4), in the hall just before she fell (3/9/23). I was holding her hand, as a gesture of kindness. Our hands were linked together and (R4) still had bare feet. Usually, she (R4) walks by herself. She tripped over something, I think it was her own feet. I tried to stop her fall (R4) but I couldn't. She fell face first and broke her nose. I felt so bad. On 4/26/23 at 2:10 PM, V16, Certified Nursing Assistance (CNA) adamantly stated I (V16, CNA) was charting in the break room. I came out to the nurse station to get a drink. I looked down the hall immediately before (R4's) fall. (V8, CNA) was walking behind (R4). (V8, CNA) had her arms wrapped around (R4), about chest high. Like in a bear hug. I took a drink of water and before I could set the water down, I heard (V8, CNA) scream for me to get a nurse. I didn't see the fall itself. But it happened literally, within seconds after I saw (V8, CNA) walking behind (R4) like that. They were both on the floor kind of behind the linen cart. (R4) usually walks alone. (R4) walks pretty slow. (V8, CNA) is hyper-energetic. (V8, CNA) may have been rushing her (R4) a bit. I don't think (V8, CNA) meant to cause (R4) a problem. She (V8, CNA) felt really bad that (R4) fractured her nose. On 4/27/23 at 9:30 am, V18, Regional Director of Clinical Operations/ Registered Nurse stated I help with reportables ( falls with injury, that must be reported to IDPH) and (I) am part of the IDT team that reviews all falls with injury. (R4's) fall, I know (V8, CNA) was walking with (R4) in the hallway. I understood (R4) tripped over her own feet. She did not have proper footwear. V18 also stated The cause of R4 nasal fracture was the fall, due to the root cause, (R4) was bare foot. It is the standard for safety that all ambulatory residents have on shoes or non-slip-wear to prevent falls. On 4/27/23 at 10:35 am, V1, Administrator/Licensed Practical Nurse confirmed V1 assist with all fall investigations. V1 reviewed R4's fall investigation witness statements. V1 confirmed V16, CNA statement that documents V8, CNA was walking behind R4 in the hall immediately before the fall. V1, Administrator, Ok, I understand there is direct correlation that may have contributed to (R4's) fall, with (V8) walking behind (R4). That coupled with (R4) not wearing shoes or non-slip socks. The facility Fall Prevention policy dated revised 11/10/18 documents the following: Policy: To provide for resident safety and to minimize injuries related to falls; decreases falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All staff Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. A visual prompt may be placed on the name plaque by the entrance to the resident's room. If used, any assistive device such as a walker or cane will be identified with the same visual prompt to match the prompt at the entrance to the room. This system provides staff a visual alert to monitor those at risk for falls. (blank documentation space) indicates high risk for falls. (The facility should signify what the visual prompt will be and if none is used signify with N/A) All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. The same facility Fall Prevention policy documents Fall Prevention Interventions: 18. Non skid footwear 33. Remind staff to allow residents to proceed at their own pace.

Based on observation, interview and record review the facility failed to ensure residents were not subjected to physical and mental abuse by another resident. This failure affects five ( R1, R2, R3, R4, R5) of five residents in the sample list of five residents reviewed for abuse. These failures resuled in R4 being repeatedly struck in the head by another resident(R3), also R4 and R5 experiencing mental anguish caused by R3. Findings include: 1) On 1/21/23 at 10:30AM, the facility provided investigation documents that R3 struck R4 on the head and face repetitively until V8 Certified Nursing Assistant (CNA) pulled R3 off of R4. R4's nurse's notes dated 1/21/23 document, R4 was walking back to his room after getting a shower and passed another resident in the hall, by R4's door. R3 started to walk past and turned around and punched R4 in the back of the head and on the right side of the face and kept swinging until (V8 CNA) separated them. Nurse's notes of the same date document the physician orders to monitor R4 closely due to R4's history of stroke and use of blood thinners, post head injury. On 2/1/23 at 2:50PM, R4 stated, I remember walking down the hall and all of a sudden I felt a blow to my head from behind and he kept hitting me until (V8CNA) got him off of me. I have seen him hit staff and come close to hitting other residents and I am very fearful that he will come back to my room and I will have to defend myself. In the dining room, I won't sit anywhere but with my back to a wall because of him. I didn't used to do that, but I felt safer then. I have to be more alert because of him. R4's admission note dated 1/12/23 documents R4 as cognitively intact. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as severely cognitively impaired and ambulatory. On 2/1/23 at 3:00PM, V7 Licensed Practical Nurse (LPN) stated, I was the nurse the night that (R3) hit (R4). (R4) was walking down the hall and a CNA was coming out of another resident room and R3 just started hitting (R4). There was no provocation. R3 is definitely a [NAME]. I am concerned for the safety of the residents and staff. (R3) will come up behind you and you just never know what he is going to do. 2) R3's medical record documents that on 10/3/22, R3 was sent to a behavioral health hospital for an inpatient stay to address increasing aggression in the nursing home including punching, kicking, biting, hitting and exit seeking. R3's December 2022 and January 2023 behavior monitoring sheets document physical aggression and wandering. R3's nurse's notes dated 1/29/23 document at 10:00AM, Consent received for haldol 1 milliliter intramuscularly for aggression to others, throwing over tables and agitation. Nurse's notes on the same date from 2-10PM document that R3 was agitated and attempted to go out the side doors several times and was combative with staff when redirected. R3 was also documented as wandering into other resident rooms, getting into their beds and being resistive to all redirection and care. On 2/1/23 at 9:08AM, V1 Administrator stated, He (R3) wanders in and out of other resident rooms. He is on 15 minute checks and we have tried to find alternative placement, but his family wants him to stay here. On 2/1/23 at 9:30AM, R3 was walking around the facility, wearing a wander guard going into and out of resident rooms. On 2/1/23 at 9:35AM, V5 Certified Nursing Assistant (CNA) stated, R3 wanders in and out of resident rooms all day long. We just redirect him. On 2/1/23 at 9:36AM, V6 CNA stated, (R3) lays down in beds that aren't his but since he's on 15 minute checks, we find him pretty fast. He can be aggressive when we give care, sometimes it takes 3 people because he is strong and fast. On 2/1/23 at 10:00AM, R3 walked into R5's resident room and stayed there until R5 could be heard screaming, Get out! This is a girl's room. Get out now!!!! Staff entered the room at this time and redirected R3 out of the room. On 2/1/23 at 2:25PM, R5 stated, (R3) comes in here all of the time and I don't like it. I yell at him and tell him that this is a girl's room. I have told the CNA's that I don't want him in here. Thank you for helping me. On 2/1/23 at 3:05PM, V7 LPN stated, On Sunday night (1/29/23) I found (R3) trying to get into (R5's) bed while she was sleeping. He was trying to pull up the covers and I tried to redirect him but he fought me so I had to yell for help and thank god, two other staff came and helped me get him out of her bed. 3) On 12/26/22 at 2:25PM, the facility provided investigation documents that R2 came out of the resident room that R1 and R2 shared and stated to a nurse that R1 had scratched his face. On 2/1/23 at 9:08AM, V1 Administrator stated, I was the nurse that day and R2 came out of his room and said that R1 had scratched his face. He did have new scratches on his face and hand. I went down to talk to R1 and he said that R2 had started it. I immediately separated them and made all of the notifications. On 2/1/23 at 2:31PM, R1 was calmly lying in his bed, in a private room. R1 stated that he remembered arguing with his roommate and that he was glad that he didn't have one any longer. On 2/1/23 at 10:30AM, R2 stated that he liked the facility and that he did not remember being scratched by anyone however; old scratch marks were visualized on the right side of R2's face. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired and wheel chair bound. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as severely cognitively impaired and wheel chair bound. On 2/1/23 at 9:15AM, V1 Administrator stated, We separated them(R1,R2) into different rooms and they are both scheduled to see a psychologist. There have been no further issues between them, since this event. On 2/1/23 at 3:15PM, V9 Director of Nursing stated, Both R1 and R2 dislike having roommates. We are just going to have to keep them in their own rooms. The facility abuse policy dated 11/28/16 documents that this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation, as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by various means including dementia management and resident abuse prevention including, how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff.

