Every finding on record at Elevate Care Niles

Based on interview and record review, the facility failed to establish a correct indication and frequency in the use of antipsychotic medication (Seroquel); failed to obtain complete consent for use of antipsychotic medication; and failed to adequately monitor adverse reactions, evaluate effectiveness and relevance of antipsychotic medication on a resident with Alzheimer's disease. This failure resulted in R1 hanging himself with a cellphone cord and required emergent transfer to the hospital.Findings include:R1 is a [AGE] year-old, male, admitted in the facility on 02/14/26 with the following diagnoses: Alzheimer's Disease, Unspecified; Unspecified Dementia, Moderate, with other Behavioral Disturbance; Memory Deficit Following Cerebral Infarction and Restlessness and Agitation.R1's MDS (Minimum Data Set) dated 02/21/216 documented:Sec C: BIMS (Brief Interview for Mental Status) score of 5, which means severe cognitive impairment.Sec D:A. Little interest or pleasure in doing things, 7-11 days (half or more of the days)B. Feeling down, depressed, or hopeless, yes, 7-11 days (half or more of the days)C. Trouble falling or staying asleep, or sleeping too much, yes, 2-6 days (several days)D. Feeling tired or having little energy, yes, 2-6 days (several days)F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down, yes, 2-6 days (several days)G. Trouble concentrating on things, such as reading the newspaper or watching television, yes, 7-11 days (half or more of the days)Physician visit Summary dated 01/09/26 documented that R1 was prescribed to take Quetiapine (Seroquel) 50 mg (milligrams) tablet by mouth nightly as needed (sleep) for up to 60 days. R1 was assessed to have Insomnia, unspecified type. V23 (Physician) also attached a doctor's note that R1 needs nursing home or facility for 24-hour care and did not exhibit aggressive behavior or show signs of aggression.Progress notes dated 02/14/26 documented R1 was admitted in the facility.On 04/15/26 at 9:45 AM V3 (Assistant Director of Nursing) was asked regarding medication orders upon admission. V3 stated, He takes Seroquel, Hydroxyzine, Memantine and Melatonin upon admission. V3 showed surveyor the Quetiapine bottle that R1 presented during admission. The prescription reads: Quetiapine Fumarate 50mg 1 tablet as needed for insomnia at bedtime.In R1's POS (Physician Order Sheet) dated 02/14/26, it was entered as Quetiapine Fumarate oral tablet 50 mg give 1 tablet by mouth at bedtime for dementia.R1's consent for Quetiapine (Seroquel) dated 02/14/26 did not indicate date the consent was given and there was no name of authorized person giving consent.Progress notes dated 02/17/26 authored by V20 (Attending Physician) and psychiatry progress notes dated 02/20/26 written by V19 (Nurse Practitioner, Psychiatry) recorded: Quetiapine 50mg every hours of sleep (bedtime). V19 indicated Quetiapine for dementia related agitation.On 04/14/26 at 12:03 PM, V19 (Nurse Practitioner, Psychiatry) was interviewed regarding R1. V19 stated, He does have a diagnosis of Alzheimer's disease, high-functioning, ambulatory, able to feed self. Able to engage, very pleasant guy. He had some underlying anxiety-dementia related. He had a diagnosis of neurocognitive disorder related to Alzheimer's, Dementia. Initially he came from home. He was on Memantine, on Seroquel 50 mg at night and he had PRN (when needed) Hydroxyzine and was discharged from hospital with these medications. I had the initial evaluation on 02/20/26 and at the time he was only taking Seroquel and Hydroxyzine PRN, as well as Melatonin. I just continued the medications. I did another evaluation a few weeks after and he was having increased anxiety per staff, Buspirone was added. Seroquel was prescribed, I believe during hospitalization, it was prescribed because of a sundowning episode and dementia related.On 04/14/26 at 1:27 PM, V20 (Attending Physician) was also asked regarding R1. V20 replied, He had dementia, he had cognitive impairment. I didn't do any memory assessments formally. He was on Memantine. I didn't see any unusual behavior when I saw him. There were no reports, not that I noticed too when I was visiting. Seroquel is for mood control, not for dementia but for agitation. He'd been taking it before admission, we continued it.R1's Physician visit summary dated 03/07/26 documented: Quetiapine (Seroquel) 50 mg tablet take 1 tablet by mouth nightly as needed (sleep) for up to 60 days. Indication: Insomnia, unspecified type.There was no clarity regarding indication and frequency related to R1's order for Quetiapine (Seroquel).On 04/13/26 at 2:03 PM, V15 (Licensed Practical Nurse, LPN) was asked regarding R1. V15 stated he was confused all the time and wandered from room to room. V15 added, He just walked around the unit. Polite, kind, quiet and loved to walk around. R1 was confused, alert, oriented to self. He was able to walk, pour himself water, and do most of his daily activities independently.On 04/13/26 at 2:46 PM, V13 Certified Nurse Aide, CNA) also verbalized, R1 was friendly. I saw him walking around the hallway. He does everything by himself.On 04/13/26 at 4:20 PM, V18 (LPN) mentioned, R1 was very confused. I checked on him when I would go into his room, when I saw him wandering, I redirected him. Normally, he wanders along the hallway, asking where his room was, redirection is provided.R1's progress notes dated 03/11/26 documented that he was reported going into another resident's room a few times during the night. Progress notes dated 03/11/26, time stamped 9:16 PM also documented he was observed wandering hallway throughout shift entering other residents' rooms. Progress notes dated 03/31/26 also stated his roommate complained about his (R1) wandering around the room during night.Psychiatry progress notes dated 03/12/26 stated that R1's sleep was poor with nighttime wandering and entering other resident's rooms, Buspirone was increased to 7.5 mg BID (twice a day) to address ongoing anxiety; and to continue Quetiapine 50mg at bedtime.Per POS, R1's Buspirone was initially ordered on 03/05/26 at 5 mg twice a day for anxiety.A review of R1's care plans revealed the following:Potential for cognitive problem related to Alzheimer's Dementia, Forgetfulness, Confusion, Poor historian, initiated 02/25/26: Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness.There was no care plan specifically addressing R1's use of antipsychotic medication; ongoing monitoring for adverse effects, and/ or changes in behavior. There was no documentation of ongoing assessment or behavior flowsheets regarding response to antipsychotic medication and its effectiveness. R1's physician progress notes dated 02/17/26 documented:Past medical history: Alzheimer's dementia, moderate to severePlan: continue Quetiapine 50mg QHS (at bedtime); monitor for sedation, EPS (extrapyramidal symptoms), metabolic effects.During interview with V19 on 04/14/26 at 12:03 PM, he mentioned sedation is most common side effect of Seroquel. V19 continued, Seroquel side effects are metabolic, sedation is most common. There is an increased sedation risk, staff has to monitor for safety and behavior. Increased agitation, increased psychosis, delusion, safety and needs close monitoring, frequent rounding while taking this medication. They have to notify me if behavior is worsening. Anything acute could be considered medical condition, labs like urinalysis is needed.V20 verbalized during interview on 04/14/26 at 1:27 PM that for elderly demented people, sedatives are not recommended. V20 continued, We should avoid sedatives, a patient already has cognitive impairment, and it can knock him out for 1-2 hours but it has a longer effect in the brain and can make patients more confused, more agitation and increasing anxiety.On 04/15/26 at 2:08 PM, V22 (Psychiatrist) was asked regarding use of antipsychotic medication such as Seroquel. V22 replied, Seroquel is an antipsychotic medication, for schizophrenia, psychotic spectrum disorder, bipolar disorder. Off label for agitation related dementia, meaning not FDA (food and drug administration) approved, significant data behind this as an effective treatment. If a resident has no agitation, it is the job of clinician if medications could be continued or not. They have to do psychiatric assessments which includes dementia related behavior, anxiety or any psychiatric conditions. Seroquel is sedative.Progress notes dated 04/03/26 documented R1 was found hanging with cellphone cord around his neck, unresponsive still with pulse, skin was noted cyanotic. He was brought down to bed, was assessed and provided with oxygen, paramedics were called, transferred to hospital.Hospital records dated 04/03/26 documented R1 presented with traumatic cardiac arrest, last seen around 10:30 AM, at 11:45 AM was found hung himself with a cable around his neck and cardiac arrest. Ligature marks around the neck, no other traumatic injuries. R1 was intubated in the field.Death Certificate dated 04/13/26 recorded R1 passed away on 04/08/26 due to complications of hanging.On 04/15/26 at 1:37 PM, V2 (Director of Nursing) was asked regarding use of psychoactive medications. V2 verbalized, Care plan should be initiated for psychotropic medications. We need to monitor side effects such as increased confusion, EPS (extrapyramidal symptoms), poor appetite. Nurses monitor for side effects after giving medication, nurses and CNAs (Certified Nurse Aides) monitor for any side effects. They are to report to me if they see any unusual behavior and whole clinical aspect of the resident; proper communication with physician and family if any changes are noted.Facility's policy titled Psychotropic Medication - Gradual Dosage Reduction dated 2-1-18 documented in part but not limited to the following:Purpose:To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions.Guidelines:Informed consent shall be obtained as follows:Psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative.The plan to alternatives to psychotropic medication and/ or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals and approaches as it relates to the use of psychotropic drug use.Monitoring:Staff will monitor residents for side effects, withdrawal symptoms and/ or changes in behavior and report to physician and/ or psychiatrist. Documentation of observed side effects by nursing staff will occur as indicated in the nurses notes and/ or on the EMAR.Facility was requested to present any behavior management policy but nothing was submitted.

Based on observation, interview, and record review the facility failed to ensure that residents (R1 and R2) who need assistance with ADLs (Activities of Daily Living) is given nail care, shaved facial hair and provided incontinence care in a timely manner. This failure affects two (R1 and R2) of three residents reviewed for ADL care program. Findings include:1.On 2/24/26 at 12:53PM V6 (Case Manager) said that V10 (Family member of R1) reported to her every time she visits R1, she always finds R1 soiled with urine and feces. R1 is incontinent of B&B (Bowel and Bladder) and unable to call for assistance due to her cognitive impairment cause by Alzheimer's. V10 also reported poor hygiene due to found feces on hands, face and hair. She reported V10's concerns to V3 (SSD-Social Service Director) but they missed calls and playing phone tag.On 2/24/26 at 9:30AM, Observed R1 lying on low air loss (LAL) mattress. R1 is awake, nonverbal and confused. She is calm and quiet. She does not have bilateral boots. V11 (LPN-Licensed Practical Nurse) said that R1 is nonverbal, confused and needs total care with ADLs and transfers. R1 is fed by CNAs (Certified Nursing Assistant) during meals. R1 does not have behavioral issues or refusal of care. V2 (ADON-Assistant Director of Nursing) and V11 (LPN) checked R1 for incontinence care. Observed disposable brief is soiled with urine. Observed sacral area (sacrococcygeal area) with superficial multiple clustered (4) superficial open wounds/excoriations and redness on entire sacral/buttocks area and dark discoloration extending to inner thigh. Observed bilateral heels with redness, dry with peeling skin and dark scab formation of right heel. V11 (LPN) said that she is not aware of R1's superficial open wound/ skin impairment. She did not receive report from the nurse during endorsement and from her CNA (V12) this morning. V11 LPN called V4 (Wound Care Coordinator). V2 (ADON) said that the CNA should notify the floor nurse or wound care coordinator for any changes in resident skin condition.On 2/24/26 at 9:50AM, V12 (CNA) said that she is the CNA assigned for R1. She has not provided morning care or incontinence care to R1, but she fed her this morning. R1 is confused, calm, quiet and no behavioral issues of refusal of care. V2 (ADON) said that the CNA should physically check resident for incontinence care every 2 hours. R1 was admitted on [DATE] with diagnosis listed in part but not limited to Pneumonia, Elevated WBC, Nondisplaced intertrochanteric fracture or right femur for closed fracture with routine healing, Contusion of right shoulder, Alzheimer's disease, Dementia, Type 2 Diabetes mellitus, Irritant contact dermatitis due to fecal, urinary or dual incontinence. Comprehensive care plan indicated: She has ADL self-care performance deficit. She has bladder and bowel incontinence. She is disoriented to place/time/person. Her memory is impaired. She has problems with decision making, insight, logic, calculation, reasoning, planning, organization, sequencing, social skills and or judgement. She has alteration in ability to communicate related to Spanish speaking.2.On 2/24/26 at 10:04AM, Observed R2's room door closed with posting COVID infection. V2 (ADON) said that R2 is on respiratory isolation for COVID. Observed no N95 mask or surgical mask, no face shield nor eye protection, no disinfectant/sanitizer on isolation cart. V2 took supplies from the nursing station. At10:08am Surveyor, V2, and V14 (LPN) entered the isolation room. Observed no isolation waste bin inside the room. Observed R2 lying on LAL mattress with machine on the floor. She was still marked with ashes on her forehead. She said she received ash marking on her forehead last Wednesday (2/18/26). She said that they have not given her a bath or shower since then. She has facial hair and has oxygen via nasal cannula. Her breakfast tray is on the bedside tray table. R2 said that she only ate the sausages. She said that she was not provided morning care, and she is soiled. Observed bilateral nails long with black matter inside. R2 said that her nails need to be trimmed. She denied refusal of care. V2 said that the CNA is responsible for providing nail care and shaving facial hair. V2 said that the CNA has to physically check for incontinence care every 2 hours. V15 (CNA) said that she is not the CNA assigned to R2 but was requested to help them with incontinence care. She said she does not know who the assigned CNA for R2 is. V14 (LPN) and V15 (CNA) repositioned R2 to her right side. Observed R2 soiled with urine, the disposable brief and bed linen were soaked with urine. V14 and V15 provided incontinence care. On 2/24/26 at 1:16PM, Informed V11 (LPN) that V15 (CNA) said that she is not the assigned CNA for R2. No one provided morning care nor checked for incontinence care to R2 this morning not until the surveyor came. V11 said that she did the residents assignment, and that V15 (CNA) is the assigned CNA for R2. She said she will talk to V15.On 2/24/26 at 1:48PM, Informed both V1 (Administrator) and V2 (ADON) of above concerns. V2 (ADON) said that they don't have policy on nail care and facial care shaving for female residents. Both cares are incorporated in ADLs care. On 2/25/26 at 11:17AM, V19 (CNA) said that she is the regular CNA for R2 on 7-3 shift. She said that she always provided incontinence care after breakfast. She always starts her rounds for all her assigned residents after breakfast around 9am because she has to pass breakfast trays first. She does not check for incontinence first. She said that she did not provide morning care or a bed bath to R2, she just provides incontinence care and changes her gown and bed sheets.R2 was admitted on [DATE] with diagnosis listed in part but not limited to Cerebral palsy, COVID 19, Chronic obstructive pulmonary disease, Arthritis multiple sites, Idiopathic peripheral autonomic neuropathy. Comprehensive care plan indicated: She has ADL self-care performance deficit. She has bowel and bladder incontinence. R2's progress notes dated 2/19/26 to 2/23/26 indicated no refusal of care.Facility's policy on Incontinence care revision 1/16/18 indicated: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode.Facility's policy on Activity of daily Living indicated: Grooming: Maintaining personal hygiene, including planning the task and gathering supplies combing and or styling hair, face and hands, brushing teeth, shaving or applying make-up, oral hygiene, self-manicure (safety awareness with nail care) and or application of deodorant or powder.Facility unable to provide policy on Nail care and facial shaving.Facility's policy on complete bed bath revised 1/31/18 indicated: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Procedure: wet wash cloth and apply soap, if requested. Wash, rinse and pat dry face, neck, ears and behind ears.

Based on observation, interview, and record review the facility failed to implement wound/skin care interventions to prevent deteriorating of MASD (Moisture Associated Skin Disorder), to resident (R1) who is at high risk for skin impairment. This failure affects one (R1) of three residents reviewed for Pressure Ulcer/Wound Care Management. Findings include:On 2/24/26 at 12:53PM V6 (Case Manager) said that V10 (Family member of R1) reported to her every time she visits R1, she always finds R1 soiled with urine and feces. R1 is incontinent of B&B (Bowel and Bladder) and unable to call for assistance due to her cognitive impairment caused by Alzheimer's. On 2/24/26 at 9:30AM, Observed R1 lying on low air loss (LAL) mattress. R1 is awake, nonverbal and confused. She is calm and quiet. She does not have bilateral boots. V11 (LPN-Licensed Practical Nurse) said that R1 is nonverbal, confused and needs total care with ADLs (Activities of Daily Living) and transfers. R1 is fed by CNAs (Certified Nursing Assistant) during meals. R1 does not have behavioral issues or refusal of care. V2 (ADON-Assistant Director of Nursing) and V11 (LPN) checked R1 for incontinence care. Observed disposable brief is soiled with urine. No sacral dressing. Observed sacral area (sacrococcygeal area) with superficial multiple clustered (4) superficial open wounds/excoriations and redness on entire sacral/buttocks area and dark discoloration extending to inner thigh. No barrier /treatment cream residue observed on sacral area. No bilateral heel dressing. Observed bilateral heels with redness, dry with peeling skin and dark scab formation on right heel. V11 (LPN) said that she is not aware of R1's superficial open wound/ skin impairment. She did not receive report from the nurse during endorsement or from her CNA (V12) this morning. V11 (LPN) called V4 (Wound Care Coordinator). V2 (ADON) said that CNA should notify the floor nurse or wound care coordinator for any changes in resident skin condition.On 2/24/26 at 9:47AM, V4 (WCC-Wound Care Coordinator) said that R1 has MASD. V4 said that R1's last assessment dated [DATE] indicated 100% redness on sacral area extending to buttocks/perineum/ thigh improved. He said that R1 has a healed right heel pressure ulcer dated 2/20/26. V4 said that he is not aware that R1 has superficial open wounds on sacral area and a dark scab on right heel. He said that R1 has MASD and it may have on and off denuded wound/excoriations. R1 received mycology cream for wound care. V4 said that he is not aware of these skin changes. He was not notified by CNA or floor nurse. V4 said that The CNA or the floor nurse should notify him if there are any changes in resident skin condition.On 2/24/26 at 9:50AM, V12 (CNA) said that she is the CNA assigned to R1. She has not provided morning care or incontinence care to R1, but she fed her this morning. R1 is confused, calm, quiet and no behavioral issues of refusal of care. V2 (ADON) said that the CNA should physically check resident for incontinence care every 2 hours. On 2/24/26 at 10:00AM, V4 (WCC) and V12 (WCN) provided wound care to R1. After cleaning with normal saline, measured clustered open wound/excoriated skin as 4cm (centimeters) x 4cm, applied mycology cream and covered with foam dressing to sacral area. V4 also applied mycology cream to reddened sacral area extending to dark discoloration on inner thigh. V4 applied bilateral foam dressing to bilateral heels. V4 said that R1 has bilateral heel foam dressing three times per week. Informed V4 that R1 was not observed with sacral dressing, heel dressing and bilateral boot protectors. V4 said that R1 usually refused heel boots and dressing. R1 was observed calm, quiet and receptive to treatment. No refusal nor agitation was observed during wound care. Surveyor requested wound report after wound care to both sacral and right heel. On 2/24/26 at 11:17AM V4 (WCC) presented copy of R1's wound report completed today. Informed V4 and V24 (Vice President of Clinical services) of picture taken today 2/24/26 was not clear/visible of the multiple/clustered superficial open wounds on sacral area. The way the picture was taken does not provide view of the sacral area as compared to the previous pictures of wound report taken appropriately. V24 said that he will have V4 (WCC) take another picture for better visualization of the denuded/excoriated wound.On 2/24/26 at 1:08PM, V9 (LPN) said that she is the regular nurse for R1. She took care of R1 yesterday morning and evening shift (2/23/26). She is not aware that R1 has skin impairment/ open wound on sacral, but she knows that she is at high risk for skin impairment. She has not seen R1's sacra area. She said, the CNA assigned to R1 did not report any skin changes. The CNA should check resident for incontinence care at every 2 hours and report any changes to the nurse. On 2/24/26 at 1:48PM, Informed V1 (Administrator) and V2 (ADON) of above concerns.On 2/25/26 at 12:29PM, V23 (Care Plan Coordinator) said that they are expected to implement care plan interventions for wound care.On 2/25/26 at 2:23PM, Followed up with the updated wound picture of R1 to V2 (ADON). Facility unable to provide. R1 was admitted on [DATE] with diagnosis listed in part but not limited to Pneumonia, Elevated WBC (White Blood Cell), Nondisplaced intertrochanteric fracture or right femur for closed fracture with routine healing, Contusion of right shoulder, Alzheimer's disease, Dementia, Type 2 Diabetes mellitus, Irritant contact dermatitis due to fecal, urinary or dual incontinence. Active physician order sheet indicated: Wound care: sacrum extended to buttocks/perineum/thighs: clean with cleaning wipes or soap and water apply mycology cream daily and as needed for MASD. Wound care: sacrum/buttocks: cleanse with NS (Normal saline) apply foam dressing as needed every 24 hours as needed for protection. Wound care right and left heel: cleanse with NS apply ABD (dressing) and tubigrip or foam 3x/week MWF and as needed. Comprehensive care plan indicated: She has sacrum extended to buttocks/perineum/thighs extensive MASD. Interventions: Keep skin clean and dry. Monitor skin during care and report any changes. Offload heels using heel protecting devices. Ongoing assessment of wound to evaluate signs of deterioration or improvement. She has ADL self-care performance deficit. She has bladder and bowel incontinence. R1's care plan and progress notes does not indicate that R1 is noncompliance with bilateral heel protectors' boots/offloading with pillows.Most recent wound report indicated: 2/17/26 -Sacrum extending to buttocks/perineum. MASD incontinence. Date identified 1/10/26. No blanchable erythema 100%. Measures 0x0x0cm. Improved. 2/24/26 Sacrum extending to buttocks/perineum. MASD incontinence. Blanchable erythema 95%. Pale pink non-granulating 5%. Measures 4x4x0cm. Cluster as one superficial open wound to sacral area. 2/17/26- Right heel pressure ulcer. Date identified 1/10/26. 100% skin intact. Measures 0x0x0cm. 2/24/26- Right heel pressure ulcer. Dry scaly skin with scab formation. Blanchable redness.Facility's policy on Skin condition assessment and monitoring- Pressure and non- pressure revised 6/8/18 indicated: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non- pressure skin conditions and assuring interventions are implemented. Guidelines: *Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. *Care givers are responsible for promptly notifying the charge nurse of skin breakdown.*At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.Facility's policy on Pressure ulcer prevention revised 1/15/18 indicated: Purpose: To prevent and treat pressure sores/pressure injuryGuidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin.3. Change bed linen per schedule and whenever soiled with urine, feces or other material.11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated. 12. Moisture barrier may be applied by CNA as needed to intact skin and may be kept at bedside.Comprehensive care plan revised 11/17/17 indicated: Purpose: To develop a comprehensive care plan that directs the care plan team and incorporates the resident's goals, preferences and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Guidelines:The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to follow its Incontinence Care Guidelines by failing to provide timely incontinence care to dependent residents. This applies to 3 of 3 (R1, R2, and R3) residents reviewed for Activities of Daily Living (ADL) care in a sample of 3.The findings include:1.R1 is a [AGE] year-old female admitted on [DATE], with intact cognition as per the Minimum Data Set (MDS) dated [DATE]. The MDS review also indicates that R1 is dependent on toileting hygiene.On 12/16/25 at 2:30 PM, R1 stated, There were times they didn't change me for long periods. They will change me around 6:00 AM, 10:30 AM, and 1:00 PM. Sometimes the morning CNAs (Certified Nurse Assistants) don't change me at 1:00 PM, so I have to wait for the evening shift, and they don't change me right away when they start at 3:00 PM. Then I must wait for extended hours to get changed.2.R2 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. The MDS review also indicates that R2 is dependent on toileting hygiene.On 12/16/25 at 10:20 AM, observed R2's call light going off, and V9 (LPN/Licensed Practical Nurse) answered the call light and stated that R2 needs to be changed and will notify her CNA (V10).On 12/16/25 at 10:27 AM, V10 stated, I started at 7:00 AM and didn't change R2 yet. We are supposed to check the resident every two hours for incontinent care, but I was passing trays.On 12/16/25 at 10:30 AM, V10 provided incontinent care to R2, and R2 was observed with a brownish, soaked incontinent brief with stool spread over to the buttocks and soaked linen and mattress.A review of R2's incontinence care plan document interventions, including:Incontinent: Check at least every 2 hours when providing ADL care or as required for incontinence. Wash, rinse, and dry the perineum. Change clothing as needed after incontinence episodes.3.R3 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the MDS dated [DATE]. The MDS review also indicates that R3 is dependent on toileting hygiene.On 12/16/25 at 9:55 AM, R3 stated that she is wet and needs to be changed.On 12/16/25 at 10:50 AM, observed R2's call light going off and R2 stated, I have been waiting for a while to get changed.On 12/16/25 at 11:00 AM, observed V11 (Restorative CNA) answering R2's call light and turning it off, saying to R2 that he would let R2's CNA (V3) know about your call.On 12/16/25 at 11:03 AM, observed V11 (CNA) and V3 providing incontinent care to R2, and R2 was observed with a moderately urine-soaked incontinent brief.On 12/16/25 at 12:30 PM, V2 (Director of Nursing/DON) stated that residents need to be checked for incontinent care every two hours and as needed.The facility presented the Incontinence Care Guidelines revised on 1/16/18 document: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode.

Based on observation, interview, and record review, the facility failed to ensure multi-dose medications are labeled and discarded accordingly for one of two medication rooms (second floor medication room) reviewed for medication storage and labeling. Findings include:On 11/18/2025 at 9:10AM during medication room observation with V33 (Registered Nurse), second floor medication room was observed with the following:1. R78's Latanoprost ophthalmic solution with open date of 08/01/2025 and pharmacy label that reads Throw away any drug left after 6 weeks2. R18's insulin lispro with no open date and pharmacy label that reads Throw any medicine that remains 28 days after first use3. Two open, undated vials of Tuberculin Purified Protein Derivative with bottle label that reads Once entered, vial should be discarded after 30 days, and medication literature that reads Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency On 11/18/2025 at 9:20AM during interview with V33, V33 stated that all multidose medications and vials should be labeled with open date once opened. R78's Order Summary Report dated 11/19/2025 indicated R78 was admitted in the facility on 09/01/2017 with diagnosis of not limited to primary open-angle glaucoma, bilateral, indeterminate stage, and an order for Latanoprost solution with order date of 06/11/2019. R18's Oder Summary Report dated 11/19/2025 indicated R18 was admitted in the facility on 09/16/2024 with diagnosis of not limited to type 2 diabetes mellitus without complications, and an order for Insulin lispro with an order date of 10/17/2025. Review of facility's policy entitled Storage of Medications with effective date of 10/25/2014 indicated the following:Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures:B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. Expiration DatingD. Drugs by the pharmacy staff will generally carry an expiration date as follows: (Note: the pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation)2) Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is:- in a multi-dose injectable vial- an ophthalmic medication- An item for which the manufacturer has specified a usable life after openingE. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.

Based on observation, interview, and record review the facility failed to date and label food items and beverages after preparing and storing. The facility also failed to maintain sanitizing solution at level required per manufacturer's instruction. This deficiency affects all 146 residents in the facility receiving food trays from kitchen. Findings include: Based on observation, interview, and record review the facility failed to date and label food items and beverages after preparing and storing. The facility also failed to maintain sanitizing solution at level required per manufacturer's instruction. This deficiency affects all 146 residents in the facility receiving food trays from kitchen. Findings include:On 11/18/25 at 6:32AM, Observed in cooler storage fridge 15 cold sandwiches and 4 juices in plastic cup not dated and labeled with V18 Night Supervisor. V18 called V19 [NAME] and asked when it was prepared. V19 said it was prepared last night. Surveyor asked why it was not dated and labeled then he changed his statement and said it was prepared this morning. Both V18 and V19 said that all food items and beverages prepared should be dated and labeled. On 11/19/25 at 9:19am Surveyor observed V15 Dietary manager (DM) tested the red bucket sanitizing solution with cloth using sanitizer testing strip. The test strip color barely changes indicating 0 ppm (parts per million). V16 Food Service Director (FSD) also tested the red bucket using sanitizer testing strip and obtained the same reading. Both said that for sanitizer test strip manufacturer's recommendation should be between 200-400 ppm for effective sanitization and food safety handling. On 11/19/25 at 9:24AM, V25 Dietary Aide applied dishwasher testing strip to fork and placed inside the dishwasher machine. V16 FSD said that the black strip bar should change to bright orange indicating the dishwasher is maintaining the proper temperature. The test strip faded black color strip into gray but did not change into bright orange as recommended by test strip manufacturer. On 11/19/25 at 9:50AM, Reviewed Sanitizing sink chemical log and Dishwasher test strips for [DATE] with both V15 DM and V16 FSD. Sanitizing sink chemical log indicated 100ppm on 11/7 and 11/8/25. Test strip recommendation should be 200 to 400ppm. Dishwasher test strips indicated not bright orange but faded black/grayish color strip on 11/1 dinner, 11/2 breakfast, lunch and dinner, 11/3 lunch, 11/6 breakfast, 11/13 breakfast and 11/19 tested with surveyor. On 11/19/25 at 10:30AM, Informed V1 Administrator of above concerns. On 11/20/25 at 8:51AM, Both V15 Dietary Manager and V16 Food Service Director said that they provide 146 food trays in the facility. Facility's policy on Sandwich indicated: *Cold sandwiches made for non-immediate use should be dated and labeled. The labeled should include the food item, date made and use by date. * Once complete, the sandwiches should be stored in a fridge on a ready to use items shelf on a tray or in a container/pan of some sort. Facility's policy on Buckets, red and [NAME] indicated: Frequency: A green bucket with detergent solution and a red bucket with sanitizing solution must be available, changed at least 3 times and every prep area, throughout the workday. Purpose: To ensure food safetyProcedure: 3. Red buckets should be filled with sanitizing solution with a clean cloth and kept every prep area. Change solution every 2 hours and the cloths, as needed to remain clean. Sanitizer solution cannot be too hot. Over 100F will lose potency. 4. Use a test strip to check the PPM of the sanitizing solution before use and record at least before preparing every meal (3 times a day) and log accordingly. Facility's policy on Mechanical Ware Washing (Dish Machine) indicated: Policy: The Dish machine should be used in accordance with the manufacturer's specifications. Purpose: To ensure safetyProcedure: The proper cleaning and sanitizing of dishes in the dietary department is extremely important to health and safety or residents. It is especially important to follow the guidelines noted below and the requirements of the dish machine.5. The internal temperature of the sanitizing cycle (if a high-temperature machine) or the PPM of the sanitizer (if a low temperature machine) should be tested and logged before washing dishes from each meal to ensure the dish machine is properly sanitizing dishes. Dishwashing Machine Testing strip instruction: 2. If the color [NAME] has turned bright orange, the dishwasher is maintaining the proper temperature.

Based on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R10) of three residents in the sample of 34 reviewed for ADLs (Activity of Daily Living) Program. Findings include: On 11/19/25 at 8:56AM, Observed R10 lying in Low air loss mattress. He is awake but nonverbal and needs total care with ADLs and transfers. He has tracheostomy tube connected to ventilator and gastrostomy tube connected to enteral feeding pump. R10 has bilateral arms contractions. Observed with V4 WCC (Wound Care Coordinator) and V5 WCN (Wound Care Nurse), R10 has long discolored fingernails on both hands with black matter inside the finger. Both V4 and V5 said that nail care is part of the ADLs program, and the CNA (Certified Nurse Assistant) is responsible for providing the care. On 11/19/25 at 9:00AM, V7 LPN (Licensed Practical Nurse) said that she is the regular nurse for R10. Surveyor showed to V7 bilateral hands with long discolored with black matter inside the fingernails. She said that she did not notice when she made rounds. She said that CNA is responsible for R10's nail care. On 11/19/25 at 2:00PM, Informed V2 DON (Director of Nurses) of above observation made. V2 DON said that they should provide appropriate care to residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal oral hygiene. Nail care is part of ADLs includes daily cleaning and regular trimming to prevent infection. R10 is admitted on [DATE] with diagnosis listed in part but not limited to Anoxic brain damage, Chronic respiratory failure with hypoxia, Tracheostomy, Dependent on respirator/ventilator, Colostomy, Gastrostomy, Stage 4 Sacral pressure ulcer. Comprehensive care plan indicated she has ADL self-care performance deficit. MDS quarterly assessment dated [DATE] indicated: Section GG 0130 Functional Abilities marked 01 Dependent on Personal hygiene. Facility's policy on ADLs (Activity of Daily Living) indicated: Grooming: maintaining personal hygiene, including planning the task and gathering supplies, combing, and styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care) and or application of deodorant or powder. Facility's policy on Nail Care revised 1/25/18 indicated: Guidelines: 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails. 2. Trim fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming. Additional soaking in warm soapy water may be necessary to soften nails.

Based on observation, interview and record review, the facility failed to ensure splints/braces are applied to residents with contractures affecting two of seven residents (R111, R139) reviewed for range of motion. Findings include: On 11/18/2025 at 8:15 AM, R111 was observed lying in bed. R111 has a right-hand contracture without a splint on. On 11/18/2025 at 12:20 PM, observed with V8 (LPN-Licensed Practical Nurse) that R111 didn't have a right-hand splint or right ankle orthosis on. V8 said that R111's right-hand splint and right ankle orthosis should have been on. V8 said that R111 using the hand splint and ankle orthosis is to prevent R111's contractures from worsening. On 11/19/2025 at 3:09 V12 (Restorative Nurse/LPN) said that V12 is familiar with R111. V12 said that R111 is alert and oriented x 2 – 3 times. V12 said that R111 can make her needs known. V12 said that R111 has a history of stroke. V12 said that R111 is on range of motion (ROM) exercises program, splint program for right hand upper extremity, and right ankle orthosis. V12 said that the restorative aide is responsible to apply R111's right hand splint and right ankle orthosis. V12 said that the splint and the ankle orthosis are to prevent further contracture. V12 said that if not applied, R111 has the potential to be more contracted. V12 said that the right-hand splint and the right ankle orthosis should have been applied on R111 as ordered. On 11/19/2025 at 11:29 AM, V2 (Director of Nursing) said that V2 expectation for the staff is to carry out orders as prescribed. V2 said that R111's right-splint and right ankle orthosis should have been applied on R111. R111 is a [AGE] year-old female who was admitted with a diagnosis not limited to hemiplegia, unspecified affecting right dominant side, major depressive disorder, hypertensive heart disease without heart failure, and primary generalized osteoarthritis. Physician order dated 10/18/2025 indicate that OT evaluation and treatment as indicated. R111 care plan (pg. 60 of 80), indicate that R111 will wear R (right) hand resting splint for 6-8hrs release during ADL (Activities of Daily Living) care, Exercise and mealtime check skin integrity and circulation. Application schedule: ON – 9 AM, OFF – 3 P 2. R139 is a [AGE] year-old male who was admitted in the facility with diagnoses of not limited to anoxic brain damage, and other abnormalities of gait and mobility. On 11/18/2025 at 7:31AM during observation, R139 was lying on bed without hand splints on both hands. R139 was unable to fully open R139's both hands. On 11/18/2025 at 12:30PM during observation with V41 (LPN), R139 was again observed without hand splints on both hands. On 11/18/2025 at 12:30PM, V41 stated that the restorative aides are the ones putting on hand splints on R139's both hands. On 11/18/2025 at 12:42PM during interview with V12 (Restorative Nurse), V12 stated that R139 should have splints on both hands to prevent further development of contractures R139's Order Summary Report dated 11/18/2025 indicated R139 was admitted in the facility on 09/28/2023, and an order to apply resting hand splints to bilateral hands daily after morning care for six hours as tolerated with order date of 03/22/2024. R139's undated Care Plan indicated that R139 would benefit from use of Splint/Brace due to R139 has actual contracture related to impaired mobility and limited ROM (range of motion). R139's Documentation Survey Report for October 2025 indicated that R139's resting hand splints were not being applied daily. It also did not indicate that R139 refused application of hand splints. R139's Documentation Survey Report for November 2025 indicated that R139's resting hand splints were not being applied daily. It also did not indicate that R139 refused application of hand splints. R139's Minimum Data Set, dated [DATE] indicated R139 is on splint/brace assistance program. Review of facility's undated policy entitled Application of Splints indicated the following: Purpose: To properly apply a splint for support, comfort, or aid in contracture. Equipment: Physician's order and specific splint for the resident Procedure: 6. Document initials and total minutes for the appropriate shift. Document any difficulties or unusual situations on the reverse form or in the nursing notes and contact nursing supervisor.