Based on record review and interview the facility failed to ensure that one (R1) resident was free from abuse out of four residents reviewed for abuse. This failure resulted in R1 being physically abused by another resident (R2) causing harm resulting in Hyphema of Left Eye and [MEDICATION(S)] Hemorrhage of Left Eye for R1. Findings include: R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same POS documents a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents modified independence in decision making skills and R1 requires extensive assistance of one person for personal hygiene and toileting. This same MDS documents R1 requires extensive assistance of two people for bed mobility, transfers and dressing. R1's Nurse Progress Noted dated [DATE] at 7:05 PM documents (R1) came to the lobby very upset, had large swollen and bleeding Left eye. (R1) stated that another resident (R2) had come behind (R1) and hit (R1) in the back of the head and Left eye. R1's Hospital emergency room Progress Note dated [DATE] documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Final Abuse Investigation Report to Illinois Department of Public Health (IDPH) dated [DATE] documents After a thorough investigation the facility determined that the incident did occur. The facility Abuse Prevention Program Policy revised [DATE] documents the following The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility is committed to protecting residents from abuse including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual family members or legal guardians, friends, or any other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish or pain. 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. On [DATE] at 3:45 PM V5 Maintenance Director stated had a good rapport with (R2). (V5) had helped (R2) with (R2) television before and (R2) seemed to like (V5). (R2) had been sent into the hospital for health reasons and was released on [DATE]. (R2) needed a ride back to facility so (V5) took the facility van to pick (R2) up at the hospital. (R2) was talking with (V5) pleasantly at the hospital and on the way back to the facility. We (V5 and R2) were making casual conversation. (V5) had to stop at at stop sign and when (V5) turned on to the highway, (R2) had unbuckled (R2) seatbelt and began to hit (V5) in the head from the back. (V5) pulled the van over at the first safe place (V5) could and got out of the van with the keys in hand. (R2) was inside the van. (R2) then unlocked the door and exited the van. (R2) was walking down the highway. (V5) was waving (V5) shirt around above head to [NAME] off traffic so (R2) wouldn't get hit by another car. (V5) had already called the facility and 911. The 911 dispatcher called the sheriff's office also. As (R2) was walking down the highway and (V5) was walking a safe distance with (R2) when the county Sheriff arrived. The sheriff placed (R2) in the back of the police car. When the ambulance arrived, (R2) was assisted from the back of the police car into the ambulance per the Sheriff and ambulance crew. (V5) returned to facility. (V5) declined medical treatment and decided to not press charges against (R2). The ambulance took (R2) back to the hospital for evaluation. V5 stated the next day ([DATE]) (R2) was released from the hospital again and again needed a ride back to the facility. (V5) and V2 Director of Nurses used facility van to pick (R2) up from the hospital. V2 was driving and (V5) was sitting up front in the passenger seat. (R2) was buckled in the back seat. As V2 was driving, (R2) reached from the back seat and grabbed V2 by the arm attempting to pull V2 out of the drivers seat. V5 was attempting to remove R2's hands from V2 while (V2) was driving. R2 began punching V5 in the face, bloodying V5 lip. V2 pulled the van over, the sheriff and the ambulance met us (R2, V2, V5) on the highway again and R2 was released to the ambulance crew. R2 was returned to the hospital and was admitted . On [DATE] at 9:55 AM V2 Director of Nurses stated (R2) was released from the hospital on [DATE]. (V2) was working that night and the hospital called to say (R2) needed a ride back to the facility. V5 Maintenance Director and (V2) drove the facility van to pick up (R2) from the hospital. On the way back, (R2) was sitting in the backseat and out of nowhere (R2) started pulling hard on (V2) right arm. (R2) was trying to pull (V2) out of the drivers seat as we (R2, V2, V5) were in motion. (V5) intervened, attempting to release (R2) grip on (V2) arm and (R2) then started punching (V5) in the face. (V2) think (R2) bloodied (V5) lip. (V2) was able to pull the van over and the sheriff picked up (R2). (R2) was delivered to the ambulance staff on the highway. (R2) was taken back to the hospital and then they (hospital) kept him (R2) this time. There didn't seem to be any reason (R2) became aggressive. It came out of nowhere. V2 Director of Nurses stated I was the nurse on duty the day ([DATE]) (R2) hit (R1). (R2) was upset after supper time. (R2) kept looking for (R2) family and wanted to call family. (R2) was assisted in calling R2's wife and temporarily calmed down. V2 stated we (staff) knew (R2) was agitated with (V2) so asked V8 Certified Nurse Aide (CNA) to assist (R2). (R2) likes (V8). (R2) allowed (V8) to assist (R2) to bed and (R2) was calm again for awhile. Then, (R2) walked out of (R2) room and sat in the lobby area. (R2) then became agitated again. (R2) walked over to V2 and attempted to hit V2 in face with R2 elbow. (R2) called (V2) names and yelled F*** off. (R2) allowed V8 CNA to assist (R2) back to room to watch television and calmed again. A few minutes later, (R2) walked up to lobby and sat down again. (R1) wheeled self out to nurses station. (R1) was yelling at (R2) and seemed very distraught. (R1)'s left eye was bleeding, swollen and very bruised. (R2) stood up and started walking towards (R1), so (V2) intervened. (V8 CNA) stayed with (R2) and (V2 DON) assessed (R1) eye, applied ice to (R1) left eye and started making phone calls. The 911 dispatcher stated two ambulances would be dispatched, one for each resident. I (V2) would not have guessed (R2) would injure another resident. (R2) had behaviors with staff prior to this, but never with any other residents. On [DATE] at 3:45 PM V1 Administrator stated (R2) was agitated that evening ([DATE]) but that happens sometimes with Dementia. (R2) can get agitated in the evening, so the staff assist (R2) in calling family and (R2) calms down. The evening of [DATE], (R2) became agitated with staff and calmed after staff helped (R2) call family. We (staff) think (R2) became confused after using the bathroom and exited out the other resident (R1) door into (R1) room (R1 and R2 live in separate rooms that share a bathroom). (R2) must have thought (R1) was in (R2) room and started hitting (R1). As soon as the staff were made aware of the situation, (R1) and (R2) were both placed on 1:1 status until they were released to the ambulance crews. (R1) and (R2) left facility in two separate ambulances. The police were called, there was a police report made and they (police) came to facility and questioned both residents and staff. (R1), (R1)'s family and staff all declined to press charges against (R2). The other residents were never in any danger. (R2) had never had any behaviors towards other residents prior to this. On [DATE] at 3:30 PM V11 Medical Director stated facility is not able to care for this resident due to unprovoked outbursts. (R2) has a long history of mental health issues, but nothing ever this violent. The facility should have sent R2 to emergency room after physical altercations with staff on evening of ,d+[DATE]. They (facility) could have gotten an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They (facility) shouldn't wait for the Physician to call back. They (facility) should have just sent (R2) out. This is the worst resident to resident abuse I have ever seen in decades of being a Medical Director. This episode of violence came out of nowhere. It was an isolated event. This resident did not have any other behaviors towards other residents. I (V11) don't believe any other residents were ever in jeopardy. The facility couldn't have known (R2) was going to have this outburst.