Based on interview and record review, the facility failed to provide adequate supervision and monitoring to prevent accidents for two of four residents (R183 and R129) reviewed for accidents. Findings include:R183 is a [AGE] year-old female who was admitted in the facility in 10/26/2021 with diagnoses of not limited to major depressive disorder, generalized anxiety disorder and bipolar disorder, and was discharged on 07/28/2025. R183 was R129's roommate. R129 is a [AGE] year-old female who was admitted in the facility with tracheostomy, and diagnoses of not limited to chronic respiratory failure and chronic obstructive pulmonary disease. R129 is on low air loss mattress and high humidity tracheostomy collar. On 11/19/2025 at 9:59AM during interview with R129, R129 stated that she cannot remember when the fire happened but can remember what happened. R129 stated that she was on bed and watching the television when she felt something hot on her right leg and saw something flickering on the right side of her bed by her bed. R129 stated that she immediately yelled out fire repeatedly to call for help. R129 stated that when it happened, her roommate, R183 got up and ran quickly out of the room. R129 stated that the nurse came in and tried to put out the fire. R129 stated that R129 had seen candles in a glass on R183's bedside table before the fire happened but had never seen it after the fire incident. On 11/19/2025 at 11:45AM during interview with V43 (Certified Nursing Assistant), V43 stated that she heard R129 yelling fire so she went to R129's room and saw the fire on R129's blanket. V43 stated that the nurse came in and took out R129's blanket off of her and put on the floor to take out the fire. V43 stated that they extinguished the left-over fire on R129's bed with a bucket of water from the shower room. On 11/20/2025 at 2:38PM during interview with V1 (Administrator), V1 stated that it was concluded during the investigation that R183 lit up a candle as the root cause of the investigation based on the other residents' statement that R183 admitted to them that R183 started the fire and how R183 described the candle that R183 lit up in detail. On 11/21/2025 at 9:21AM, V1 stated that residents are not allowed to have anything that poses a fire hazard in their rooms, including smoking materials and candles. On 11/21/2025 at 10:07AM during interview with V47 (Social Worker), V47 stated that if a resident is a smoker or expressed that they want to smoke, the resident is first assessed if they are safe to smoke. V47 stated that if the resident is deemed a safe smoker, they were allowed to keep all their smoking materials inside their room before the fire incident happened. V47 stated that R183 started smoking in September of 2024 was deemed a safe smoker at that time. On 11/21/2025 11:30AM during interview with V49 (Registered Nurse), V49 stated that she was at the nurse's station when she heard a resident scream fire. V49 stated that she immediately responded to the scream and saw the fire on R129's blanket. V49 stated that she took R129's blanket off and put out the fire, then she screamed for help. R129's Order Summary Report dated 11/21/2025 with active orders as of 05/06/2025 (prior to the fire incident) indicated R129 was on low air loss mattress and high humidity tracheostomy collar with order date of 03/22/2025. R183's admission Record indicated R183 was admitted in the facility in 10/26/2021 with diagnoses of not limited to major depressive disorder, generalized anxiety disorder and bipolar disorder, and was discharged on 07/28/2025. R183's signed facility admission contract on 11/10/2021 did not indicate any personal property restrictions. R183's smoking contract signed 09/16/2024 did not indicate that smoking materials are not allowed in the rooms. Facility Report sent to Illinois Department of Public Health dated 05/09/2025 indicated that the new and final root cause of the fire was the candle that was lit up in the room by R183. Facility was unable to provide policy on Fire Prevention.

Based on observation, interview, and record review the facility failed to ensure enteral (tube) feeding was administered at a correct rate per physician order and enteral feeding container was labeled per policy. This deficient practice has the potential to affect 2 of 2 residents (R124, R39) reviewed for enteral feeding management in a sample of 34.Findings Include:On 11/18/2025 at 08:30 AM, R39 was observed in his room. R39's tube feeding was infusing at the rate of 55 ml/hr (milliliters/hour). On 11/18/2025, at 12:15 PM, V8 (LPN-Licensed Practical Nurse) observed with surveyor R39's tube feeding infusing at the rate of 55 ml/hr. At 12:17 PM, V8 and surveyor reviewed R39's tube feeding order. R39's physician order indicates enteral feed every shift (nutritional supplement) 1.5 @ 65 ml/hr. V8 said that R39 tube feeding rate should have been set at 65 ml/hr per physician order. On 11/19/2025 at 11:29 AM, V2 (Director of Nursing) said that V2's expectation for the staff is to carry out orders as prescribed. V2 said that R39's tube feeding rate should have been set at a rate of 65 ml/hr. R39 is an 80 -year-old male admitted on [DATE] with diagnosis not limited to personal history of malignant neoplasm of prostate, Parkinson disease without dyskinesia, multiple fracture of ribs, and other abnormalities of gait and mobility. Physician order indicates enteral feed every shift (nutritional supplement) 1.5 @ 65 ml/hr. R124 was admitted to facility on 12/10/2024. Diagnoses include diffuse traumatic brain injury with loss of consciousness of unspecified duration, encounter for attention to gastrostomy, unspecified dysphagia, oropharyngeal phase. Order summary report, start date 5/7/2025 read Enteral Feed Order every shift (nutritional supplement) 1.5 @50ml/hr X21 hours or until 1050ml total volume infused. Care Plan Report, date initiated 12/17/2024 read Focus: Potential for alteration in fluid or nutritional status related to NPO (nothing by mouth) status + Feeding tube. Interventions include Administer medications as ordered. Enteral nutrition per physician order. On 11/19/2025 at 10:00 AM R124 in bed with enteral feeding connected and running at 50ml/hr. Enteral feeding bag observed without any visible identification label. V4 (Wound Care Coordinator) stated, feeding bag should be labeled with resident's name, date, start time, rate, and volume to infuse per physician order before administration. On 11/19/2025 at 11:30 AM, V2 (Director of Nursing) stated enteral feeding container should be labeled for identification and proper administration. Policy and Procedure Title: Gastrostomy Tube – Feeding and Care, Revision date 8/3/20 Purpose: To provide nutrients, fluids, and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Procedure: 1. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration. 3. Label container with resident's name, flow rate, date and time.

Based on interview and record review, the facility failed to follow a provider order for a STAT (immediately) x-ray to be completed for a resident after a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a delay in being transferred to the hospital for evaluation and treatment of a fractured hip, which required surgical intervention. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses that include: right femur fracture; unspecified dementia, moderate, w/out behavioral disturbance, psychotic disturbance, psychotic disturbance, mood disturbance, and anxiety; and mild cognitive impairment. Fall Report dated 1/24/25 3:34pm written by V8 (Licensed Practical Nurse / LPN) reads: Incident Description: Writer heard residents in the dining room yelling. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Floor was noted dry and free of clutter. Noted walker was next to resident at the time of the incident. Immediate Action Taken: Patient was assessed from head to toe and was given pain medication and helped back to her room. NP (V9-Nurse Practitioner) assessed resident and ordered right hip x-ray and bilateral shoulder x-ray .Patient reported having pain in her right hip. There was no bruising or shortening of her legs . Mobility: Ambulatory with assistance Nursing progress notes read the following: 1/24/2025 3:58pm Nurses Note written by V8 (LPN) reads: Note Text: Writer heard residents in the dining room yelling at each other. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Writer checked residents vitals and is as follow; bp (blood pressure) 126/86, rr (respiratory rate) 18, p (pulse) 71, o2 (oxygen saturation) 98%. Pupils equal and reactive and same size and no weakness bilateral, Patient reported having pain in her right hip. There was no bruising or shortening of her legs. Resident was assisted back to her room and given pain medication. The administrator was informed and the (V9) NP was informed. (V9) NP assessed patient and asked writer to order right hip x-ray and bilateral shoulder x-ray. All orders carried out. Administrator informed writer that she would contact family. Patient was assisted into bed and made comfortable. HOB (head of bed) raised and call light within reach. 2/08/2025 at 6:08PM V10 (Registered Nurse/RN) said, I have worked here almost a year. On 1/24/25 I worked 3-11pm. During that time, the morning nurse endorsed to me that there was an incident that another resident pushed R1 and that's why she fell . They ordered an x-ray. The morning nurse ordered the x-ray. Surveyor asked V10 if the x-ray company was called to find out the status. V10 responded, yes and they said that they would come but I don't remember them giving me a time frame. If an x-ray is ordered STAT (immediately) it should be ordered within 30 minutes to one hour. Since they said they would come, I endorsed it to the next nurse for them to follow-up again. Surveyor asked if it was expected that the x-ray company would not come within the timeframe of the eight hour shift that V10 worked. V10 said, no, I know it should have been done sooner. I don't remember what time I followed up with them. When asked if anything should have been done differently, V10 said, maybe I would have followed up again and informed the supervisor and then maybe we could have sent the patient to the hospital. During my assessment with her she was sleeping at first. Towards the end of the shift, I checked her again, I touched her left and right back and you could notice that she was in pain. The first thing I did was put the Lidocaine patch and give Tylenol since those pain orders were already in the system. V10 affirmed that she did not call the doctor to notify them that R1 was having pain but did endorse it to the oncoming nurse; because it was towards the end of V10's shift already. V10 added, I did assess her lower extremities and I didn't see any swelling or shortening of the leg. She (R1) was quiet, but she had facial grimacing when I touched her back. I applied the Lidocaine patch to her back. V10 said, sometimes when I call (x-ray company) they give a rough estimate but not an exact time. They may say we'll be there in the morning or evening but not an exact time. 2/8/25 at 6:20PM V11 (LPN) said, I have worked at the facility about 14-[AGE] years. I normally work the overnight shift. I remember that the 3-11 nurse told me that R1 had a fall and that we were waiting for the x-ray company to come and take the x-ray. I made rounds and she was in bed sleeping so I did not touch her. When I made rounds again, she had her eyes open, and I asked her if she was in pain. She is hard of hearing, so I checked her leg. When I moved her leg, she made a noise and verbalized ow. I noticed the swelling and I called V2 (Director of Nursing/DON) and the doctor right away to tell them that I had to send her to the hospital. I called the x-ray company and they said they were on their way but with the swelling and the little bit of external rotation I did not want to wait for the x-ray company. I left a message with the doctor, called her POA (Power of Attorney), and notified V2 (DON) that I had to send R1 out. I called the ambulance, and they were here within 10 minutes. For x-rays that are ordered STAT, I don't really encounter that problem (with delays) because I work night shift so there are not a lot of incidents because the residents are sleeping. My expectation as a nurse is that if it's a STAT x-ray they come soon. I don't think that I would wait eight hours for a STAT x-ray; so, they should come right away. I would follow up again and see if they are really coming to do the x-ray and if they still are not coming and it's a fall, I would have to use my judgment as a nurse. If I notice something unusual, I will call the doctor, Director of Nursing, and POA right away to send the patient to the ER. I did my part as the nurse on duty. I know the assessment is very important as a nurse, especially when the patient has had a fall. I always make sure that I check them right away and do frequent rounds because they might not have a visible injury right away, but you never know. You might think there is nothing wrong and then later on you see something. I always ask the CNA (Certified Nurses Assistant) for help because if they are sleepy, they may hit you or something because it is a dementia unit. 2/08/2025 at 5:06PM V2 (DON) said, since R1 hasn't had a fall for years she can be independent. The reason we have her as supervision (on MDS) is more for incontinence because she needs assistance to the bathroom. Again, she hasn't had any falls. When she doesn't have an infection, her ambulation is quite good. For us, the concern was because of the UTI (urinary tract infection) and the COVID with this fall. She walks around in the morning and in the afternoon but it's not realistic for us to have a one to one. Someone is always there. There is always staff monitoring them. Someone always has to be visible in the hallway, but they can't just be sitting in the dining room. It has to be something that's going to work for all residents. I can't restrain her. She is safe to walk around with the walker. If we order a STAT x-ray, it should be done within a 4-6-hour window and we do call that in after we call the nurse practitioner. We noticed there was swelling in the right leg, and we notified the doctor. At 10:38pm it was the left right back where she was having pain. No mention of swelling. If the x-ray isn't done within 6 hours, we call the doctor to send them out to the hospital. If it's not STAT, then waiting 24 hours is okay. 2/8/25 at 3:20PM V9 (NP) said, I wasn't a witness to the incident. I just remember that it was unclear circumstances. She fell and broke her hip and required an ORIF (Open Reduction and Internal Fixation - (ORIF) is a type of surgery used to stabilize and heal a broken bone). Typically, those x-rays are ordered STAT (immediately) but I'm not sure what time the x-ray was done. V9 was asked if she would expect the facility to wait 12 hours for a STAT x-ray to be done. V9 said, if the patient was not feeling well, I would have expected it a lot sooner or the patient sent out. The nurses told me she was pain free and I didn't think she had broken that hip based on how she looked really. But if the nurses assessed and she was not in pain I could understand why she wasn't sent out sooner. When I saw her (immediately after the fall), she was stable, and I asked if she had any pain and she said no. It could have been pain from the fall and if they knew the x-ray department wasn't coming in time then of course they should not wait. As much as I wish they would come sooner, we are at their (x-ray company) mercy. For a STAT x-ray, I would ideally like it done within the hour but at least 3-5 hours. Review of R1's hospital record documents that R1 was admitted on [DATE] for a right, closed, hip fracture. Physical exam documents that R1's right hip was externally rotated, pulses intact and pain with movement of the hip. Hospital x-ray confirmed partially impacted right femoral neck fracture; mild to moderate displaced fracture of the right superior and inferior pubic rami. Hospital record also documents that R1 had sepsis, urinary tract infection, pneumonia, COVID-19, and leukocytosis present on admission, in addition to the fracture. Facility policy titled, Physician Notification of Laboratory/ Radiology/Diagnostic Results (last revised 7/8/24) reads: Purpose: To assure physician ordered diagnostic test are performed, and to assure test results are reported to the ordering physician so that prompt, appropriate action may be taken if indicated for the resident's care. Guidelines: A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. A requisition is to be completed and lab to be drawn on next scheduled lab draw day UNLESS Stat or Same Day order is received. oCollect and label specimen, name, date, time and name of test. Place in plastic transport bag - note stat. oCall for transport service. STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Laboratory and/or diagnostic company will contact assigned licensed nursing staff with any abnormal or critical results that require prompt attention. Test results should be reported to the primary care physician or other ordering practitioner pursuant S483.50 Laboratory, radiology, and other diagnostic services guidelines. Guidelines for Reporting Abnormal Results: o All Critical laboratory values - also called Alert or Panic values o X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: o Pneumonia o New fracture In the event a physician does not respond promptly to attempts to convey critical laboratory results, the alternate physician or Medical Director will be notified. Promptly may be defined based on the clinical condition of the resident and the judgement of the nurse in each individual situation. For example, some conditions may require immediate 911 intervention, others may be delayed 4 or more hours if the condition of the resident is stable. Should the alternate physician or Medical Director not respond, the Director of Nursing will be notified. The Director of Nursing interventions should include: o Assessment of the resident's clinical condition (in person or by phone) o Further attempt to contact the Physician, Alternate Physician or Medical Director o Emergency transfer based on clinical judgement .

Based on interview and record review, the facility failed to provide supervision/touching assistance for a resident when moving from a seated to standing position, per the residents plan of care and assessments, in order to prevent a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a fall causing a fractured hip that required surgical intervention. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses that include: right femur fracture; unspecified dementia, moderate, w/out behavioral disturbance, psychotic disturbance, psychotic disturbance, mood disturbance, and anxiety; and mild cognitive impairment. R1's Minimum Data Set (MDS) assessments document the following: 1/4/25 Section GG Functional Abilities codes R1 as requiring supervision or touching assistance during sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed); walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space); walk 50 feet with two turns (once standing, the ability to walk at least 50 feet and make two turns); walk 150 feet (once standing, the ability to walk at least 150 feet in a corridor or similar space). Fall Report dated 1/24/25 3:34PM written by V8 (Licensed Practical Nurse / LPN) reads: Incident Description: Writer heard residents in the dining room yelling. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Floor was noted dry and free of clutter. Noted walker was next to resident at the time of the incident. Immediate Action Taken: Patient was assessed from head to toe and was given pain medication and helped back to her room. NP (Nurse Practitioner) assessed resident and ordered right hip x-ray and bilateral shoulder x-ray .Patient reported having pain in her right hip. There was no bruising or shortening of her legs . Mobility: Ambulatory with assistance Nursing progress notes read the following: 1/24/2025 3:58PM Nurses Note written by V8 (LPN) reads: Note Text: Writer heard residents in the dining room yelling at each other. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Writer checked residents vitals and is as follow; bp (blood pressure) 126/86, rr (respiratory rate) 18, p (pulse) 71, o2 (oxygen saturation) 98%. Pupils equal and reactive and same size and no weakness bilateral, Patient reported having pain in her right hip. There was no bruising or shortening of her legs. Resident was assisted back to her room and given pain medication. The administrator was informed, and the NP was informed. NP assessed patient and asked writer to order right hip x-ray and bilateral shoulder x-ray. All orders carried out. Administrator informed writer that she would contact family. Patient was assisted into bed and made comfortable. HOB (head of bed) raised and call light within reach. 2/7/25 at 3:38PM V7 (Certified Nursing Assistant / CNA) said, I was standing by room [ROOM NUMBER]; not in the dining room. I was supervising the unit. R1 and R2 were having a verbal disagreement. I saw R1 put her hand on the walker to get up and the walker tipped over and she fell on the right side. At no point did I see R2 hit R1 or R1 hit R2. The nurse then came, and the other CNA came to help. No issues with either of them being aggressive with other residents. There were no other residents in the dining room at that time. 2/8/25 at 1:13PM V8 (LPN) said, I have worked here since May 2024. I normally work on the second floor but recently I have been floating around. Regarding the incident with R1 and R2, I was at the nurses station charting and I heard a commotion. I went to the dining room and R1 was on the floor. R2 was in the room, right next to her or over her. I don't remember exactly. The dining room is not in view of the nurses' station. I think they were right when you first go into the dining room. I don't recall any other residents being in there are the time. When I got there the CNA (V7) was there. I don't remember her name because I don't work with her that often, but it wasn't CNA (V4) because I know her, so yes it was V7 and then V4 came in after. R1 was hysterical and saying, I fell . I was asking her what happened, but she was just saying that her leg hurt. I just examined her, and we helped her get up and I called V1 (Administrator). R1's walker was in there with her. I usually see her getting up independently and she walks over to the dining room with her walker, sometimes I'll see her by the nurses station. Surveyor asked V8 if she would have expected someone to be in the dining room monitoring R1 and R2. V8 responded, there is usually someone in there monitoring. I know that around that time of day, a lot of them like to walk around. Right before the shift ends there are rounds and I am usually charting getting ready to go home. I don't know if the CNA was in there the entire time. She didn't report anything specific to me. I had to open my charting, call V1 (Administrator) and the Nurse Practitioner (NP). When I did go to get a statement from V7, I couldn't find her. I assumed she had left for the day. The NP ordered the x-ray. We helped R1 to her room and then right after that, the NP came to the floor and assessed her as well. Surveyor asked, what type of supervision is expected for a resident who has an MDS code of (4) Supervision / Touching Assistance. V8 said, I would say that you have to guide them and be there when they are getting up so if they look weak you may have to provide them with more assistance than usual. A lot of times they get up on their own, but you have to watch them. I would expect for someone to be around them when they are getting up from the bed or chair. I would probably say staff should be within eye length distance; within your view. I have never seen R1 get aggressive. I have heard about R2 getting aggressive, but I have never witnessed it; he may touch things or move things around; or he can get close to you. Again, I haven't experienced that with him. 2/7/25 at 2:03PM, V3 (LPN) said she was not present during the incident with R1 and R2. V3 said that the residents must always be monitored because this is a dementia unit. Some people can be more agitated, and we have to monitor them closely and they can fall. Safety is the priority. V3 added that she has not witnessed any abuse between R1 and R2 but that R1 can get mad at times, and she is hard of hearing so she can get frustrated. 2/7/25 at 2:17PM, V4 (CNA) said, I was here during the incident with R1 and R2, but I was in the room with another resident. R2 was out for a few months but he is calm now and seems to have gotten better actually. Someone is in the dining room at all times; the residents can fall. If activities is in the dining room, they will monitor them too. 2/7/25 at 2:34PM V2 (Director of Nursing) reviewed facility fall report with surveyor. V2 added that they were not aware that R1 had COVID at the time of the fall, until the hospital called to report it to them. There are cameras in the dining room, but you can ask V1 (Administrator) to see it. All of the progress notes and assessments are in the chart. 2/7/25 at 2:45PM V1 (Administrator) said there is no video to see currently because the cameras loop every 48 hours. V1 added, I didn't get a chance to look at the video. I had left early that day because I had just gotten back from vacation. This was our only incident for January. I unsubstantiated the abuse. I initially reported it as abuse because the nurse (V8) said she didn't know what happened but assumed R2 pushed R1. During my investigation though, V7 (CNA) said she saw when R1 fell and that R2 had not pushed her. V7 said she was walking towards the dining room and could not get to R1 before she fell . When I tried to interview R1, she said she couldn't hear me, and she was confused. The combination of COVID and UTI (urinary tract infection) explain a lot about why she fell . V1 added that R1 is normally very careful when getting up but that having the infections contributed to the fall. It had been a while since R1 had any falls or infection. 2/08/2025 at 5:06PM V2 (Director of Nursing) was interviewed, and surveyor asked if R1 should have been supervised when getting up from the chair or had supervision while in the dining room since her MDS has her coded as requiring supervision and/or touching assistance. V2 said, since R1 hasn't had a fall for years she can be independent. The reason we have her as supervision is more for incontinence because she needs assistance to the bathroom. Again, she hasn't had any falls. When she doesn't have an infection, her ambulation is quite good. For us, the concern was because of the UTI and the COVID with this fall. She walks around in the morning and in the afternoon but it's not realistic for us to have a one to one. Someone is always there. There is always staff monitoring them. Someone always has to be visible in the hallway, but they can't just be sitting in the dining room. It has to be something that's going to work for all residents. I can't restrain her. She is safe to walk around with the walker. 2/8/25 at 7:10PM V1 (Administrator) said, V7 (CNA) was standing in front of room [ROOM NUMBER] and if she had been in the dining room, she would not necessarily have been any closer to the resident. We will send you a picture of the distance from the room to the dining room entrance where the residents were at the time of the fall. She was about 5 feet from the resident at the time of the fall. Review of R1's care plans include: High Risk for Falls, Initiated: 2/18/21, Revised: 2/7/25 Interventions: Needs activities that minimize the potential for falls while providing diversion and distraction (Initiated: 2/18/21); Be sure call light is within reach and encourage (R1) to use it for assistance as needed (Initiated: 2/18/21) (R1) presents with a functional deficit in ambulation due to: generalized weakness, Initiated and Revised: 4/5/21 Interventions: Staff to assist as needed (Initiated: 4/5/21); Observe for signs/symptoms of fatigue, SOB (shortness of breath), pain, discomfort, or intolerance (Initiated: 4/5/21) (R1) has an ADL Self Care Performance Deficit related to Dementia and dx of HL, HTN (hypertension), and h/o (history of) UTI, Initiated and Revised: 2/18/21 Interventions: Encourage (R1) to use bell to call for assistance (Initiated: 2/18/21). R1's restorative observation - quarterly review, dated 11/12/24 documents that R1 has Maintained ability to ambulate 100-200 feet using rolling walker with staff supervision .Resident AO (Alert and Oriented) x1-2, able to express needs, able to feed self, able to follow simple command, continent of bowel, occasionally incontinent of bladder, ambulatory with supervision touching assist using rolling walker .Resident with ADL (Activities of Daily Living) Self Care Performance Deficit related to generalized weakness, unsteady gait and poor safety awareness. Resident requires supervision to partial assist to safely complete ADLs . R1's fall risk assessment dated [DATE], documents that R1 is high risk for falling, with a weak gait and mental status limitation of overestimates or forgets limits. 2/8/25 at 3:20PM V9 (Nurse Practitioner) said, I wasn't a witness to the incident. I just remember that it was unclear circumstances. She fell and broke her hip and required an ORIF (open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone). Review of R1's hospital record documents that R1 was admitted on [DATE] for a right, closed, hip fracture. Physical exam documents that R1's right hip was externally rotated, pulses intact and pain with movement of the hip. Hospital x-ray confirmed partially impacted right femoral neck fracture; mild to moderate displaced fracture of the right superior and inferior pubic rami. Hospital record also documents that R1 had sepsis, urinary tract infection, pneumonia, COVID-19, and leukocytosis present on admission, in addition to the fracture.

Based on interview and record review, the facility failed to follow their call light policy and answer residents' call light in a timely manner for three (R1, R3, and R4) residents out of four residents reviewed for call lights in a total sample of four residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Findings include: On 12/15/2024, 9:29 AM, V5 (Certified Nursing Assistant) states that currently there are two certified nursing assistants working on this floor and one nurse. V5 states that there are approximately 22 residents on this floor. On 2/15/2024, 9:44 AM, R1 is laying down on her bed, head of her bed slightly elevated, and in no apparent distress. R1 is wearing black sunglasses. R1's call light is within reach. R1 reports that she has waited several hours to be changed. R1 states that sometimes staff take long to answer her call lights. R1 states that it takes 2 hours for someone to answer her call light. R1's MDS/Minimum Data Set, dated dated dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. 12/15/2024, 9:57 AM, R3 is standing up, using oxygen via nasal cannula, with a steady gait. R3 states that she observes staff taking a long to attend to R1. R3 states that staff can take up to one hour before they answer R3's bedroom call light. R3's MDS/Minimum Data Set, dated dated dated [DATE], documents that R3 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R3 is cognitively intact. 12/15/2024, 1:25 PM, R4 is sitting in his wheelchair in his bedroom, R4 is alert and responsive. R4 states that he does need assistance with staff to change his incontinence briefs. R4 states that he does utilize his call light to call for assistance. R4 states that he has waited more than 2 hours for his call light to be answered. R4 states that no other staff help answer call lights, and usually just the nursing aids. Sometimes the nurses answer the call lights. R4's MDS/Minimum Data Set, dated dated dated [DATE], documents that R4 has a BIMS/Brief Interview for Mental Status score of 14/15, indicating that R4 is cognitively intact. 12/15/2024, 10:22 AM, at the nurse's station with V5 (Certified Nursing Assistant) and V6 (Certified Nursing Assistant), V5 states that the call light system is at the nurse's station. It will alert like a doorbell, and it shows how long it's been on for. V5 states that residents could be waiting for a very long time for just some water. V5 states that residents could need urgent help. If the call lights are not answered in a timely manner their care can get delayed. 12/15/2024, 10:25 AM, V6 (Certified Nursing Assistant/CNA) states but if I am in the room giving a bed bath, and the call light is on, it won't get answered until I answer it. All staff are supposed to answer the call lights. V6 states I've seen 50 minutes there, pointing at the call light system where it reflects how long the call light has been on for. 12/15/2024, 12:41 PM, observed V5 and V6 collecting lunch trays. One call light went on. Call light noise heard at nurse's station. V10 (Financial Coordinator) sitting at nurse's station in front of computer. 12/15/2024, 12:43 PM, V6 went into room and answered call light. 12/15/24, 12:56 PM, call light sound went on, V8 (Registered Nurse) and V10 (Financial Coordinator) sitting at the nurse's station, V10 stated I just saw V5, where is she. 12/15/2024, 1:48 PM, V2 (Director of Nursing) states that when a resident pulls the call light, staff need to answer right away. V2 states sometimes its's challenging if the nurse is giving medication and giving patient care, it can take a little. They can't just leave to go answer the call light. Facility document dated 10/15/2024, titled Resident Council Meeting Minutes documents in part residents had mentioned regarding call light response. Facility document dated 2/2/2018, titled Call light documents in part, in all departments, resident call lights will be answered in timely manner. All staff should assist in answering call lights.

Based on observation, interview, and record review the facility failed to follow manufacturer's instruction in using low air loss (LAL) mattress by using multiple layers of linens for residents with pressure ulcers and at high risk for skin impairment. The facility also failed to apply bilateral heel protectors as ordered by physician and care plan intervention. This deficiency affects all five ( R62, R100, R104, R112 and R208) residents in the sample of 30 reviewed for Pressure ulcer prevention management. Findings include: 1. On 10/1/24 at 11:57AM, R208 was observed sleeping, lying in bed leaning to the left side of the bed. He was exposed and uncovered. He was wearing gown and disposable brief. His body from abdomen to lower extremities were exposed. A folded linen sheet placed at the left corner side of the bed was seen. The left heel protector was on the floor. The right heel protector was not properly placed. R208 was wearing bilateral hand mittens. V15 (Nursing Supervisor) was showed observation. V15 said that R208 should have bilateral heel protectors in place. R208 was admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure with hypoxia, Tracheostomy, Dependence of respirator(ventilator), Hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, Dysphagia, Gastrostomy, Stage 4 Pressure ulcer of sacral region. Active physician order sheet indicates heel protecting devices or offload to bilateral heels. Wound care: Left and right heel- cleanse with normal saline, apply skin prep cover with bordered gauze or foam dressing 3x/week and as needed. May cover with abdominal wrap with kerlix if gauze or foam does not stay. Comprehensive care plan indicates: R208 has pressure injury to sacrum extending to right buttocks, bilateral heels and right side back is at risk for delayed wound healing and is at very high risk for further alteration in skin integrity. Intervention: Off load heels using heel protecting devices. 2. On 10/1/24 at 11:59AM, R62 was observed lying in bed with LAL mattress. V15 (Nursing Supervisor) lifted the linen covering R62. A flat sheet and cloth pad was observed under R62 on the mattress. R62 is wearing a disposable adult brief. V15 said that residents on LAL mattresses should only have a flat sheet over the mattress, no cloth pad. R62 was admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure, Tracheostomy, Dependence on Respirator, Gastrostomy, Cerebrovascular disease (CVA), Encephalopathy. Active physician order indicates: Low air loss mattress at all times. Comprehensive care plan indicates R111 is at high risk for developing skin breakdown related to immobility, bowel, and bladder incontinence, CVA with right sided weakness, Encephalopathy, and contracture to lower extremities. Intervention: Provide low air loss mattress at all times. 3. On 10/1/24 at 12:04PM, R104 was observed lying in bed with LAL mattress. V15 (Nursing Supervisor) lifted the linen covering R104. A flat sheet and cloth pad was observed under R104 on the mattress. R104 is wearing a disposable adult brief. V15 said that residents on LAL mattress should only have a flat sheet over the mattress, no cloth pad. R104 is admitted on [DATE] with diagnosis listed in part but not limited to Amyotrophic lateral sclerosis, Acute and chronic respiratory failure, Tracheostomy, Dependence on respirator, Gastrostomy. Active physician order indicates Low air loss mattress in use. Check for proper functioning and setting. Comprehensive care plan indicates R104 is at high risk for pressure ulcer development or skin alteration related to decreased mobility, lateral sclerosis, respiratory failure, vent dependence, atelectasis, incontinence, and self-care deficit. Intervention: Low air loss mattress at all times. 4. On 10/1/24 at 12:10PM, R112 was observed lying in bed with LAL mattress. V15 (Nursing Supervisor) lifted the linen covering R112. A flat sheet and cloth pad was observed under R112 on the mattress. R112 is wearing a disposable adult brief. V15 said that residents on LAL mattress should only have a flat sheet over the mattress, no cloth pad. R112 is admitted on [DATE] with diagnosis listed in part but not limited to Encephalopathy, Intracranial injury, Acute and chronic respiratory failure, Tracheostomy, Dependence on respirator, Gastrostomy, Stage 4 pressure ulcer left buttocks, Type 2 Diabetes Mellitus, Morbid obesity. Active physician order indicates: Low air loss mattress in use. Check for proper functioning and settings. Comprehensive care plan indicates: R112 is at very high risk for impaired skin integrity related to chronic disease process/comorbidities, impaired mobility, and incontinence. She has pressure injury to left buttocks ischium and is at high risk for delayed wound healing and is at risk for further alteration in skin integrity. Intervention: Low air loss mattress in place with appropriate settings and functioning properly. 5. On 10/1/24 at 12:16PM, R100 was observed lying in bed with LAL mattress. V15 (Nursing Supervisor) lifted the linen covering R100. A flat sheet and folded towel was obserevd under R100 over the mattress. R100 is wearing a disposable adult brief. V15 said that residents on LAL mattress should only have a flat sheet over the mattress, no folded towel. R100 is admitted on [DATE] with diagnosis listed in part but not limited to Amyotrophic lateral sclerosis, Tracheostomy, Dependence on respirator, Gastrostomy, Stage 4 pressure ulcer sacral region, Stage 4 pressure ulcer right and left buttocks, Unstageable pressure ulcer part of back, Deep tissue damage of left upper back, right elbow, right ankle, right upper back, Unstageable pressure ulcer of left elbow. Active physician order sheet indicates Low air loss mattress in use, Check for proper functioning and settings. Wound care: Buttocks/perineum/groin cleanse with normal saline (NS), pat dry, apply zinc oxide every day shift and as needed. Left elbow cleanse with NS, betadine paint cover with foam or bordered gauze 3x/week and as needed. Left ischium cleanse with NS, keep contact layer for 3 days, change adaptic, but leave skin substitute apply alginate light pack cover with foam or bordered gauze 3x/week and as needed. Left scapula cleanse with NS, betadine paint xeroform cover with foam or bordered gauze 3x/week and as needed. Mid upper back cleanse with NS, betadine paint, xeroform cover with foam or bordered gauze 3x/week and as needed. Right buttock/ischium cleanse with NS, keep contact layer for 3 days, change adaptic, but leave skin substitute apply alginate lightly pack cover with foam or bordered gauze 3x/week and as needed. Right elbow cleanse with NS apply foam or bordered gauze 3x/week and as needed. Right lateral distal foot cleanse with NS betadine paint cover with foam or bordered gauze 3x/week and as needed. Right lateral midfoot cleanse with NS betadine paint cover with foam or bordered gauze 3x/week and as needed. Sacrum cleanse with NS keep contact layer for 3 days, change adaptic but leave skin substitute apply alginate lightly pack cover with foam or bordered gauze 3x/week and as needed. Comprehensive care plan indicates: R100 has pressure injury to sacrum, bilateral buttock/ischium, bilateral elbow, mid upper back, bilateral scapula, right flank, right lateral mid foot/distal foot and is at risk for further alteration in skin integrity. Intervention: Low air loss mattress in place with appropriate settings and functioning properly. On 10/1/24 at 1:15PM, Informed V10 (Wound Care Coordinator/WCC) of above observations with V15 (Nursing Supervisor). Requested for policy. On 10/2/24 at 2:03PM, V10 (WCC) presented policy on pressure ulcer prevention and low air loss (LAL) mattress. V10 said that they only apply a flat sheet over the LAL mattress. V10 said that they follow physician orders and implement care plan interventions. Facility's policy on Pressure Ulcer Prevention revision 1/15/18 indicates: Purpose: To prevent and treat pressure sores/injury. Guidelines: 9. Pressure reducing (foam) mattress are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc., may be used as determine clinically appropriate. Facility provided manufacture's recommendation for using low air loss mattress: 2. Cover the mattress system with a cotton sheet to avoid direct contact and reduce friction. Facility's policy on Wound Management 3/2/24 indicates: The facility will treat wounds according to physician's order and current standards of clinical practice.