Based on observation, record review and interview, the facility failed to develop and implement effective behavioral interventions for R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12, each with a known cognitive impairment. These failures resulted in repetitive instances of resident to resident physical abuse to R1, R5, R6, R7, R10, R11 and R12. These failures put these residents at continued risk for engaging in ongoing behaviors resulting in physical violence to one another. Unmitigated behavioral interventions could result in residents sustaining severe, life-threatening, or fatal injuries. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/12/21, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of their revised Behavior Tracking and Monitoring Program and the effectiveness of their employee in-services on their Abuse Prevention Policy and caring for their residents with Dementia and Behavioral Disturbances. Findings include: The facility policy titled Abuse Prevention Program dated 11/16/16 documents the following: Procedures for Prevention Establishing am environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property; including, prohibiting staff from using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to keep, or distribute photographs and recordings of residents that are demeaning or humiliating. Procedures for Prevention: Dementia management and resident abuse preventions; including, How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; Establishing a Resident Sensitive Environment: Resident Assessment: As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. 1.) A facility Incident Report dated 6/5/21 documents the altercation between two residents (R9 and R10 as follows: V10, Certified Nursing Assistant witnessed R10 yell at R9 because R9 was standing next to R10. R9 then hit R10 with an open hand on R10's back. The incident occurred in the front lobby of the facility. A facility Incident Report dated 6/8/21 documents an altercation between the above same residents (R9 and R10) as follows: V14, Speech Therapist witnessed R9 walk up behind R10 and push R10's wheelchair. R10 asked R9 to stop pushing R10's wheelchair. R9 then hit R10 in the back twice with R9's fist. This incident occurred in the front lobby of the facility. R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R9's Minimum Data Set (MDS) dated [DATE] documents R9 as severely cognitively impaired R9's Plan of Care (current) R9's Plan of Care (current) documents a problem area of disruptive/inappropriate behaviors towards staff and residents at times. Approaches are documented as Determine if behavior is stimulated by dertain (sic) activities, noise levels, persons involved, time of day. Gain attention of Resident by using name. Talk with resident in calm manner. Redirect to area where others will not be distracted. The Care Plan does not address R9's physical aggression toward other residents. R9 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R9's facility Behavior Tracking Forms dated for May 2021 document a targeted behavior of physical aggression and documents R9 with this behavior on 5/4, 5/5, 5/7, 5/10 and 5/13/21. June 2021 Behavior Tracking Form also documents a Targeted behavior of physical aggression and R9 exhibiting this behavior toward R10 on 6/8/21 only (there is no documentation of R9's physical aggression toward R10 on 6/5/21 per the facility Incident Report dated 6/5/21). July 2021 Behavior Tracking Form with the targeted behavior of physical aggression documents R9 exhibiting this behavior on 7/1, 7/3, 7/7, 7/9, 7/12 7/17/21. There is no documentation on this form correlating R9's physical aggression on 7/15/21 toward R12 per the facility Incident Report dated 7/15/21. R10's POS dated August 2021 includes a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R10's MDS dated [DATE] documents R10 as severely cognitively impaired. R10's Plan of Care (current) includes Behaviors of physical abuse, refusal of care and manipulation. Approaches include initiate behavior monitoring program, Use consistent calm approach, Maintain a Calm Environment. R10 does not have an Abuse Risk Assessment or Social History Assessment in the Medical Record. R10 had no Behavior Tracking Forms for review. 2.) A facility Incident Report dated 6/27/21 documents an unwitnessed altercation between R1 and R8. V15 Housekeeper found R1 on the floor of R8's room and reported it to V2 Assistant Director of Nursing. V2 responded and upon entrance to R8's room R1 was on the floor and R8 told V2 that R8 had pushed R1 down. Assessment of R1 showed some redness to R1's left upper back. R8's POS dated August 2021 includes a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MDS dated [DATE] documents R8 as severely cognitively impaired. R8's Plan of Care (current) documents a care area of Behaviors that includes physical aggression and wandering. Approaches include Resident will calmly accept redirection, Initiate Behavior Monitoring, Use consistent calm. firm approach, Maintain a calm environment, Review abnormal behaviors with Interdisciplinary Team. R8 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Chart. R8's Behavior Tracking Form dated for June does not document R8's physical aggression toward R1 on 6/27/21 (per the facility Incident Report of 6/27/21). There is documented wandering throughout May, June and July 2021. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS dated [DATE] documents R1 as severely cognitively impaired. R1's Plan of Care (current) documents a problem area of Wandering - Resident walks all day and will go into other resident's rooms (started 10/29/20). Approaches - Provide supervision, approach calmly, offer assistance and attempt to redirect, Provide opportunities to go outside with supervision, Walk with resident to accomplish a purpose such as greet others, Redirect when entering other rooms, Intervene as needed with others residents to prevent altercation, Post pictures of resident at other nursing stations to let them to provide supervision and assistance as needed, Ask all staff to notify nursing if resident found in other areas of the building and requires assistance to return, mark room with name, familiar object or picture, medication to improve cognition and manage anxiety. R1 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R1's Behavior Tracking Forms dated for June do not document R1 wandering into R8's room on 6/27/21. Behavior tracking for July does not document R1 wandering into R3's room on 7/17/21. Per the facility's Incident reports dated respectively. 3.) A facility Incident Report dated 7/1/21 documents witnessed abuse between R7 and R11. V18 Dietary Aide stated V18 heard R11 yell and went into the room and witnessed R7 kick R11 in the left foot. R11 stated that R7 had also kicked R11 in the knee. There were no injuries. 15 minute checks continued and for R7 and R7 was moved off the hall per the above report. R7's POS dated August 2021 includes a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R7's MDS dated [DATE] documents R7 as severely cognitively impaired. R7's Plan of Care (current) documents a care area of behaviors with known wandering, but does not document R7 having physical aggression. Approaches include redirect resident when wandering. R7 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R7's Behavior Tracking Forms do not document any physical aggression behaviors in May, June or July 2021 (7/22/21 incident is not documented). R11's POS dated August 2021 includes a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R11's MDS dated [DATE] documents R11 as moderately impaired. R11's Plan of Care (current) documents R11 with Behaviors of wandering, resistive to care and may exhibit behaviors that are disruptive to others and may result in harm to resident from others as reprisal. R11 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R11 had no Behavior Tracking Forms for review. 