Based on observation, interview, and record review the facility failed to monitor and supervise a resident (R154) who is identified at high risk for elopement that had eloped from the facility. The facility also failed to ensure no medications and used syringes were left at a resident's bedside. This deficiency affects all four residents (R20, R43, R53 and R154) in the sample of 30 reviewed for Residents' safety. Findings include: 1. On 10/1/24 at 11:00AM, R154 is not in his room according to resident roster given by the facility. V25 said that R154 is out on pass. R154's medical records document that R154 was admitted on [DATE] with diagnosis of Cellulitis of right lower limb, Unsteadiness on feet, Acute post hemorrhagic anemia and long-term use of antibiotics. R154 was identified as elopement /unauthorized departure risk on 9/25/24 indicated: A Evaluation: Resident have the physical ability to leave the facility; Resident verbalize anger and or a serious intent to leave the facility and has a history of unauthorized departure; Resident seek exits, pull door handles, hang around facility exits and stairways or wanders between floors; Resident becomes easily agitate, confused, and or disoriented and show poor judgement ( wound not be able to safely care for him/herself outside of the facility; B. Outcome and recommendations: R154 is considered at risk for unauthorized departure/elopement/flight risk. The resident is considered at risk for unauthorized departure. Resident will be placed on elopement watch. R154's progress note entered on 10/1/24 by V25 (LPN/Licensed Practical Nurse) that R154 was out on pass at 9:13AM, then V32 (Social Service) documented that R154 was discharged to another facility at 12:13PM. V32 documented as if the resident was in the facility when discharged to another facility. R154's active physician order did not have a discharge order. There were episodes documented of R154's behavior and verbalization of leaving the facility on 9/25, 9/26 and 9/27/24. No monitoring elopement documentation found in chart. On 10/2/24 at 9:15AM, Surveyor asked V27 (Night Supervisor) What happened to R154?. V27 said that on 9/30/24 around 11:15PM, V33 (RN/Registered Nurse) reported to her that R154 is missing. They searched the 4th floor unit and other floors but were unable to find R154. V27 said that R154 was up and about and goes to other floors. R154 is alert and oriented. He uses a wheelchair within the facility, but he can ambulate. V27 said that she notified V1 (Administrator) and V2 (Director of Nursing/DON) past midnight that resident is missing and cannot be found in the facility after thoroughly searched. V27 said that she notified R154's friend of his elopement. V27 said that she called the police around 6:00AM. V27 said that R154's friend found him in a shelter home and brought him to another facility. V27 said that she did not document because she assumed V33 (RN) documented what had happened. V27 said that she did not do the incident report because the management usually does the elopement incident. On 10/2/24 at 9:25AM, V1 (Administrator) said that they did not do an incident report and did not report to IDPH (Illinois Department of Public Health) of R154's elopement because he was found, unharmed and was brought to another facility of his choice. V1 said that R154 was a planned discharged to this facility. V1 was informed that there is no documentation of what happened on 9/30/24 between 3:00PM to 8:00AM 10/1/24. V1 did not present any incident documentation to surveyor. On 10/2/24 at 9:28AM, V9 (Social Service Director/SSD) said that R154 has planned to discharge to another facility of his choice. R154 is not an elopement risk as indicated in his admission assessment dated [DATE]. However, he presented elopement risk behavior on 9/25/24 and was placed on the elopement risk list and care planned for elopement. V9 said that he was not aware that R154 had eloped the facility until 10/1/24 when she came to work. On 10/2/24 at 9:45AM, V15 (Nursing Supervisor) said that it was endorsed to her by V27 (Night Supervisor) that on 9/30/24 evening shift that R154 eloped from the facility. She did not know what happened to R154. On 10/2/24 at 10:00AM, During resident council meeting, R96 said that recently a resident tried to elope from the facility and was caught at the front desk. R96 did not know the name of the resident. On 10/2/24 at 10:45AM, V25 (LPN/Licensed Practical Nurse) said that she did not know that R154 had eloped from the facility. She presumed that R154 was out on pass thats why she documented it. V25 said that R154 is still active in their system and appearing on the medication administration record. R154 is alert and oriented x 2 but with periods of forgetfulness. He propels himself in wheelchair within the facility, but he can ambulate. On 10/2/24 at 10:54AM, V32 (Social Service) said that he documented the discharge notes for R154 even though he was not in the facility. V32 said that it was a planned discharged to another facility of his choice. R154 had eloped from the facility and was found by his friend in a shelter home and brought him to the facility where he supposed to be transferring. V32 said that R154 was identified as risk for elopement and care planned on 9/25/24. On 10/2/24 at 11:28AM, V34 (Primary Care Physician) of R154 said that she was not aware that R154 eloped from the facility on the evening of 9/30/24 and was transferred to another facility. V34 said that R154 is homeless and was denied by other facilities. Only this facility accepted him, and he needs medical treatment. V34 said that she would expect the facility to notify her when R154 eloped and was transferred to another facility. V34 said that she did not give an order for him to be transferred to another facility. On 10/2/24 at 11:52AM, V35 (Administrator) and V36 (Admission Director) of another facility where R154 was transferred said that R154 was dropped off by his friend to their facility. They are not aware that R154 had eloped from the facility. They called V32 (Social Service) to fax documents of R154 to their facility. On 10/2/24 at 1:29PM, V37 (Regional Director) said that they should have documentation of the elopement incident including an incident report but not necessary to report to IDPH because the resident is unharmed. On 10/2/24 at 1:41PM, V2 (DON/Director of Nurses) presented an elopement incident report dated 10/1/24 at 6:54AM that she completed. V2 said that she informed V27 (Night supervisor) that she will do the incident report. V2 said that she did not notify V34 (R154's Physician) and his case manager of elopement and transfer to another facility. V2 presented R154's police report of elopement incident date 9/30/24. On 10/2/24 at 7:09PM, V38 (LPN) said that she is not aware that R154 had eloped from the facility on evening of 9/30/24. She said that R154 is alert and oriented, propels himself in wheelchair. R154 goes to other floors and stays late. V38 is not aware that he is on elopement risk. She said that R154 has 5pm and 9pm scheduled medications. She cannot recall when she gave his medication and what time she last saw him in the unit. On 10/3/24 at 9:10AM, Surveyor asked V1 (Administrator) how soon they have to document or make an incident report for a missing person. Informed V1 that R154 was noted missing on 9/30/24 at 11:15PM and no documentation was in the resident chart about the elopement incident and the elopement incident report was initiated on 10/1/24 at 6:54AM. On 10/3/24 at 11:00AM, V1 (Administrator) said that she was told by corporate that it is accepted to document at end of the shift after the task was completed. On 10/3/24 at 9:27AM, V32 (Social Service) said that R154 was placed on elopement risk on 9/25 and the interdisciplinary team was notified. V39 (Interim SSD) said that residents on elopement risk should be on monitoring every 2 hours or at least every shift it should be documented. V2 (DON) said that nursing staff monitor R154 every 2 hours, but they did not have documentation. Informed V32 that he wrote the discharge notes for R154 without physician orders of discharge to another facility. V32 did not document that R154 had eloped from the facility, went to shelter care, and was brought by R154's friend to another facility. Instead V32 charted that R154 was discharged from this facility and was transferred to another facility. V2 said that they cannot document a discharge summary if the resident is not in the facility. V2 said that nursing staff will write the discharge narrative which include resident clinical condition/status/stability, vital signs, medications and treatment instructions, personal belongings, medical equipment, transportation arrangements and discharge instructions. V2 said that discharge orders should be obtained from the primary care physician. On 10/3/24 at 10:21AM, V3 (ADON/Assistant Director of Nurses) said she is not aware that R514 is an elopement risk. V3 said that on 9/26/24, R154 displayed exiting behaviors and was observed rummaging through the dietary food cart. Resident had called 911 multiple times and stated wanting to leave the facility. V3 said that V1 (Administrator) and V2 (DON) were notified of R154 's behavior. V3 said that residents at risk for elopement should be monitored every hour to visually see the resident and document in behavior monitoring or in progress notes. V3 said that R154 did not have documentation that elopement risk monitoring was done. V3 said that on 10/1/24 when she came to work, she was notified that R154 had eloped from the facility. On 10/3/24 at 10:36AM, V5 (Infection Control) said that he is not aware that R154 was on elopement risk. V5 said that on 9/28/24, he was called by reception staff that R154 was agitated and insisted to go out of the facility to go home. He went to see R154 and noted him to be agitated and insisted to go out of the facility to go home. V5 explained to the R154 the risk of going home without proper processess for his safety and well-being. V5 was able to convince the R154 to stay until proper discharge could be done. R154 went back up to the floor with a police officer (who according to receptionist was called by the R154). Discussed with the police officer that R154 was insisting to go home without proper and safe discharge planning. Police officer went to talk to R154. R154 was convinced to stay and follow proper process for safe discharge. V5 said that they should monitor resident every 2 hours and as needed who are at risk for elopement. V5 said that he has to check the policy but if she is the assigned nurse to R154 she will document monitoring done for R154. On 10/3/24 at 12:38PM, Informed V37 (Regional Director) of concerns above identified that there is no communication among the IDT (Interdisciplinary Team) that R154 was placed on elopement risk since 9/25/24. No documentation of elopement monitoring or supervision was done despite the risk of elopement. V34 (Physician of R154) was not notified of elopement and discharged to another facility. R154 was recently admitted to the facility due to a medical condition and needed treatment as indicated in his diagnosis and active physician order sheet. On 10/3/24 at 2:41PM, V33 (RN) said that when she made rounds on 9/30/24 around 11:15PM, she noted that R154 was not in his room. V33 said that he usually stays in the dining area on the first floor. Around 12:30AM, R154 was not yet back to his unit, she asked his 2 CNAs (Certified Nurses Assistant) to search for him. When they couldn't find him, she notified V27 11-7 Nursing supervisor. V27 notified V1 (Administrator) and V2 (DON) that R154 was missing. No code green announcement was done. They went floor to floor and asked staff to look for R154. She did not call V34 (Physician of R154). She did not document of the elopement incident; she assumed that the supervisor and DON would document. V33 said that she should have documented in R154's chart of his elopement and what they did. V33 said that she did not fill out the elopement incident report. On 10/3/24 at 8:14PM, V40 (3-11 shift supervisor) said that he is aware that R154 is at risk for elopement. V40 said that they monitor him every 2 hours but did not document it. V40 said that they should document monitoring done for R154. R154 is up and about and goes to different floors. He cannot recall when he last seen R154. He was not aware that R154 eloped from the facility on his shift. On 10/3/24 at 8:24PM, V41 (CNA) said that she is aware that R154 is risk for elopement. V41 said that they monitor him but did not document it. V41 said that she made rounds at 10:00PM, she did not see R154 in his room and in the unit. She did not report to the nurse because R41 usually goes to other floors/units and stays late at night. V4 said that she is not aware that R154 had eloped from the facility. Facility's policy on Code Green- Missing Resident/Elopement reviewed 11/15/18 indicates: Guidelines: 1. All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the charge nurse as soon as practical. This includes any resident did not sign out or did not notify a staff member of his or her leaving. 3. Should an employee discover that a resident is missing from the facility, he or she should: a. Immediately report the missing resident to the charge nurse or nursing supervisor. c. Alert staff by announcing Code [NAME] over the paging system d. Inform staff of the name of the missing resident and visualize picture of resident if available e. Make a thorough search of the building premises. f. Notify the administrator and Director of Nursing immediately, if resident is not found after the search. g. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. The following steps should occur: 1. A nurse should notify the attending physician. 2. Notify the resident legal representative/responsible party *Determine if friends or family knows where the resident may be attempting to go. 3. Notify the Sheriff and or police department and file a missing person report 4. Provide a search team with a resident identification information. 5. Increase search by a more extensive search of surrounding area. 6. Remain in contact with hospitals, nursing facilities, family members 7. Complete incident report and notify the state agency according to reporting guidelines. 8. Document appropriate notations in the medical record. 2. R53 was admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus with diabetic neuropathy, Morbid obesity due to excess calories, Acute and chronic respiratory failure with hypoxia, Tracheostomy. Active physician order sheet indicates Nystatin external powder 100,000 unit/gram (Nystatin Topical) apply to skin folds, topically every 12 hours for MASD (Moisture Associated Skin Disease) abdominal and breast folds. On 10/1/24 at 11:54AM. Observed R53 lying in bed with tracheostomy connected to oxygen. Observed Nystatin powder medication container on top of her bedside tray table. V15 (Nursing Supervisor) was shown observation. The medication label read Nystatin powder 100,000 USP units/gram with R80's name. V15 said that medication should not be left at the resident bedside for safety, and medication treatment cannot be shared with another resident. On 10/1/24 at 1:15PM, Informed both nurses on 5th floor- V18 (RN) and V30 (LPN) of above observation. Both said, they are not aware that R80's nystatin medication was at R53's bedside tray table and they did not know how it got to R53's room because R80 is on the 2nd floor. Both said that medication should not be left at the resident bedside for safety, and medication treatment cannot be shared with another resident. On 10/3/24 at 2:30PM, Informed V2 (DON) of above concerns. V2 said that medication should not be left at the resident bedside for safety, and medication treatment cannot be shared with another resident. Facility unable to provide Medication safety policy. 49871 3. On 10/1/2024 at 11:20 AM, R20 was observed with three medications in a plastic bag on top of the bedside table. Medications include one nose drop (Fluticasone) and two eyedrops (Latanoprost, Dorzalamide). R20 said the medications belongs to her. On 10/1/2024 at 11:23 AM, V21 (Licensed Practical Nurse/LPN) said R20 has an order for those three medications and those medications should not be at bedside. V21 proceeded to take the medications with her. On 10/1/2024 at 12:13 PM, V2 (Director of Nursing/DON) said it is the expectation that no medication should be left at residents' bedside table. 50469 On 10/01/24 at 11:10 AM, observed used needle syringe on top of R43's beside counter. R43 is alert and oriented and said the nurse must have left it there. On 10/01/24 at 11:18 AM, V25 (LPN) said that used needle syringes should be disposed in a sharps container and not left at bedside. On 10/01/24 at 12:12 PM, V2 (Director of Nursing) said her expectations are not to have used needle syringes at bedside, the needle syringes should be discarded in the sharps container after use. Facility's policy on Syringe and Needle Disposal- Effective date 10/25/2014 Policy: Used syringes and needles are disposed of safely and in accordance with applicable laws and safety regulations. Procedure: B. Immediately after use, syringes and needles are placed into puncture resistant, one-way containers (sharps) specifically designed for that purpose.

Based on observation, interview, and record review the facility failed to provide privacy and dignity to a totally dependent and cognitively impaired resident. This deficiency affects one (R208) of three residents in the sample of 30 reviewed for Resident's rights. Findings include: R208 was admitted on [DATE] with diagnoses listed in part but not limited to Acute and chronic respiratory failure with hypoxia, dependence on ventilator, Hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, Tracheostomy, Gastrostomy. On 10/1/24 at 11:57AM, R208 was observed lying in bed sleeping, leaning to the left side of the bed. He was exposed and uncovered wearing a gown and disposable brief. His body from his abdomen to lower extremities were exposed. A folded linen sheet was seen on the left corner side of the bed. The left heel protector was on the floor. The right heel protector was not properly placed. R208 was wearing bilateral hand mittens. The door was open and R208 was visible to any passerby walking in the hallway. The room is close to and can be viewed from the nurses station. Staff were observed at the nurses station and in the hallway. V15 (Nursing Supervisor) was showed observation. V15 said that R208 should be covered with linen for privacy and dignity. V15 took the folded linen from the corner of the bed and spread it to cover R208. On 10/1/24 at 1:30PM, Informed V1 (Administrator) and V2 (Director of Nursing) of above concern. Requested for policy. Facility's policy on Resident Rights reviewed 1/4/19 indicates: Purpose: To promote the exercise rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: *Exercise his or her rights. *Privacy and confidentiality.

Based on interview, and record review the facility failed to obtain discharge orders from the physician to transfer a resident (R154) to another facility and failed to provide a discharge summary to the continuing provider and receiving facility at the time of discharge. This deficiency affects one (R154) of one in the sample of 30 reviewed for Discharge summary. Findings include: A review of R154's records show that R154 was admitted on [DATE] with diagnoses of Cellulitis of right lower limb, Unsteadiness on feet, Acute post hemorrhagic anemia and long-term use of antibiotics. R154 was identified as elopement/unauthorized departure risk on 9/25/24 indicated: A Evaluation: Resident have the physical ability to leave the facility; Resident verbalize anger and or a serious intent to leave the facility and has a history of unauthorized departure; Resident seek exits, pull door handles, hang around facility exits and stairways or wanders between floors; Resident becomes easily agitated, confused, and or disoriented and show poor judgement (wound not be able to safely care for him/herself outside of the facility); B. Outcome and recommendations: R154 is considered at risk for unauthorized departure/elopement/flight risk. The resident is considered at risk for unauthorized departure. Resident will be placed on elopement watch. R154's progress notes were reviewed. On 10/1/24, a progress noted was entered by V25 (LPN/Licensed Practical Nurse) that documents that R154 was out on pass at 9:13AM, then V32 (Social Service) documented that R154 was discharged to another facility at 12:13PM. V32 documented as if the resident was in the facility when discharged to another facility. R154's active physician order did not have discharge orders. There were episodes documented of R154's behavior and verbalization of leaving the facility on 9/25, 9/26 and 9/27/24. No monitoring elopement documentation was found in the chart. On 10/2/24 at 9:25AM, V1 (Administrator) said that R154 reported that he has eloped from the facility on 9/30/24 around 11:15PM. Elopement incident was done on 10/1/24 at 6:54AM. R154's friend and police officer were notified. R154's friend found him in a shelter home and took him to another facility of his choice. V1 said that R154 was a planned discharged to the facility he was transferred to. On 10/2/24 at 10:54AM, V32 (Social Service) said that he documented the discharge notes for R154 even though he was not in the facility. V32 said that it was a planned discharged to another facility of his choice. R154 had eloped from the facility and was found by his friend in a shelter home and brought him to the facility where he supposed to be transferring. On 10/2/24 at 11:28AM, V34 (Primary Care Physician) of R154 said that she was not aware that R154 eloped from the facility on the evening of 9/30/24 and was transferred to another facility. V34 said that R154 is homeless and was denied by the other facility. Only this facility accepted him, and he needs medical treatment. V34 said that she would expect the facility to notify her when R154 had eloped and transferred to another facility. V34 said that she did not give an order for him to be transferred to another facility. On 10/2/24 at 11:52AM, V35 Administrator and V36 Admission Director of another facility where R154 was transferred said that R154 was dropped off by his friend to their facility. They are not aware that R154 had eloped from the facility. No discharged instructions and resident's personal belongings received. They called V32 Social Service to fax documents of R154 to their facility. R154's progress note by V32 (Social Service) dated 10/1/24 at 12:13PM, documented R154 was admitted on [DATE] and V32 assisted R154 with finding another nursing home due to resident stating this nursing home not meeting his medical needs and requesting to transfer to a nursing home in Chicago. R154 was discharged and this facility arranged for transportation to another nursing home facility on 10/1/24. R154 did not show any signs or symptoms of depression or manic episodes or behaviors. R154 was re-educated on safety, home needs and medical requests, including proper nutrition, medical advice, medication usage and side effects, doctor needs and all information pertaining to R154's health and well-being relative to discharge. R154 was asked if they needed any additional medical services. R154 is stable upon discharge. The resident was asked if they needed any additional medical information, help and or education on medications/prescriptions by nursing staff. The resident expressed that he is excited to be transferred to a nursing home and happy to be discharged to pursue individual goals. Social service will follow up and provide support as appropriate. On 10/3/24 at 9:27AM, Informed V32 (Social Service) that he wrote the discharge notes for R154 without a physician order of discharge to another facility. V32 did not document that R154 had eloped from the facility, went to shelter care, and was brought by R154's friend to another facility. Instead V32 charted that R154 was discharged from this facility and was transferred to another facility. V32 did not see nor spoke with R154 on 10/1/24. V2 (DON/Director of Nurses) said that they cannot document discharge summary if the resident is not in the facility. V2 said that nursing staff will usually write the discharge narrative which includes resident clinical condition/status/stability, vital signs, medications and treatment instructions, personal belongings, medical equipment, transportation arrangements and discharge instructions. V2 said that a discharge order should be obtained from the physician before they can discharge resident. On 10/3/24 at 2:20PM, V1 (Administrator) said that they don't have policy on Discharge summary. Facility unable to provide policy on discharge summary.

Based on observation and record review the facility failed to provide a resident (R111) with a backup tracheostomy tube of appropriate size at the bedside for accidental extubation. This deficiency affects one (R111) of three residents in the sample of 30 reviewed for Respiratory care. Findings include: R111 was admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure with hypoxia, Tracheostomy, Gastrostomy, Anoxic brain damage. Active physician order sheet indicates Change inner cannula 6.5 size every day and night and as needed. Comprehensive care plan indicates that she has tracheostomy for impaired breathing mechanics due to acute and chronic respiratory failure with hypoxia. Interventions: Keep an additional tracheostomy tube (same size as the resident's) at bedside for an emergency situation. On 10/1/24 at 11:42AM, Rounds were made to R111 with V8 (Respiratory Therapist) and V15 (Nursing Supervisor). R111 was observed lying in bed with tracheostomy tube on room air. V8 showed surveyor the spare tracheostomy tube size of 7.5 at bedside. V8 said that R111 is on trach size 6.5. V8 said that R111 should have a trach size of 6.5 at the bedside, not 7.5. V8 said that residents with a tracheostomy should have 1 same size and 1 downsize tracheostomy tube at bedside for emergency/accidental extubation. On 10/1/24 at 1:20PM, Informed V2 (Director of Nursing) of above concern identified. Facility's policy on Accidental Extubation indicates: Purpose: A patient's airway is essential to maintain the patient's cardiopulmonary status. In case of an accidental extubation, it is absolutely necessary to re-establish an airway as quickly as possible. Policy: It is the policy of this facility to prevent accidental extubation whenever possible, however not all accidental extubation are preventable. In such instances, management of extubation will be done in a safe and effective way in accordance with applicable rules and regulations and standard of care. II. Unable to reinsert tracheostomy tube A. If unable to re-insert tracheostomy tube of original size, a tracheostomy tube of the next smaller size should be inserted. IV. Special Considerations A. A backup tube the same size or one size smaller than the prescribed size will be always kept at bedside.

Based on observation, interview, and record review the facility failed to implement its medication administration policy by failing to administer treatment medication by authorized personnel and failed not to administer medication treatment supplied for one resident to another resident. This deficiency affects one (R53) of three residents reviewed for Medication administration safety. Findings include: R53 was admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus with diabetic neuropathy, Morbid obesity due to excess calories, Acute and chronic respiratory failure with hypoxia, Tracheostomy. Active physician order sheet indicates Nystatin external powder 100,000 unit/gram (Nystatin Topical) apply to skin folds, topically every 12 hours for MASD (Moisture Associated Skin Disease) abdominal and breast folds. On 10/1/24 at 11:54AM. R53 was observed lying in bed with a tracheostomy connected oxygen. Nystatin powder medication container was seen on top of her bedside tray table. Observation was shown to V15 (Nursing Supervisor). The medication label read Nystatin powder 100,000 USP units/gram with R80's name. V15 said that medication should not be left at the resident bedside and medication treatment cannot be shared with another resident. R53 said that the CNAs (Certified Nurse Assistant) apply the nystatin powder to under her breast, abdominal folds, and groin areas. V15 said that CNAs cannot administer Nystatin medication to R53, only the nurse. On 10/1/24 at 1:15PM, Informed both nurses on 5th floor - V18 (RN/Registered Nurse) and V30 (LPN/Licensed Practical Nurse) of above observation. Both said that they did not apply the nystatin powder medication to R53. Both said, the wound care nurses are the one's administering the medication, and they are the one's documenting it in the MAR (Medication Administration Record). Both said, they were not aware that R80's nystatin medication was on R53's bedside tray table and they did not know how it got to R53's room because R80 is on the 2nd floor. Both said that medication should not be left at the resident bedside and medication treatment cannot be shared with another resident. Both said that CNAs cannot administer Nystatin medication to R53, only the nurse. On 10/1/24 at 2:00PM, Informed V2 (Director of Nursing/DON) of above observation. V2 said that medication should not be left at the resident bedside and medication treatment cannot be shared with another resident. V2 said that CNAs cannot administer medication to a resident. On 10/2/24 at 11:08AM, V16 (CNA) and V17 (CNA) said that they are administering the nystatin power medication that was at the bedside tray table of R53 to her groin, abdominal folds and under the breast as the resident requested when they were providing care to her. They did not notice that the Nystatin powder is R80's medication. They are aware that they are not allowed to administer medication, but they are just following the resident request. On 10/2/24 at 2:03PM, V10 (Wound Care Coordinator) said that they usually administered R53's nystatin medication but the nurses on the floor will document it. Informed V10 of above observation. V10 was not aware that R80's nystatin medication was at R53's bedside tray table. V10 said that medication should not be left at the resident bedside and medication treatment cannot be shared with another resident. V10 said that CNAs cannot administer Nystatin medication to R53, only the nurse. On 10/3/24 at 1:02PM, V31 (Wound Care Nurse) said he administrated R53's Nystatin powder treatment on 10/1/24 at 9AM and informed the floor nurse to document it. V31 said that he can document that he did administer the medication to R53, but it was already their practice that the floor nurse will document for them. V31 said that he used R53's Nystatin powder medication that was kept in the treatment cart. On 10/3/24 at 1:13PM, Informed V1 (Administrator) of above concerns and showed R53's Medication Administration record of Nystatin powder for September and October 2024. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: A. Preparation 4. Five Rights- Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. B. Administration 1. Medications are administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders. 15. Medications supplied for one resident are never administered to another resident. D. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. 3. Topical medications used in treatments are listed on the Treatment Administration Record.

Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living for 2 of 4 residents (R2, R3) reviewed for activities of daily living in the sample of 8. The findings include: 1. On 9/13/24 at 9:54 AM, R2 was in bed, dressed in a patient gown. R2 said she is waiting for the staff to help her get dressed and out of bed and into her chair. R2 said she likes to get up usually between 10:00 to 11:00 AM. R2 said it takes two staff and the mechanical lift machine to get her out of bed. On 9/13/25 at 11:27 AM, R2 was still in bed waiting for staff to get her up. On 9/13/24 at 12:05 PM, R2 was still in bed and was eating her lunch. R2 stated They are really dragging their feet about getting me up today and I'm a little upset about it. They had to get the dialysis residents up first so they are the priority. On 9/13/24 at 1:22 PM, R2 was dressed and up in her motorized wheelchair. R2 said they got her up about 1:15 PM and at least she was up in time to go to the activity at 2:00 PM. R2's Minimum Data Set, dated dated dated [DATE] shows R2 is cognitively intact and is dependent on staff for bed to chair transfers. R2's Care Plan shows R2 requires a full body lift for transfers and is dependent on two staff. 34490 2. R3's Minimum Data Set assessment dated [DATE] shows that R3 is always incontinent of stool and is dependent on staff for toileting and hygiene. On 9/13/24 at 9:58 AM, R3 was laying in bed. R3 said that his catheter is leaking and he was last changed around 5:00 AM. At 10:26 AM, V7 (Registered Nurse) went to R3's room to observe his catheter. R3's incontinence brief was wet. R3 stated, How come this is wet? when he touched the top of his brief. V7 then told R3 that she would have the Certified Nursing Assistants (CNAs) come in and change him. V7 exited the room and continued with passing medications. On 9/13/24 at 10:30 AM, V5 said, We are doing him next. We have not gotten to him yet today since there is only two of us and I was here for the first two hours of my shift by myself. V5 said that his shift starts at 7:00 AM. At 11:00 AM, V5 said that residents should be checked every two hours to see if they need to be changed. On 9/13/24 at 10:39 AM, V4 and V5 (CNAs) provided incontinence care to R3. R3's incontinence brief was wet and had stool present. R3's Care Plan shows that he is at high risk for further skin breakdown due to incontinence with an intervention to include: Educate Resident / Representative on importance of keeping skin clean and moisturized.

Based on observations, interviews, and record reviews, the facility failed to consistently monitor resident's skin every shift, turn and reposition every two hours, carry out wound treatment orders as prescribed, and implement pressure relieving interventions to prevent a facility acquired pressure ulcer from recurring for one resident. This affected one of three residents (R3) reviewed for pressure sore prevention. This failure resulted in R3's sacral/right buttock stage 3 pressure ulcer re-opening and new wound treatment orders to be obtained. Findings include: On 12/13/23 at 10:40am, this surveyor observed V12 CNA (certified nurse aide) perform incontinence care for R3. R3 was observed to have a small blue brief tucked within large yellow brief. There was a disposable incontinence pad also under R3. V12 removed the briefs, provided care, and placed two new briefs on R3. Barrier cream was not applied to R3. On 12/13/23 at 11:00am, this surveyor observed V3 (wound care nurse) perform wound care treatments for R3. R3's sacrum to right buttock stage 3 pressure ulcer was cleaned with normal saline, then medihoney, adaptic, and calcium alginate were applied to wound and covered with a bordered gauze dressing. On 12/13/23 at 12:43pm, V3 stated that R3' sacrum to right buttock wound opened again. V3 stated that V3 observed wound open during wound treatment today. V3 stated that he will notify the physician that wound has re-opened and obtain treatment orders. V3 stated that there should be a single flat sheet and one brief when a resident is on a low air loss mattress. V3 stated that a disposable incontinence pad and double briefing resident is not recommended. V3 stated that the low air loss mattress manufacturer's instructions recommend only a flat sheet under resident. V3 stated that he was not aware that V10 (wound care physician) changed R3's treatment order for R3's sacrum/right buttock wound on 12/6/23. V3 acknowledged R3's sacrum/right buttock treatment should have been changed on 12/6 per V10's order. V3 stated that low air loss mattress are designed to allow air flow to pass through and prevent moisture build up. On 12/13/23 at 2:00pm, V3 was observed performing wound care treatment for R3. R3's wound measures 2.5cm x 1cm. V3 stated that the wound is superficial, shallow open wound. On 12/13/23 at 3:15pm, V10 (wound care physician) stated that V10 was not aware staff have been placing two incontinence briefs on R3 when providing care. V10 stated that using two incontinence briefs could affect wound healing and should not be used. V10 stated that there is no literature in medical journals on what effect the incontinence pad would have on wound development or deterioration. V10 stated that it is common sense not to use two briefs and an incontinence pad under resident on low air loss mattress. V10 stated that he spoke with V3 (wound care nurse) and gave new treatment orders for R3's sacrum/right buttock wound. On 12/13/23 at 3:35pm, V11 (nurse) stated that when the order is written in the resident's EMR (electronic medical record), it is also entered on the resident's TAR (treatment administration record). V11 stated that all scheduled treatments will pop up when due when in the resident's EMR. V11 stated that if a treatment is scheduled for day shift, evening shift, and night shift, it will continue to pop up until it is marked as completed by the nurse on that shift. V11 stated that skin checks are completed every shift for all residents. V11 stated that if the scheduled treatment time on the TAR is blank then the treatment was not done. V11 stated that the nurse should make sure all scheduled treatments for his/her shift are completed. R3's medical record notes R3 with diagnoses including, but not limited to, left buttock stage 4 pressure ulcer, right buttock stage 3 pressure ulcer, chronic respiratory failure, tracheostomy, ventilator dependent, functional quadriplegia, gastrostomy, and anoxic brain damage. R3's MDS (minimum data set), dated 11/2/23, notes R3 with severely impaired cognition and total dependence on staff for all ADLs. R3's braden score, dated 12/8/23, notes resident is at very high risk for skin breakdown. R3's POS (physician order sheet), dated 11/10/23, notes an order for a low air loss mattress. There is an order, dated 11/15, for heel protector at all times or offload with pillows. On 12/2, skin checks every shift. On 12/11, turn and reposition every two hours and as needed. R3's ADL care plan, revised 10/21/22, notes R3 has an ADL self-care performance deficit related to activity intolerance, impaired mobility, and poor cognition. R3 is totally dependent and requires two person physical assistance with bed mobility. R3 is at risk for skin breakdown/pressure ulcer development related to impaired mobility, bladder/bowel incontinence, co-morbidities. On 10/21/23, R3's sacrum to right buttock stage 3 pressure ulcer re-opened. Interventions identified, but not limited to, apply moisture barrier ointment after each incontinent episode, heel protectors at all times or offload with pillows, low air loss mattress, and turn and reposition every 2 hours and as needed. V10 (wound care physician) note, dated 12/6/23, notes R3's musculoskeletal functional status is total care. R3's upper and lower extremities-contractures stiff. Sacrum to right buttock stage 3 pressure ulcer, re-opened on 10/21/23. Wound measures 2.5cm (centimeters) x 5cm, 50% epithelialization and 50% maroon. Treatment changed on 12/6 to clean with normal saline, apply zinc oxide, and cover with bordered gauze. R3's TAR (treatment administration record), dated December 2023, notes R3's skin was not checked on the evening shift or night shift on 12/10, the evening shift on 12/11, or the evening shift on 12/12. It also notes R3 was not turned or repositioned from 12:00pm until midnight on 12/12 or 8:00am and 10:00am on 12/13. The low air loss mattress manufacturer's instructions note the low air loss mattress is designed to prevent and treat pressure ulcers. Residents can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the resident.