4.) A facility Incident Report dated 7/3/21 documents V16 Certified Nursing Assistant witnessing R1 attempting to pick up a cookie from another resident's (unknown) place and R2 reached across the table in the dining room and hit R1 on the arm, leaving a slight redness on the left forearm of R1. R2's POS dated August 2021 includes a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R2's MDS dated [DATE] documents R2 as cognitively intact. R2's Plan of Care (current) R2's Plan of Care (current) has no care area for physical aggression toward staff or other residents as exhibited on 7/3/21 (per facility Incident Report and on 6/6/21 toward a CNA per Nursing Notes). R2 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Chart. R2's Nursing Notes dated 6/6/21 also document that R2 hit a staff member multiple times in the back because the staff member was blocking R2's television view while providing care to R2's roommate). R2's Behavior Tracking Form dated for June does not document R2's physical aggression toward staff on 6/6/21 per R2's Nursing Notes. R1's information as above. 5.) A facility Incident Report dated 7/5/21 documents V17 Licensed Practical Nurse witnessing R4 propelling down the hallway in R4's wheelchair and encountered R5 and reached out and smacked R5 on the arm. Before V17 could reach R4, R4 proceeded down the hall and encountered R1 wandering in the hall and smacked R1. R4 was placed on 15 minute checks. R4's POS dated August 2021 includes a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R4's MDS dated [DATE] documents R4 as severely cognitively impaired. R4's Plan of Care (current) documents that R4 wanders and has frantic movements in R4's wheelchair. The Plan of Care does not address R4 having any physical aggression. Approaches for wandering include redirect resident. R4 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R4's Behavior Tracking form dated for May 2021 and June 2021 does not document any aggressive behaviors. The July 2021 Behavior Tracking form documents on 7/1, 7/5/, 7/9, 7/15, 7/16 and 7/21 R4 having aggressive behaviors (there are no signatures on the form to identify who documented these entries). R5's POS dated August 2021 includes a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R5's MDS dated [DATE] documents R5 as severely cognitively impaired. R5's Plan of Care (current) has no documented care areas for physical aggression. R5's Behavior Tracking Form dated May, June and July 2021 documents no physical aggressive behaviors. 6.) A facility Incident Report dated 7/15/21 documents V3, Social Service Director witnessing R9 picking something up off a table in the dining hall. R12 then yelled at R9 and R9 became agitated and pinched R12 on the right forearm. See R1's Information above. See R9's Information above. R12's POS dated for August 2021, includes a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R12's MDS dated [DATE] documents R12 as cognitively intact. R12's Plan of Care (current) documents that R12 is known to or has history of displaying inappropriate behavior and or resisting care. Specific behavior exhibited, arguing/fighting with husband and daughter, physical and verbal abuse to others, self abuse, [CONDITION(S)], repetitive health complaints related to anxiety. R12 does not have an Abuse Risk Assessment or a Social History Assessment in the Medical Record. R12 had no Behavior Tracking Forms for review. 7.) A facility incident Report dated 7/17/21 documents V12 Certified Nursing Assistant reporting that R1 was in R3's room in R3's bed. R1 got out of the bed and was heading out of R3's room when R3 shoved R1 to the floor. V12 also stated V12 saw R3 use R3's feet to push R1 along the floor, trying to get R1 out of R3's room. R1 had slight redness to left hip and back. R1 was put on one to one supervision. R3's POS dated August 2021 includes a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's MDS dated [DATE] documents R3 as severely cognitively impaired. R3's Plan of Care (current) documents on 8/5/21 a care area under [CONDITION(S)] Drugs: exhibits signs of physical aggression as shown by swinging fists at staff. There are no interventions documented for this care area of physical aggression. R3 does not have an Abuse Risk Assessment and R3's Social History Assessment is incomplete. R3's Behavior Tracking Form dated for July documents physical aggression on 7/14/21 and wandering the facility on this same date, but does not document R3's physical aggression toward R1 on 7/17/21 (per facility Incident Report of 7/17/21). Behavior tracking for June documents two instances of behaviors on 6/26 and 6/27/21. An entry dated 6/18/21 documents R3 hitting a staff member (unidentified) in the head. See R1's information above. 8.) A facility Incident Report dated 7/22/21 documents V19 Certified Nursing Assistant was walking down the hall and saw R7 grab R6 and push R6 up to the wall. R6 grabbed a wet floor sign and swung it at R7, hitting R7 on the left body side. No injuries were sustained. R6 was sent to the hospital for evaluation. This report does not document what intervention was implemented for R7. See R7's information above. R6's POS dated August 2021 includes a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R6's MDS dated [DATE] documents R6 as moderately cognitively impaired. R6's Baseline Plan of Care (current) does not document R6's aggressive behaviors as documented in the Incident of 7/22/21. R6 has no Behaviors Tracking Forms for physical aggression. On 8/3/21 at 9:45 am residents were congregated in the front lobby of the facility. Verbal bickering was heard between several residents. Residents in rooms were screaming through out the survey on 8/3, 8/4, 8/5 and 8/6/21. On 8/5/21 at 10:00 am V1, Administrator stated the facility was aware that Care Plans and Behavior Tracking documentation was not up to date and they were working to get them updated. V1 also stated that Dementia training had been done only once since May 2021. An Immediate Jeopardy was identified on 8/11/21. The Immediate Jeopardy began on 6/5/21, when R9 and R10, two of twelve cognitively impaired residents, are first documented to have engaged in repetitive physical abuse to one another. On 8/11/21 at 9:47 am, V1 was notified of the Immediate Jeopardy. The surveyor confirmed through interviews, observations, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) In-servicing all staff in the facility on the Abuse Policy, along with Anger and Aggression in the facility's Dementia population. Completed by Administrator and Regional Clinical Director 8/12/21. 2.) The Interdisciplinary Team (IDT) has identified 20 residents within the facility that are at risk for abuse and aggressive behaviors to ensure person centered interventions are in place through their Care Plans and Behavior Tracking. This includes the residents that were identified in resident to resident physical abuse allegations, ensuring that targeted behaviors have the appropriate person centered interventions. Completed by Administrator, Social Service Director, Assistant Director of Nursing, Care Plan Coordinator 8/12/21. 3.) New interventions have and will continue to be communicated to staff in the facility by the Social Service Director through a Communication Book. Completed by the Social Service Director 8/12/21. 4.) All residents with aggressive behaviors or have potential for aggressive behaviors will be reviewed by the Behavior Quality Assurance meeting. Root Cause Analysis will be completed to determine potential triggers. Ongoing weekly. Completed by Administrator, Social Service Director, Assistant Director of Nursing and Care Plan Coordinator 8/12/21. 5.) Activities being performed at various times, including evenings, for different cognition levels to prevent detrimental behaviors. Completed by Activities Director 8/12/21.

Based on record review and interview, the facility failed to prevent ongoing, repetitious physical abuse between residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12. This failure puts these residents at high risk for severe, life-threatening, and potentially fatal injuries. R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12 are 12 of 12 residents reviewed for abuse in the sample of 12. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/12/21, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of their revised Behavior Tracking and Monitoring Program and the effectiveness of their employee in-services on their Abuse Prevention Policy and caring for their residents with Dementia and Behavioral Disturbances. Findings include: 1.) A facility Incident Report dated 6/5/21 documents the altercation between two residents R9 and R10 as follows: V10, Certified Nursing Assistant witnessed R10 yell at R9 because R9 was standing next to R10. R9 then hit R10 with an open hand on R10's back. The incident occurred in the front lobby of the facility. This same report documents the above physical abuse as substantiated. On 8/4/21 at 11:05 am, V10 confirmed that V10 had witnessed R9 hit R10 and V10 reported the abuse to Administration. 2.) A facility Incident Report dated 6/8/21 documents an altercation between the above same residents (R9 and R10) as follows: V14, Speech Therapist witnessed R9 walk up behind R10 and push R10's wheelchair. R10 asked R9 to stop pushing R10's wheelchair. R9 then hit R10 in the back twice with R9's fist. This incident occurred in the front lobby of the facility. This same report documents the above physical abuse as substantiated. On 6/8/21, V14 wrote a statement documenting that V14 had witnessed R9 hit R10 in the back with R9's fist twice. V14 was not available for interview. 3.) A facility Incident Report dated 7/15/21 documents V3, Social Service Director witnessing R9 picking something up off a table in the dining hall. R12 then yelled at R9 and R9 became agitated and pinched R12 on the right forearm. This same report documents the above physical abuse as substantiated. On 8/4/21 at 1:30 pm, V3 confirmed that V3 had witnessed R9 pinch R12 after R12 had yelled at R9 and had reported the abuse to Administration. 4.) A facility Incident Report dated 6/27/21 documents an unwitnessed altercation between R1 and R8. V15 Housekeeper found R1 on the floor of R8's room and reported it to V2 Assistant Director of Nursing. V2 responded and upon entrance to R8's room R1 was on the floor and R8 told V2 that R8 had pushed R1 down. Assessment of R1 showed some redness to R1's left upper back. This same report documents the above physical abuse as substantiated. On 8/4/21 at 3:00 pm V2 confirmed the above incident and stated R8 told V2 that R8 pushed R1 to the floor because R8 thought R1 was going to hurt R8. V2 Confirmed that R1 wanders but does not have any physical aggression. 5.) A facility Incident Report dated 7/8/21 documents V16 Certified Nursing Assistant witnessing R1 attempting to pick up a cookie from another resident's (unknown) place and R2 reached across the table in the dining room and hit R1 on the arm, leaving a slight redness on the left forearm of R1. This same report documents the above physical abuse as substantiated. On 7/8/21 V16 wrote a statement confirming and describing the above physical abuse that V16 had witnessed. V16 was not available for interview. 6.) A facility Incident Report dated 7/5/21 documents V17 Licensed Practical Nurse witnessing R4 propelling down the hallway in R4's wheelchair and encountered R5 and reached out and smacked R5 on the arm. Before V17 could reach R4, R4 proceeded down the hall and encountered R1 wandering in the hall and smacked R1. R4 was placed on 15 minute checks. This same report documents the above physical abuse as substantiated. On 7/5/21 V17 confirmed and documented the above abuse on a signed statement, stating that V17 had witnessed R4 slapping R5 and R1. V17 was not available for interview. 7.) A facility incident Report dated 7/17/21 documents V12 Certified Nursing Assistant reporting that R1 was in R3's room in R3's bed. R1 got out of the bed and was heading out of R3's room when R3 shoved R1 to the floor. V12 also stated V12 saw R3 use R3's feet to push R1 along the floor, trying to get R1 out of R3's room. R1 had slight redness to left hip and back. R1 was put on one to one supervision. This same report documents the above physical abuse as substantiated. On 7/17/21 V12 wrote a statement confirming that V12 had witnessed the above abuse between R3 and R1. V12 was not available for interview. 8.) A facility Incident Report dated 7/1/21 documents witnessed abuse between R7 and R11. V18 Dietary Aide stated V18 heard R11 yell and went into the room and witnessed R7 kick R11 in the left foot. R11 stated that R7 had also kicked R11 in the knee. There were no injuries. 15 minute checks continued and for R7 and R7 was moved off the hall per the above report. This same report documents the above physical abuse as substantiated. On 7/1/21 V18 wrote a statement confirming that V18 had heard R11 yell out and went to find out what was going on and witnessed R7 kick R11 in the left foot. V18 also stated R11 reported R7 kicking R7 in the knee. V18 was not available for interview. 9.) A facility Incident Report dated 7/22/21 documents V19 Certified Nursing Assistant was walking down the hall and saw R7 grab R6 and push R6 up to the wall. R6 grabbed a wet floor sign and swung it at R7, hitting R7 on the left body side. No injuries were sustained. R6 was sent to the hospital for evaluation. This report does not document what intervention was implemented for R7. This same report documents the above physical abuse as substantiated. On 8/5/21 at 10:30 am, V19 stated that V19 witnessed R7 grab R6 by the arms and push R6 up against the wall. V19 stated there was a wet floor sign in the hall and R6 picked it up and hit R7 in the side with it. V19 stated I reported the abuse to administration right away. On 8/4/21 at 3:30 pm V1 Administrator and V2 Assistant Director of Nursing, both confirmed knowledge of R1's wandering into other resident's rooms in the facility prior to 6/27/21. On 8/5/21 at 1:30 pm, V1 and V13, Regional Nurse both stated it was difficult to provide one on one supervision for any of the residents. V13 stated It's sparing the staff to do the one on one supervision that makes it too difficult. An Immediate Jeopardy was identified on 8/11/21. The Immediate Jeopardy began on 6/5/21, when R9 and R10, two of twelve cognitively impaired residents, are first documented to have engaged in repetitive physical abuse to one another. On 8/11/21 at 9:47 am, V1 was notified of the Immediate Jeopardy. The surveyor confirmed through interviews, observations, and record review the facility took the following actions to remove the immediate jeopardy: 1.) In-servicing all staff in the facility on the Abuse Policy, along with Anger and Aggression in the facility's Dementia population. Completed by Administrator and Regional Clinical Director 8/12/21. 2.) The Interdisciplinary Team (IDT) has identified 20 residents within the facility that are at risk for abuse and aggressive behaviors to ensure person centered interventions are in place through their Care Plans and Behavior Tracking. This includes the residents that were identified in resident to resident physical abuse allegations, ensuring that targeted behaviors have the appropriate person centered interventions. Completed by Administrator, Social Service Director, Assistant Director of Nursing, Care Plan Coordinator 8/12/21. 3.) New interventions have and will continue to be communicated to staff in the facility by the Social Service Director through a Communication Book. Completed by the Social Service Director 8/12/21. 4.) All residents with aggressive behaviors or those with potential for aggressive behaviors will be reviewed by the Behavior Quality Assurance meeting. Root Cause Analysis will be completed to determine potential triggers. Ongoing weekly. Completed by Administrator, Social Service Director, Assistant Director of Nursing and Care Plan Coordinator 8/12/21. 5.) Activities being performed at various times, including evenings, for different cognition levels to prevent detrimental behaviors. Completed by Activities Director 8/12/21.

Based on interview and record review the facility failed to hold a medication used for behaviors when lethargy was present, failed to transcribe a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure affects one of one residents (R15) reviewed for death on the sample list of 27. This failure resulted in R15 having a significant weight loss and the development of three stage 3 facility acquired pressure ulcers due to continued untreated lethargy. Finding include: R15's Admission assessment dated [DATE] at 8:50 AM written by V8 Registered Nurse documents R15 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's Nurse's Note dated [DATE] at 8:50 AM written by V8 documents R15 ambulates independently with verbal cues, wanders facility and needs redirection. This note documents R15 appears well nourished. R15's 3 Day Weights sheet documents R15 weighed 195 pounds on [DATE]. R15's Fall Risk assessment dated [DATE] documents R15 does not have gait or balance problems and has not had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] R15's Pressure Ulcer Risk assessment dated [DATE] documents R15 is at moderate risk for the development of pressure ulcers. This assessment documents that R15 does not have pressure ulcers and has not had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's Nursing Note dated [DATE] at 9:20 AM, documents R15 was sent to the hospital for a psychiatric evaluation due to physical aggression. R15's Social Service note dated [DATE] at 1:25 PM documents R15 was readmitted to the facility. This note documents, (R15) arrived via stretcher. (R15) lethargic and responds to name by moving head towards speaker. Requiring (extensive) assist of 2 for all transfers. Totally dependent on staff for all ADLs (Activity of Daily Living) including meals. R15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:40 PM, V18 Licensed Practical Nurse stated when R15 was admitted ([DATE]), R15 was aggressive and would walk around. R15 was cognitively impaired. R15 could walk when R15 was first admitted but towards the end of R15's stay R15 could not walk at all. R15 was more lethargic towards the end of R15's stay and wouldn't eat much. After R15 was sent to the hospital and came