Based on interview and record reviews, the facility failed to include documentation in the residents medical record of assessment and monitoring of tracheotomy status and cares provided. This failure affected one (R7) of one resident reviewed for tracheotomy care and resulted in R7 being found unresponsive, with tracheotomy tube not in place and the facility was not able to identify how long the resident was without the trache tube in place; R7 expired of respiratory distress. Findings include: R7 is a [AGE] year-old female, admitted in the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Unspecified, Unspecified Whether with Hypoxia or Hypercapnia and Encounter for Attention to Tracheotomy. Nurse Practitioner progress notes dated [DATE] recorded that R7 was alert and oriented to time, place, person and event. She was able to write and mouth out words as a way of communication. She had a tracheotomy tube in placed to oxygen source. According to progress notes dated [DATE] time stamped 8:30 AM, V6 (Respiratory Therapist, RT) documented that around 7:25 AM, she was called to come to R7's room. As she entered the room, R7 appeared to be dusty and unresponsive. Code blue was called, and CPR (cardiopulmonary resuscitation) began. V6 observed in R7's left hand her trache. Another RT (V24) entered the room and replaced the trache and started ambu bagging the resident (R7). CPR was continued until paramedics entered and took over. Progress notes dated [DATE] time stamped 9:00 AM, R7 expired at 8:20 AM. On [DATE] at 11:17 AM, V6 was asked regarding R7. V6 stated, I remember she had her trache in her hand. I did start CPR immediately and chest compressions. I don't know how the entire trache got to her hand. When I started CPR, V24 (Respiratory Therapist) inserted the same trache to get an airway. The trache ties were there, one part is open and the other part still has the tie. I might say that she pulled it and it came out, not sure. She was alert and oriented. She had anxiety. She could have been redirected or notify nurse that she is anxious so PRN (as needed) medication for anxiety could be administered. V6 was also asked on what could be the cause of her (R7) death. V6 verbalized, Because she did need oxygen and she removed it, then it could be the cause of her death, which is due to lack of oxygen. On [DATE] at 12:24 PM, V24 (Respiratory Therapist) was interviewed regarding R7 but denied any knowledge regarding R7 and incident. However, in progress notes dated [DATE] time stamped 12:03 PM, V24 documented R7 was found unresponsive, CPR was done for 50 minutes. V5 (Licensed Practical Nurse, LPN) was also asked regarding R7. V5 replied, That time, I already saw her lying down, unresponsive. We tried to talk to her but she was not responding. We started CPR. After paramedics arrived, they checked her. And after one to two hours, they said she (R7) expired. Respiratory Therapist does trache care and changing of trache. They don't have a specific time, they do it as needed. As a nurse, I monitor resident's trache when doing rounds in the morning, when I started my shift, and during med pass. I checked trache every two hours or less. When I came that morning, I saw her unresponsive already. I was morning shift that time. Usually, after night shift gave report around 7 AM, I do my rounds. R7 was found unresponsive around 7:25 AM as progress note documented. There was no other documentation noted pertaining to R7's condition prior to 7:25 AM, unable to determine how long she (R7) was unresponsive. On [DATE] at 1:14 PM V16 (Respiratory Therapy Director) was interviewed regarding trache monitoring. V16 verbalized, Residents can remove their own trache. If it is a resident who continuously remove the trache or tubing, Nursing Department is informed so mittens could be used on those residents. Trache removal usually happens on residents who are very anxious, having periods of restlessness; when they have anxiety episode, they can remove the trache. Staff has to do frequent monitoring, if staff observed a resident having anxiety, let nurses know so PRN medication can be administered. If a resident is alert and conscious, staff has to redirect them and reeducate on the importance of trache in breathing process. Further review of R7's progress notes showed no documentation related to any anxiety episodes. Her (R7) face sheet listed Anxiety Disorder, Unspecified as one of the diagnoses. POS (Physician Order Sheet) dated [DATE] indicated that R7 had an order of Alprazolam tab 0.25mg (milligrams) - give 1 tablet via Gtube (gastrostomy tube) every 12 hours as needed for anxiety. MAR (Medication Administration Record) recorded that Alprazolam was administered to R7 on [DATE] and [DATE] only. R7's care plan on tracheotomy documented: Intervention ([DATE]) - Monitor for s/s (signs and symptoms) of respiratory distress (restlessness, agitation, confusion, increased heart rate (tachycardia), air hunger and / or bradycardia. On [DATE] at 2:10 PM, V10 (Nurse Practitioner, NP) was interviewed regarding R7. V10 stated, She was alert, oriented to time, place, person and event; very pleasant lady. She was diagnosed with acute hypoxemic and hypercapnia respiratory failure. When she was at the facility, she needed a trache collar to oxygen source. She felt anxious on and off. When I saw her last [DATE], she felt that she was having slow progression in mobility and she wanted to get disconnected from trache and oxygen. She wanted to get back to normal life. V10 was also asked about the importance of trache in R7's condition. V10 stated, If she cannot breathe and not getting adequate oxygenation, she would clearly not do well and need a trache. R7's Death Certificate dated [DATE] documented: date of death : [DATE] Causes: Respiratory Failure On [DATE] at 9:37 AM, V20 (NP/Pulmonology) was asked regarding tracheotomy care and respiratory failure. V20 stated, Residents with respiratory failure is not able to breathe on their own, they have tracheotomy placed on them to assist with breathing. It is a system that helps residents breathe on their own. The lungs cannot get enough oxygen in the blood, and not able to breathe out their carbon dioxide which is a waste gas. If trache is removed and no oxygen, you don't breathe, you die. Staff needs to make sure trache is in place, make sure the resident is alive and breathing. Staff needs to monitor residents for breathing and tracheotomy placement. Residents can still remove the trache when they are confused, or accidentally remove the trache when they scratch the neck. If residents are anxious, it is possible that they can also remove their trache. Facility's policy titled Tracheostomy Care, undated, does not specifically address procedures or guidelines on trache monitoring and management.

Based on interview and record review, the facility failed to have effective interventions in place to prevent a resident, admitted with intact skin, from developing a Stage III pressure injury while in the facility. This failure applied to one (R4) of one resident reviewed for pressure ulcers. Findings include: R4 is a [AGE] year old female admitted to the facility 8/7/23 with diagnosis that include enterocolitis due to C-Diff, Acute and Chronic Respiratory Failure with Hypoxia, Tracheostomy, Dependence on Respirator (Ventilator), Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis and Dementia. According to R4's electronic health record, she was admitted requiring total assistance for all activities of daily living including turning, repositioning and incontinence care. According to admission notes and assessments, R4 admitted to the facility with intact skin, and no skin conditions. R4 was transferred to the hospital 10/8/23, admitted for abdominal distention and is currently hospitalized during this investigation. The facility identified MASD (Moisture Associated Skin Dermatitis) 8/28/23 on the perineum and buttock. On 9/13/23 the facility identified a Stage 3 pressure ulcer to the sacrum. Treatment administration records reviewed from August to October identified treatments were put and place at the time of assessment and carried out as ordered. Wound assessment dated [DATE] identified wound to the sacrum as healed. On 10/18/23 at 10:19AM V21 Wound care NP said R4 developed MASD due to incontinence. The pressure injury likely developed due to infrequent repositioning in addition to incontinence, but it is hard to determine the exact cause because this patient has other health concerns that can contribute to skin break down. It is the goal however that any resident coming to the facility with in-tact skin will maintain intact skin unless the factors were unavoidable. I determined the stage of the wound to the sacrum as III because there was some slough that developed. At that time, I also recommended a low air loss mattress to help alternate pressure since R4 was bed bound. The air mattress does not take precedence over the staff providing manual assistance, but it is a helpful measurement. Since the wound was not very deep, we were able to heal it quickly using daily treatments. Policy titled Pressure Ulcer Prevention revised 1/15/18 states in part: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. 4. Keep bottom sheet dry and tightly stretched and free of wrinkles; 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow pr pads protecting bony prominences as indicated.

Based on interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not identifying and implementing personalized care plan interventions on admission and not providing adequate supervision for a resident at high risk for falls; they also failed to adequately supervise or remove a safety hazard when identified, for a resident at high risk for falls. These failures applied to two of three residents (R5 and R6) reviewed for falls and resulted in R5 sustaining a head injury requiring sutures. Findings include: R5 is an [AGE] year-old male with a diagnoses history of Prostate Cancer, Bone Cancer, Mild Cognitive Impairment, Major Depressive Disorder, Anxiety Disorder, and Cognitive Communication Deficit who was admitted to the facility 08/09/2023. R5's Hospital Record dated 08/09/2023 and included in the facilities electronic medical record documents he is a high fall risk with interventions implemented including: place of bed locked in lowest position, bed alarm set, side rails up times three, and frequent rounds maintained. R5's Fall Risk assessment dated [DATE] documents he was at moderate risk for falls. R5's current care plan initiated 08/10/2023 documents he is at high risk for falls related to confusion, being unaware of safety needs, hearing problems, and history of falls with interventions including: Review information on past falls and attempt to determine cause of fall, record possible root causes, alter remove any potential causes as possible, educate resident/family/ caregivers/ interdisciplinary team as to causes; effective 9/1/23 anticipate resident's needs, offer toileting before bedtime or during night shift when awake, encourage resident to use assistive device, therapy to screen; physical therapy to evaluate and treat as ordered or as needed; does not include low bed as an intervention. R5's current care plan initiated 08/18/2023 documents he displays socially inappropriate and maladaptive behavior as manifested by wandering aimlessly and leaving room Disrobed; These symptoms are related to mild cognitive impairment with interventions initiated 10/06/23 including: Use frequent reassuring phrases to help minimize feelings of fear and anxiety. Statements such as You are safe with me, You are okay, You are in good hands, and You and I are old friends will help instill a feeling of security and, in turn, should minimize incidents of maladaptive behavior. R5's current care plan initiated 10/06/2023 documents he exhibits movement behavior that may be interpreted as aimlessly roaming, wandering his unit, and wandering into peers rooms; behaviors are related to the diagnoses of Mild Cognitive Impairment of Uncertain or Unknown Etiology, poor safety awareness, and problems understanding the immediate environment with interventions including: Make rounds/room checks to minimize chance of unauthorized leave. R5's Nurse Practitioner progress note dated 8/9/2023 5:24 PM documents history of present illness (obtained from previous medical records and patient) patient is an [AGE] year-old male with past medical history of metastatic to bone prostate cancer, cognitive impairment, depression, anxiety, and delirium, who was admitted to the hospital on 8/2/23 with agitation/aggressive/erratic behavior and required soft restraints; was subsequently transferred to nursing facility for skilled nursing and rehab. R5's progress note dated 9/1/2023 03:13 AM documents: Heard a noise from patients room, CNA (Certified Nursing Assistant) went to check and call the nurse on duty. Patient was observed sitting by his bed bleeding at the back of his head, patient is alert and verbally responsive. 911 called. left message to V10 (Nurse Practitioner). R5's progress note dated 9/6/2023 3:44 PM documents: Removed three sutures. Facility Reported Incident Final Investigation Report dated 09/07/2023 documents on 09/01/2023 at 2:15 AM R5 had an unwitnessed mechanical fall inside his room; Assigned nurse observed R5 sitting on the floor by the edge of his bed; Observed with bleeding from the back of his head; When asked what happened, R5 stated he wanted to go to the bathroom to urinate, ambulated without using his walker, lost his balance and fell ; R5 sustained a head injury, was sent to Lutheran General Hospital emergency room for further evaluation of head injury and staples to his head wound and was readmitted back to the facility at 10:59 AM; The facility concludes that the root cause of R5's fall included unsteady gait, impulsiveness related to cognitive impairment and poor safety awareness prompting him to overestimate his ambulatory ability; R5 returned to the facility from the emergency room with three staples which will be removed in one week. Care plan was reviewed to include nursing interventions of prompted toileting, anticipate his needs, remind to use assistive device, physician, and family aware of investigation; R5 is interviewable and alert and oriented times two. R5's progress note dated 10/2/2023 08:49 AM documents Patient seen and examined in room. Patient currently walking around room comfortably putting on his clothes. Patient has shown improved ambulation and strength but just limited by poor cognition and safety awareness. Facility Reported Incident Final Investigation Report dated 10/12/2023 documents on 10/06/2023 the facility received a complaint from R5's family claiming he was neglected, V9 (Family Member) reported he observed R5 in the bed with no sheets or clothes on during a weekend visit but could not specify when; multiple interviews with staff who worked with R5 from 10/02/2023 - 10/04/2023 included reports of him often attempting to get out of bed and in doing so hitting his elbows on the side rails, attempting to use the bathroom without calling for assistance, attempts to walk on his own and being redirected, and having a continual behavior of taking off his clothes and incontinence brief with staff constantly having to redress him; On 10/04/2023 V10 (Nurse Practitioner) noted in his progress notes: R5 had been hospitalized [DATE] for agitation, aggressive/erratic behavior and required soft restraints and was transferred to the facility for skilled nursing rehab; on 09/01/2023 R5 had a fall, hit the back of his head, lacerated his scalp, was sent to the hospital emergency room and returned the same day to the facility with staples to the back of his head; was being seen on 10/04/2023 for follow up and was observed to be more confused than usual, agitated, requires assistance with transfers and overall observed with weakness and confusion, was observed with scratch marks/skin abrasions that are self-inflicted when he hits side rails, table, etc; R5's care plan was reviewed and documents he displays socially inappropriate and maladaptive behavior as manifested by wandering aimlessly and leaving room disrobed and these symptoms are related to mild cognitive impairment. R6 is a [AGE] year-old male with a diagnoses history of Seizure, Traumatic Subdural Hemorrhage, Dementia without Behavioral Disturbance, History of Falling, Unsteadiness on Feet, Lack of Coordination, Abnormalities of Gait and Mobility, and Abnormal Posture who was admitted to the facility 02/12/2021. Observed R6 in his room lying down in his bed fully clothed with his bed in low position, observed a falling leaf next to his name outside his room. R6 stated he had a fall but didn't have to have any stitches or anything and had no scratches or scrapes from it. Observed a walker and wheelchair in the corner of R6's room. R6 stated the wheelchair and walker are not his and he has neither. R6's current care plan initiated 02/13/2021 documents he is at high risk for fall, is alert with periods of confusion, was admitted related to post Fall with Subdural Hematoma and multiple fractures and other Medical diagnoses of hypertension, depression, stroke, Senile Dementia; R6 is able to ambulate but with unsteady gait and resident is on medication Anti-seizure, Antidepressant and Anti-Hypertensive with interventions including: Evaluate fall risk on admission and as needed. R6's Quarterly Fall assessment dated [DATE] documents he does not use any ambulatory aids and is at high risk for falls. R6's progress note dated 8/23/2023 7:37 PM documents: At 4:25 pm, staff reported to writer that resident had a witnessed fall incident in the unit. Investigation initiated. On interview staff reported that they noticed resident standing by the nurses station with his cane. Staff noted the resident took several steps back and lost balance. Head to toe assessment done, bleeding noted on back of head, area cleansed with and covered with gauze. Resident could not explain what prompted him to step backwards. Resident was transferred via 911 to hospital emergency room for further evaluation; at 8:58 PM Called hospital for follow up, resident will be admitted with diagnosis of Head Bleed. Facility Reported Incident Final Investigation Report dated 08/24/2023 documents on 08/23/2023 at 4:25 PM staff reported to V2 (Director of Nursing /Registered Nurse) that R6 had a witnessed fall on the unit; Interviewed staff reported they noticed R6 standing by the nurses station and observed he took several steps back and lost his balance; R6 could not explain what prompted him to step backwards. Upon further review staff reported R6 was observed holding a cane which was not appropriate and was not included in the plan of care; [NAME] was removed from R6's room; R6 was readmitted from hospital, care plan was reviewed and revised with new interventions including screening and evaluation for physical therapy and occupational therapy. R6's progress note created by V10 (Nurse Practitioner) dated 8/29/2023 11:38 AM documents: Patient seen and examined today post readmission; on 8/23/23 patient was sent to the hospital after a fall, patient struck the back of his head and sustained a traumatic subdural hematoma, he was closely monitored and treated. Patients back of head small skin alteration is clean, dry, and intact. On 10/18/2023 at 11:01 AM V2 (Director of Nursing) stated R5's strength improved before he left the facility and was able to dress himself. V2 stated R5 was a high fall risk. V2 stated any review of past falls and root cause analysis information would be included in a fall risk management report. V2 agreed the purpose of reviewing past falls and developing a root cause analysis is to identify any personalized interventions that may be needed for a resident. V2 stated she uses the Morse fall evaluation and the nurse fall observation to assess if a resident is high risk for falls. V2 agreed an admitting residents hospital records are reviewed for fall history information and this information would be applied to the resident's care planned fall interventions. V2 stated V27 (Family Member) visited with R5 frequently and the facility does not rely on family to supervise residents. V2 stated R5's behaviors do put him at risk for falls. V2 stated the facility cannot provide one on one supervision daily because it is not sustainable. V2 stated rounds are conducted every two hours and as needed. V2 stated as needed indicates when staff is done working with another patient, they can go back to R5 even if it was sooner than two hours. V2 stated R5 may not necessarily need one on one supervision but does require increased supervision which is not currently part of his care plan. V2 stated most of the time R5 wore a gown and did not wear a robe. V2 stated the term disrobing in R5's care plan indicates removal of any clothing the resident is wearing. V2 stated R5's history of needing soft restraints while in the hospital prior to admitting to the facility indicates he could be restless or impulsive. V2 stated she cannot explain what specific interventions could have been in place to prevent R5's unwitnessed fall 09/01/2023. V2 stated R5's decision making limitations, and overestimation of his abilities related to his cognitive impairment contributed to his fall on 09/01/2023. V2 stated although R5 was receiving rehabilitative therapy he still required the use of an assistive device to ambulate. V2 stated a low bed might have minimized the risk of R5's fall. Observed V2 read R5's care plan and confirmed it did not include low bed as an intervention. V2 stated impulsiveness does include getting up an attempting to ambulate without asking for assistance as it was documented when he fell on [DATE]. V2 stated when R6 fell in August staff were present. V2 stated if staff observed R6 using a cane and was not approved to use one they should have taken it from him. V2 confirmed due to it not being appropriate for R6 to use a cane, him using one did contribute to his fall. The facility did not provide a risk management report for R5 and R5's medical records did not include a nurse fall observation. The facility's Fall Prevention Program Policy reviewed 10/18/2023 states: The purpose of the policy is To assure the safety of all residents in the facility, when possible. The program will include implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Methods to identify risk factors, Use and implementation of professional standards of practice. Care Plan incorporates: Identification of all risk/issue, preventative measures. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA (Certified Nursing Assistant) are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible fore ensuring ongoing precautions are put in place and consistently maintained. The bed will be maintained in a position appropriate for resident transfers. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on observation interview and record review the facility failed to ensure that one residents (R313) wound was assessed properly and worsening wound was identified, and doctor was notified for one resident R313 of 3 residents reviewed for wounds in a sample of 33. Findings include: On 7/20/23 at 1:16 PM with V11 (Wound Care Coordinator) reviewing pictures and documentation of R313 sacral wound. All of the sacral wound assessment each week documents the wound to be 5x7/0 CM, area to be 35 centimeters, and the tissue to be bright pink or red=100%. 4/19/23 picture V11 states that there is some slough on the sacral wound and that V41 (Wound care nurse) assessment is incorrect but the treatment ordered is correct. Wound size documented 5x7x0 and 100% pink tissue. 4/26/2023 picture V11 states slough is more of non-adherent slough. There is a new/wider wound on the left buttock next to/attached to original sacral wound. V11 states there is more dead tissue and the measurement that V41 put is incorrect and yes these findings would signify a change in condition. 5/1/2023 picture measurement not correct some necrotic tissue. 5/8/2023 V11 states measurement incorrect and some necrotic tissue. V11 states she would say that this wound is unstageable with 90-95% slough and 5% pink viable tissue again what V41 documented is incorrect. 5/16/2023 picture V11 states the wound is unstageable and 95% slough. On 7/20/23 at 2:52 PM V2 (DON) states V2 states she expect if there is a change in condition or worsening wound that the staff will notify family and doctor and measure wound and chart what they see. Documentation should be in the resident's electronic medical record in the progress notes or wound rounds. V2 states she assumes within 24 hours of a change of condition the doctor and family should be notified. On 7/21/2023 at 1:45 PM V28 (Nurse Practitioner ) states they defer to wound care doctor to assess as soon as possible during next wound round. The facility should notify nurse practitioner and wound care doctor if worsening. V28 states a stage 4 wound should be consulted right away . V28 states Nothing should be delayed when it comes to wounds. Review of R313's progress notes did not show any documentation that family or doctor were notified of the 4/26/2023 change and worsening in wound condition. R313 progress note dated 5/20/23 documents a change in condition and with shortness of breath that is different than usual.