back ([DATE]) R15 was more lethargic and couldn't do as much. R15's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This note documents an order to check [MEDICATION(S)] ([MEDICATION(S)]) level, stop [MEDICATION(S)] and hold [MEDICATION(S)] ([MEDICATION(S)]) if sleepy. R15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's ADL flowsheet for March of 2021 documents R15 did not walk and required extensive assistance to total dependence of one to two staff for transfers, total dependence with bed mobility, dressing, eating, and toileting. R15's Physical Therapist Progress and Discharge Summary dated [DATE] documents under outcome that, (R15) was unable to make progress in therapy due to multiple underlying conditions. (R15) presently requires total assist for all mobility tasks due to cognitive deficits. This Summary also documents, (R15) requires total assist and wheelchair for mobility. This note documents start of therapy as [DATE] and end of therapy as [DATE]. R15's Occupational Therapy (OT) Plan of Care dated [DATE] documents, (R15) was referred to skilled OT after recent psych (psychiatric) hospitalization stay after choking a CNA (Certified Nursing Assistant) and resulting in sacral wound, weakness, balance, and endurance deficits, and three recent falls out of bed. R15's Occupational Therapist Progress and Discharge Summary dated [DATE] documents under outcome that, (R15) discharging due to max potential achieved and plateau in progress due to various fatigue levels, alertness, command following, and aggression. (R15) will remain at this SNF (skilled nursing facility) with assist in all aspects of self care, transfers, positioning and use of high back reclining wheelchair for positioning. This note documents start of therapy as [DATE] and end of therapy as [DATE]. R15's Monthly weight and vital sheets documents R15 weighed 188 pounds in [DATE].8 pounds in February of 2021, and 159.2 pounds in March of 2021. R15's Dietary notes dated [DATE] documents R15's weight as 159.2 pounds and documents R15 is underweight and has had a significant weight loss of 8.4 % in thirty days. R15's wound evaluation and management summary written by V22 wound physician dated [DATE] documents an unstageable deep tissue injury of the coccyx caused from pressure measuring 3 centimeters by 4 centimeters and a stage two pressure wound of the right buttock caused from pressure measuring 1.2 centimeters by 1 centimeter. R15's wound evaluation and management summary dated [DATE] documents R15 as having a stage 3 pressure ulcers to the sacrum measuring 2 by 1.5 centimeters by not measurable, stage 3 pressure ulcer to the right buttock measuring 2 by 1.5 by 0.1 centimeters and stage 3 pressure wound of the left buttock measuring 1 by 0.8 by not measurable. This summary documents a recommendation for a gel cushion to the chair. On [DATE] at 2:00 PM, V26 Certified Nursing Assistant stated R15 could walk unassisted, feed self, and turn self in bed. V26 stated when R15 returned from the hospital ([DATE]) R15 was chair and bed bound. V26 stated R15 could no longer turn self in the bed. V26 stated when R15 would try to feed self R15 would miss R15's mouth. V26 stated R15 had to be fed but wouldn't eat much because R15 was too sleepy. V26 stated R15 slept a lot. On [DATE] at 3:00 PM, V6 Care Plan Coordinator stated R15 was admitted to the facility on [DATE]. R15 was ambulatory and had behaviors. R15 was not easily redirected. R15 began to be physically abusive to the staff so R15 was sent to a geriatric psychiatric facility for an evaluation. R15 returned to the facility on [DATE]. R15 was more lethargic when R15 returned. R15 stated a couple days later they had a [CONDITION(S)] meeting due to R15 being so lethargic from R15's medication. After that the physician was called and the nurse practitioner (V24) came in to see R15 on [DATE]. V24 gave orders for labs and an order to hold the [MEDICATION(S)] if lethargic. V6 stated R15 remained lethargic. V6 stated R15 could not feed self and would not eat. V6 stated R15 wouldn't stay awake to eat. V6 stated R15 had a significant weight loss. V6 stated could not ambulate. V6 stated R15 ended up getting pressure ulcers due to R15's not getting up out of the chair and not eating. V6 stated the facility did not call to report that R15 continued to remain lethargic after R15 was initially seen on [DATE]. V6 stated the order to hold the [MEDICATION(S)] if sleepy wasn't carried over onto the March and [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 9:20 AM, V24 Nurse Practitioner stated R15 was prescribed [MEDICATION(S)] for behaviors. V24 stated V24 gave the order to hold the [MEDICATION(S)] when R15 was sleepy/lethargic. V24 stated when V24 reviewed the medication list that V24 gave the order to hold the [MEDICATION(S)] because it is known to cause sleepiness. V24 stated R15 was seen by telehealth on [DATE] and was seen on [DATE] but the staff reported no concerns. V24 stated V24 would have expected the facility to hold the [MEDICATION(S)] when R15 was lethargic and would have expected them to call and report that R15 continued to be lethargic. R15's [CONDITION(S)] medication care plan dated [DATE] documents, Observe for antipsychotic side effects: somnolence .Notify (physician) of noted side effects to determine if benefit of therapy outweigh the side effects. The facility's Medication Administration Policy with a revision date of [DATE] documents, 18. Omit giving a medication if the resident has symptoms suggestive of an undesirable reaction to the drug and report your observations to the physician as soon as practicable. (B)

Based on observation, interview, and record review the facility failed to identify and remove an accident hazard (mechanical lift) for one of four residents (R2) reviewed for falls in a sample list of four residents. This failure resulted in a fall causing R2 to fracture his nose and lacerate his head. Findings include: R2's Physician's Order Sheet (POS) for [DATE] includes the following diagnoses: [CONDITION(S)], Hyperactive [CONDITION(S)], Subdural Hematoma, and [CONDITION(S)]. On [DATE] at 10:00AM V7, Business Office Manager stated (R2) expired [DATE] according to our records. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely cognitively impaired, suffered from [CONDITION(S)] and delusions, and exhibited behaviors directed toward others. This MDS also documents R2 exhibited wandering behaviors which put him at significant risk of getting to a dangerous place. R2's Fall Risk Assessment from [DATE] and [DATE] documents R2 is at high risk for falls. There are no more recent fall risk assessments documented. R2's Care Plan initiated [DATE] includes the basic preprinted interventions for falls which the facility uses on all residents at risk for falls but no individualized resident centered interventions taking into consideration R2's history of multiple falls and individual behaviors. The last update is dated [DATE] to remove all unoccupied wheelchairs from lobby. R2's Care Plan includes an intervention dated [DATE] Encourage and assist placement of proper nonskid footwear. R2's progress notes include documentation of falls [DATE], [DATE], [DATE], [DATE], and [DATE]. There are no documented injuries resulting from these falls. These falls are documented as investigated by the facility, but no new resident centered specific interventions were documented at the time of these falls. R2's therapy Recommendations to caregivers dated [DATE] documents (R2) requires supervision during ambulation for safety. (R2) to use walker when ambulating. Use of a walker is not on R2's Care Plan. R2's Final Report to state agency dated [DATE] documents (R2) sustained a fall [DATE]. (R2) was sent to hospital who reported (R2) sustained a fractured nose. This report also documents R2 was not wearing any shoes or socks at the time of the fall. This report also states, it did appear the laceration on the top of (R2's) head was from his attempt to push himself off the floor near the (mechanical) lift (R2) fell beside. R2's medical record obtained from the hospital for the [DATE] fall documents (R2) did sustain a displaced nasal fracture and a head laceration from the fall at the facility. R2's Physician's note from [DATE] emergency room visit documents (R2) fell forward striking his face and head. R2's Computerized Tomography scan dated [DATE] documents Impression: Displaced fracture of nasal alar and anterior portion of nasal septum. On [DATE] at 2:30PM V4, Certified Nurse's Aide (CNA) stated I was here when (R2) fell and broke his nose. We saw him almost running down the hall. I saw him fall and hit his face and head on the (mechanical) lift parked at the end of the hall. We keep the lift parked down there when we aren't using it. There was a lot of bleeding. (V3) got there shortly after I did and we sent him to the hospital. (R2) was always forgetting to use his walker. He forgot it when he was running down the hall right before his fall. On [DATE] at 12:30PM V3, Care Plan Coordinator stated I was working the floor the day (R2) fell . I remember it clearly. (R2) seemed anxious. He was walking very fast down the hall. By the time I got around the nurse's desk (R2) was laying on the floor at the end of the hall by the (mechanical) lift. He was bleeding. He had a laceration on his head and was bleeding from his nose. I called the ambulance and (R2) was sent to the hospital. We later found out he had broken his nose, but didn't need sutures for the head wound. On [DATE] from 10:00AM until 4:00PM the (mechanical) lift was observed to be parked at the end of the hall where staff indicated R2 had fallen on [DATE]. The lift was parked in front of the handrail impeding use of the hand rail in an area approximately four feet long by three feet wide (the approximate size of the lift). Residents were observed ambulating and wheeling in wheelchair around the lift. On [DATE] at 1:30PM V8, Registered Nurse (RN) stated We park the (mechanical) lift at the end of the hall except at night when we charge it in the break room. There really isn't any place else to put it. We have limited space. On [DATE] V1, Administrator stated We don't have a specific policy for storage of (mechanical) lifts. The facility's policy Fall Prevention Program (not dated) states 4. Assignment of the final (fall) risk category will be determined by the Interdisciplinary Team (IDT) at their conferences based on a. Fall Risk Score b. history of Falls c. Medical condition which directly impacts on equilibrium and/or ambulation. d. Discussion of individual circumstances.

Based on observation, interview and record review, the facility failed to thoroughly investigate, identify and implement interventions to prevent recurrent falls for two of four residents ( R16, R2) reviewed with falls, on the sample of 12. These failures resulted in R16 repeatedly sliding out of the wheelchair and sustaining a Facial Laceration requiring five sutures and a Closed Head Injury. Findings: 1. The Minimum Data Set ((MDS) dated [DATE] documents that R16 requires extensive assist with transfers and toilet use. R16 is assessed to be high risk for falls on 6/16/16 and 7/19/16. The undated Care Plan documents that R16 has risks for falls, but does not document any falls for R16. The interventions dated 2/23/16 are as follows: Remind of safety precautions and limitations as necessary; 15 minute checks for safety and positioning, and attempt to anticipate needs-toileting, hunger, hydration and provide cares. The care plan does not document any interventions for R16's two falls on 6/28/16 or the fall on 6/29/16. On 8/17/16 E3, DON (Director of Nursing) confirmed the interventions for R16's falls were not documented on the care plan. The SBAR (Situation Background Assessment Request) dated 6/28/16 documents that R16 was found on the floor in his room at 11:00 am and had no injury noted. The SBAR does not document any mental status or functional changes. The SBAR documents that R16 fell out of w/c (wheelchair) while reaching for CD's (compact disc) . The SBAR documents that parking (R16} in room unattended makes the situation (fall) worse. The Occupational Therapy (OT) Daily Treatment Note dated 6/28/16 documents .(R16) experienced fall out of WC (wheelchair) late this morning, .found on floor within room believed to have slid out of chair .Nursing and administration are aware of (R16's) fall (R16) stated he was reaching for cd case, which was located behind him in cabinet. COTA (Z2, Certified Occupational Therapy Assistant) assesses (R16)current WC seat and seating dystem (system), and provides recommendation to administration. (R16) has need for wedge cushion and anti-slip pad to prevent slipping from WC seat and reduce risk of falls. Home has ordered items recommended by therapy staff and are awaiting approval. COTA adjusts (R16's) leg rests to ensure optimal fit for LE (lower extremity. On 8/18/16 at 11:15 am Z1 Occupational Therapist stated that R16 was seen after the fall which occurred on 6/28/16 at 11:00. Z1 stated a wedge cushion for the wheelchair and anti-slip pad was recommended to be used for R16 as they were trying to alter R16's sitting position. Z1 stated they didn't have any anti-slip pads available and its not an item that is available for use without approval. Z1 stated she remembered that R16 was declining, very confused, weak and reaching for anything, which was related to his falls. Z1 stated prior to R16's 11:00 am fall on 6/28/16, R16 was up for shorter periods so he wouldn't be tired and sliding. When asked on 8/17/16 at 3:25pm, about the investigation of the fall, E3, DON (Director of Nursing) stated the root cause of the fall was R16 reaching for CD, so they got him a grabber/reacher so he could reach for things. E3 stated she didn't recall anything about a wedge cushion or an anti-slip pad. Documentation of the facility fall investigation was not provided and perusal of the investigation was not allowed by E3. The SBAR dated 6/28/16 documents another fall for R16. The SBAR does not document the time the actual fall occurred. On 8/18/16 at 11:15 am E3 confirmed R16's second fall on 6/28/16 occurred at 7:05pm. The SBAR documents that R16 wheeled his wheelchair down the hall toward his room and stated he slid out of the wheelchair. The laceration measuring 4 cm (centimeters) was on the right forehead/upper eyebrow area. The SBAR does not document any mental status changes, but documents that R16 needs more assistance with ADL's (activities of daily living) due to a fall on 6/28/16 at 11:00 am. R16 was transported to the hospital at 7:50pm. On 8/18/16 at 11:15 am E3, DON stated she didn't know if anything was implemented to prevent sliding between the two falls. E3 stated the only intervention she saw in the investigation for the fall at 11:00 am on 6/28/16 was the grabber for R16. E3 stated she's not sure if Occupational Therapy was involved with R16, as there's nothing documented in the investigation about their involvement. On 8/18/16 at 11:15 am Z1 stated nothing was implemented to prevent sliding for R16 on 6/28/16. Z1 stated tilting the wheelchair back was implemented on 6/30/16, but not on 6/28/16. R16's Emergency Department Provider Documentation dated 6/28/16 by Z4, Emergency Physician documents: stated complaint - Fall/HeadLac, Activities at onset - fell out of wheelchair History - fell twice today. R16 had a laceration of the head, right brow requiring five sutures and a Closed Head Injury. The Nurse's Notes dated 6/29/16 at 2:00 am document R16 was sitting in front of his wheelchair on the ground in the facility parking lot. The note documents the mechanical lift sling remained in the wheelchair, but was tangled (the straps) around R16's legs. The SBAR dated 6/29/16 documents R16 was being transferred from the facility wheelchair van and slid forward out of the wheelchair to the ground. On 8/18/16 at 11:40 am E10 Resident Assistant (RA), Transportation Aide stated on 6/29/16, he first went to the facility and got R16's wheelchair and then went to the hospital to get R16. E10 stated he transported R16 in the facility van from the hospital back to the facility. E10 stated he got R16 out of the van, but then while he was putting the lift back up, R16 started sliding out of the wheelchair. R16 stated he didn't think there were any leg rests on R16's wheelchair when he slid out of it. On 8/17/16 at 3:25pm E3, DON stated the investigation documented R16 was leaning forward and slid out of the wheelchair. E3 stated the wheelchair was on the ground when R16 slid out of it. E3 stated it was the same wheelchair that R16 had used earlier in the day. E3 stated the intervention for the fall was a therapy re-evaluation. On 8/18/16 at 11:15 am E3, DON stated that E10 went to the hospital and transported R16 back to the facility in the wheelchair van. E3 stated she didn't know if the leg rests/foot pedals were in place on the wheelchair at the time of the fall. On 8/18/16 at 11:15 am Z1, Occupational Therapist stated ON 6/20/16 they changed R16's leg rests on his wheelchair to improve positioning. Z1 stated it was ok for the wheelchair legrest to be off if R16 was propelling his wheelchair. When asked if R16's wheelchair leg rest should have been on the wheelchair during R16's transport back from the hospital on [DATE], Z1 stated I would think (it) would have leg rests. 2. R2's Physicians Orders dated 8/2016 document R2's [DIAGNOSES REDACTED]. R2 has falls documented on the facility's fall log ranging from 10/10/15 through 7/22/2016 (10/10/15, 10/15/15, 3/27/16, 5/21/16, 5/21/16, 7/22/16). On 10/10/15 R2's fall resulted in an intervention of a pressure pad alarm being applied to R2's bed. R2's Fall Risk Assessments dated 8/17/15, 11/3/15, 1/18/16, and 7/5/16 all document R2 as a high fall risk. On 8/15/16 at 10:30 AM, 1:10 PM, and 3:10 PM, no pressure pad alarm was on R2's bed while R2 was in bed. Also on 8/17/16 at 1:20 PM, there was no pressure pad alarm on R2's bed while R2 was in bed. On 8/18/16 at 10:45 AM, E13, Certified Nurse Assistant (CNA) stated there is no pressure pad alarm on R2's bed. On 8/18/16 at 10:50 AM E3, DON stated there is no pressure pad alarm on R2's bed and there should be one when R2 is in bed. R2 was in bed at this time. On 8/18/16 at 9:05 AM, E3, DON stated the intervention for R2's fall from 10/10/15 was a pressure pad alarm on R2's bed. R2's Care Plan dated 11/15/15 does not document a pressure pad alarm as an intervention after R2's 10/10/15 fall. On 8/18/16 at 9:05 AM E3 DON stated with every fall the interventions should be put on the Care Plan with the date of the fall. Falls and interventions on 3/27/16 and 5/21/16 are not documented on R2's Care plan. The facility's Fall Prevention Policy dated 2015 document any new (fall) interventions will be written on the (resident's) Care Plan.

A. Based on interview, record review and observation the facility failed to ensure that one of six residents (R11) reviewed for falls in the sample of eleven was transferred safely with the use of a mechanical lift. Staff failed to provide stabilizing support to R11's torso during transfer, resulting in R11 falling from the lift. R11 sustained multiple rib fractures on the left side, which caused flailing of the chest and thus caused R11's death. This resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE] the facility remained out of compliance at a severity Level 2. The facility is in the process of monitoring the effectiveness of newly implemented transfer safety interventions and staff re-education measures. Findings include: R11's [DATE] physician's orders [REDACTED]. R11's Annual Minimum (MDS) data set [DATE] documented that R11 required assist of 2 with transfers with a mechanical Lift. R11 required total assist for all Activities of Daily Living. R11's admission nursing assessment dated [DATE] documents R11 is paralyzed on the left side. The Incident Log record showed on [DATE] an incident investigation was initiated regarding a fall from a mechanical lift that happened to R11 at 5:20pm that day. E2, Director of Nursing said on [DATE] at 2:00pm that E16, Certified Nurse Aide and Z3, Agency Certified Nurse Aide, were transferring R11 from her bed to the wheel chair. E2 stated R11's bed was approached with the mechanical lift from the wall side of the bed, instead of the opposite side where more space was available to maneuver the lift. According to E16 and as demonstrated by E2 the wheelchair had been put at the end of the bed so that R11 was being moved in the lift sling from the bed backwards toward the room door. Z3 was at the opposite side of the bed so the only bodily control that Z3 had was R11's legs. R11 began to slide out of the sling on the left side and fell to the floor hitting her left side on the metal leg of the lift and floor. On [DATE] at 10:45am, E2, Director of Nursing, said that R11 was immediately sent to the emergency room for evaluation and R11 returned the next day. The "Disposition from the emergency room ", dated [DATE], states, "Patient presented to the ER (emergency room ) with trauma to the left chest multiple fractures, flail chest and 70% pneumothorax, right kidney hydro[DIAGNOSES REDACTED] and obstruction secondary to a calculi". The emergency room report also said, no treatment was done per family's request. R11's family requested for R11 to go back to the nursing home for comfort measures and the emergency room Physician documented, "Prognosis poor." E16, Certified Nurse Aide said on [DATE] at 11:15am that she was in control of the mechanical lift and the reason that they did not do the transfer on the other side of the bed was because the roommate gets very upset when you get in her space. E16 said that as soon as she cleared the bed with R11 suspended in the mechanical lift sling, R11 started to slide out of the sling and Z3 was not in position to control R11's body. Failure of staff to ensure the adequate amount of space for the transfer and not having control of R11's during the transfer resulted in R11 slipping through the sling on the left side going to the floor. R11 hit her ribs on the metal base leg to the mechanical lift and the floor, causing several rib fractures and the left side which caused a flailing chest. R11 subsequently died as a result of the injuries. Z1, Physician, stated on [DATE] at 2:25pm that, "Yes the fall and fracturing the ribs ultimately was the cause of (R11's) death. She was fragile." On [DATE] at 1:15pm, an Immediate Jeopardy was identified at which time E1, Administrator was notified. The Immediate Jeopardy was determined to have begun on [DATE] when facility staff failed to ensure there was enough space to allow staff to have full access to R11's body while in the transfer sling, to prevent R11 from sliding out of the lift sling. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. R11 was sent to the emergency room immediately for medical evaluation on [DATE] and returned on [DATE]. An investigation was immediately started by the facility. 2. On [DATE] additional measures were taken to prevent re-occurrence, including, residents with left/right sided weakness were re-evaluated and additional care plan intervention were put into place to support residents on their affected side during transfer with the mechanical lift. The Mechanical Lift Policy was revised to ensure it meets the standards according to Manufacturer's Patient Positioning and Sling Application Guide. 3. On [DATE] The Director of Nursing immediately initiated an inservice (re-education) training with all nursing staff on mechanical lift transfers to only be done from the side of the bed, opposite of the wall, to allow for staff to have more space and control of the resident during the transfer. No Nursing staff will be allowed to start work on the floor until they have been retrained on this process. 4. Random audits of Mechanical Lift transfers have been initiated by E2, to ensure that all Nursing Staff have an understanding of the correct way to use the mechanical lift, especially with resident who are compromised on one side. B. Based on record review and interview, the facility failed to safely transfer R1 and R15 with the identified number of staff members required for transfer assistance, resulting in resident falls. R1 is one of six residents reviewed for falls in the sample of eleven. R15 is a supplemental resident. R15 sustained a fracture of the left knee. Findings include: 1. The Admission Sheet shows, R15 was admitted on [DATE], with [DIAGNOSES REDACTED]. R15's Minimum (MDS) data set [DATE] has R15 requiring extensive assist with two for transfers and is nonambulatory. It also documents that R15 uses a wheel chair for mobility and requires total dependance for bathing. The Investigation Report for falls dated [DATE] shows R15 fell to the floor of the shower, landing on her knees. Z2, Agency Certified Nurse Aide documented in her description of the occurrence, documents that she was in the shower room alone with R15 and in the process of transferring R15 from the wheel chair to the shower chair, R15's knees buckled and R15 went down on her knees causing a fracture to her left knee (according to the Xray report of [DATE]). R15's Care Plan dated [DATE] documents under problem falls, states, "Nursing Staff are to use 2 assist and gait belt for all transfers. Use additional assist as needed when Resident is not feeling well, feeling weak or dizzy." 2. A physician's orders [REDACTED]. A Plan of Care, dated [DATE], indicates R1 is at high risk for falling, takes psychotropic medication, has a history of aggression and agitation, and requires "2 assist and a gait belt for all transfers." A Minimum Data Set, dated dated [DATE], documents R1 is an extensive assist of two people for transfers. A Fall Investigation Report, dated [DATE], documents R1 fell while being assisted by one staff member to the toilet. On [DATE] at 9:25 a.m., E7 (Certified Nursing Assistant) stated, the morning of [DATE] she was transferring R1 by herself from the toilet to the wheelchair. E7 stated R1 let go of the grab bar, lost his balance, and he fell into the tub area. On [DATE] at 9:20 a.m., E2 (Director of Nursing) stated R1 required the assistance of two people to transfer, when he fell on [DATE].