Based on interview and record review the facility failed to provide safety by not following the mechanical lift manufacturer instruction. This failure resulted in R36 falling from a Mechanical lift while under staff direct care sustaining multicompartmental intracerebral hemorrhage (ICH). The facility also failed to follow its policy in reporting, investigating and monitoring of resident who has unwitnessed fall, and ensure resident's environment is free of accident hazards. This affected 3 of 5 residents (R36, R88, R100) reviewed for safety. Findings include: On 7/19/2023 at 12:09 PM, V25 (RN) said V32 (CNA) asked if she could help her transfer R36 into a dialysis chair with a Mechanical lift. V25 and V32 went to the resident room. V25 said that V32 was positioned on the resident right side and V25 was positioned on the resident left side. V25 said that V32 asked V25 to hook the purple loop onto the Mechanical lift hook. V25 said that she confirmed with V32 that all the purple loops are on all four sides of the Mechanical lift hooks. V25 said that the dialysis chair was positioned at the foot of the bed. V25 said that V32 elevated R36 up with the remote control. V25 said that once R36 was up, V25 went to the right side of R36 to guide her into the dialysis chair. V25 said that R36 was about 30 degrees above bed and was being moved towards the dialysis chair when R36 fell . V25 said that R36 body hit the floor first, and then R36 hit her head on the foot of the Mechanical lift. V25 said that V25 immediately assessed R36, called V11 (Wound Care Nurse) and V3 (Assistant Director of Nursing) ADON, and V11 and V3 also assessed R36. V25 said that V11 applied pressure on R36 head. V25 said that V3 and Wound Care Nurse stayed with R36 while V25 went and called 911. V25 said that V11 and V3 continued to stay with R36 and assessing her until 911 came and took R36 to the local hospital. V25 said that is possible that the resident slipped out of the sling because the loops were intact. Mechanical lift manufacturer instruction that stipulates when patient is elevated a few inches off the surface of the stationary object (wheelchair, commode or bed) and before moving the patient, check again to make sure that the sling is properly secured. On 7/19/2023 at 12:41 PM, V3 (ADON) said that she was called to room by V25 (RN) and upon entering the room, V3 noticed that R36 was on the floor. V3 said that R36 was noted with laceration at the back of her head. V3 said that V7 (Wound Nurse) was also present, so V7 applied pressure to the back of her head. 911 took R36 to local hospital. R36 was diagnosed with multicompartmental intracerebral hemorrhage (ICH), including: Left frontal intraparenchymal hemorrhage (IPH), with surrounding edema and subdural hematoma (SDH), L temporal SDH and subarachnoid hemorrhage (SAH), Left parafalcine SDH. On 7/20/2023 at 12:30 PM, V32 (CNA) said that V32 and V25 were transferring R36 to a dialysis chair using a Mechanical lift. V32 said that V32 and V25 confirmed all 4 purple loops were attached to the Mechanical lift hooks. V32 said that R36 fell from the sling while being transferred to the dialysis chair. V32 said that after the fall, she noticed that only 3 of the purple loops were intact. V32 said that she couldn't identify what caused the fall until the fire marshal came and inspected the Mechanical lift, then V32 said that V32 noticed that one of the metal lash was missing. V32 said that if she had noticed that a metal lash was missing prior to operating the Mechanical lift, she would have not used it and would have told V25 that they need to use another Mechanical lift. 07/20/2023 at 2:12 PM, V11 (Wound Care Coordinator) said that she was on second floor rounding when the floor nurse called V3 (Assistance Director of Nursing) and V11 into R36 room. V11 said that when she came to the room, R36 was on the floor with small amount of bleeding coming from back of R36 head and V11 applied pressure to the area where R36 is bleeding from until 911 arrived. 07/20/2023 at 2:24 PM, V2 said during her investigation, V25 (RN) and V32 (CNA) both said that used proper technique when transferring R36 with a Mechanical lift from her bed to dialysis chair. V2 confirmed that if the loops were properly secured, it might not gotten loose during the transfer. V2 said that the facility had an in-service in May which included all transfers. V2 said that right after the incident all clinical staff were in-serviced with return demonstration. V2 said that moving forward that all agency staff will be in-serviced to ensure that they are competent in transfer using Mechanical lift with return demonstrations and will be on-going. R36 is a [AGE] year old female admitted on [DATE] with a diagnosis not limited to acute and chronic respiratory failure, dependence on respirator (Ventilator) status, dependence on renal dialysis, and hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Facility Fall Prevention Program Effective Date: 11-28-12 Department: Nursing, Therapy, Administration Revisions: 11-21-17 Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall Prevention Program includes the following components: Adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Battery Powered Patient Lift Manufacturer Instruction Lifting Patient WARNING When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem. 39781 On 7/18/23 at 12:20pm Observed R88 lying on scoop mattress. V19 LPN said that R88 is at high risk for fall and just fell recently. On 7/19/23 at 9:58am, V7 Restorative Nurse (RN) said that she does the formulation and updating fall care plan. V2 DON does the initial investigation and root cause analysis after each fall. The floor nurse will do the fall incident documentation and report the incident. Review R88's medical record with V7 RN. V7 said that R88 is admitted on [DATE] with diagnosis listed in part but not limited to history of falling, Laceration to part of head due to fall, Vascular dementia. V7 said that admission fall assessment done on 1/5/23 indicated that R88 is at high risk for fall. V7 said that R88 has several incidents of unwitnessed fall namely: 2/1/23 - Unwitnessed fall. R88 observed sitting on the floor in his room. 5/15/23- Unwitnessed fall. R88 observed on prone position on the floor, bleeding on the left forehead. R88 was sent to hospital for suturing of laceration on left forehead. 7/14/23- Unwitnessed fall, R88 observed in supine position on the floor in his room. Informed V7 that on 7/11/23 at 4:54am documented by V30 RN on R88's progress notes indicated: Observed R88 sitting on the floor in his room. R88 denies any pain or headache, able to move all extremities and no shortening of his legs. R88's physician order dated 7/11/23 indicated: May send 911 to hospital emergency room due to fall. V29 Night shift Nursing supervisor documented that R88 strongly refused to go to the hospital. 911 paramedic staff and V29 spoke with R88's family member and refused R88 to be sent to the hospital. V7 said that she is not aware and was not notified that R88 had a fall incident on 7/11/23. V7 said that there is no fall investigation done regarding possible cause of R88's fall incident and fall care plan is not updated. V7 said that there is no fall incident done by V30 RN on 7/11/23. On 7/20/23 at 7:21am, V29 Night shift Nursing Supervisor said that on 7/11/23 R88 had unwitnessed fall, he was found sitting on the floor in his room. R88's fall incident report is completed by V30 RN on 7/11/23. V29 said that she reported to V2 DON about R88's fall incident. On 7/20/23 at 9:40am, V2 DON gave the fall incident report dated 7/11/23 done by V30 RN. V2 said that she was not notified of the incident report not until 7/19/23. V2 said that she did not complete the fall investigation and update the care plan not until she just learned about it yesterday. V2 said that V30 RN did not put R88's fall incident report in the risk management so she did not see it. On 7/20/23 at 11:30am, V7 Restorative Nurse said that she probably overlooks R88's fall incident report completed by V30 RN on 7/11/23. Facility's policy on Incident and Accident indicates: Policy: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or other and resident-to-resident altercations. Procedures: An incident/accident report will be completed for: 1. All serious accidents or incidents of residents 3. All unusual occurrences 1. An incident/accident report is to be completed by RN or LPN and is to include: a. Date and time of an incident/accident b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. 4. Documentation on nurse's notes is to include: a. a description of the occurrence, the extent of injury, the assessment of the resident, vital signs, treatment rendered, and parties notified. b. A minimum of 72 hours of documentation by all three shifts on resident status after the incident. Vital signs, mental and physical state follow up, test, procedures, and findings are to be documented. 5. All incident/accident reports are reviewed, signed, and investigated by: a. Administrator b. DON or ADON Facility's policy on Fall prevention program indicates: Purpose: To assure safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: *Care plan incorporates: Addresses each fall, interventions are changed with each fall, Standards: *Accident/incident reports involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions 46560 On 07/18/2023 at 11:20AM during observation, R100's bed was observed with plugged in power strip on the side of his bed leaning against the side rail with two chargers plugged on it and the cord coiled on the side rail. At 11:56AM, the above-mentioned was observed with V47 (Maintenance Assistant) and at 12:00PM, it was also observed with V15 (Maintenance Director). On 07/18/2023 at 11:56AM, V47 stated that he has always seen R100's extension cord like that. On 07/18/2023 at 12:00PM, V15 said that it should not be on the bed because it is not safe for the R100. R100's order summary report dated 7/21/2023 indicated admitted [DATE] and diagnoses including anxiety disorder due to known physiological condition and major depressive disorder, recurrent, mild. Facility Policy: Title: Electrical Equipment Review Date: 11/2022 Power Strips: The following are the circumstances where power strips are allowed in the facility: 4. Power strips are prohibited in patient care vicinity and may not be utilized for other devices, such as: personal electronics.

Based on observation, interview, and record review the facility failed to follow their wound prevention policies and plan of care interventions to include use of low air loss mattress and conduct skin condition assessments and measurements weekly. This affected 2 of 3 residents (R6, R8) reviewed for pressure sore prevention. This failure resulted in R6 having a deteriorating wound requiring debridement revealing a stage 4 pressure sore. Findings include: 1. R6 face sheet shows diagnosis of hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia without behavioral disturbance, hypertensive heart and chronic kidney disease, chronic systolic heart failure, atherosclerotic heart disease, encounter for attention to gastrostomy, chronic embolism and thrombosis of right femoral vein, chronic embolism and thrombosis of left popliteal vein, long tern use of anticoagulants, abdominal distension, alcohol abuse, blindness of right eye, latent tuberculosis, and dysphagia. R6 braden score (risk for skin breakdown) dated 5/31/2023 denotes score of 10 (high risk) for skin breakdown. R6 progress notes denotes R6 was sent to hospital on 5/12/23 and returned to facility on 5/17/23. On 6/6/23 at 12:00pm R6 was observed sleeping in bed, R6 open his eye to voice, R6 did not follow redirection at this time. R6 resting on mattress with no pump noted at foot of bed or head of bed or on the floor near the bed. R6 has gastric tube feeding running at 45ml/hr., water flush at 130ml every 4 hours. Tube feeding labeled and dated. R6 has bilateral heel boots. R6 observed with bilateral hand mitten. R6 hair is cut low, facial hair observed trimmed. No body odor noted, no mouth odors noted. R6 observed resting on mattress, no mattress pumps noted. At 12:17pm wound care and skin check observation conducted with V8 (wound care nurse) and V9 (wound care coordinator). R6 skin was intact to heels bilaterally, skin intact to peri area, skin intact to elbows, skin intact to back, skin intact to back of head, skin intact to ear lobes. R6 has wound the size of a grapefruit to the right buttocks that extends to the sacrum; wound has black tissue with tan tissue were the wound is open partially. R6 has open area to the left buttocks the size of a half dollar; wound bed is pink, moist, surrounding tissue is hyperpigmented. V8 said the wound to the right buttock has tunnelling, V8 said the wound doctor is planning to debride the wound when it opens. V8 said the wound has open edges now and he will notify the wound physician for an update. V9 said R6 was admitted to the facility with the wound. Pain medication given prior to wound care observation. After wound care R6 repositioned for comfort. V9 said R6 mattress is a low air loss mattress, when asked where's the pump for the low air loss mattress, V9 then said R6 was resting on a pressure redistributing mattress, the facility regular mattress are pressure redistributing. R6 mattress was firm when pressed. V9 said the wound doctor usually see residents on Tuesday, however the wound doctor had an emergency, and he would see residents on Wednesday. V9 said R6 should have in place a low air loss mattress. On 6/14/23 V9 said the mattress should have been in place upon readmission on 5/17/23 or 5/18/23. R6 plan of care dated 9/14/2022 denotes in-part R6 has high risk for further skin breakdown related to decreased mobility, incontinence, O2 (oxygen) dependent, Dx (diagnosis) hemiplegia, heart failure, vascular, dementia, and blindness to right eye and refusal of care, 1- coccyx initiated 9/14/22, R6 wound site will show signs of improvement through next review date, initiated 5/18/2023. Apply moisture barrier after each incontinent episode, evaluate ulcer characteristics, keep skin clean and well lubricated, low air loss mattress 9/14/22, low air loss mattress 10/25/22, monitor bony prominences for redness, monitor nutritional status, monitor ulcer for signs of progressions or declination, off load heels while in bed, provide skin care per facility guidelines and PRN as needed, provide wound care per treatment order, RD (register dietitian) consults, turn and reposition every 2 hours and as needed, wound Dr/ Np consults as needed. R6 wound assessment dated [DATE] denotes in-part wound-coccyx, pressure ulcer, present on admission, size- 4.50 centimeters by 3.00 centimeters, unknown depth, area 13.50 centimeters squared. R6 wound assessment dated [DATE] denotes in-part wound-coccyx, pressure ulcer, present on admission, size- 4.50 centimeters by 3.00 centimeters, unknown depth, area 13.50 centimeters squared. R6 wound assessment completed by V38 (wound doctor) dated 5/30/23 denotes in-part patient seen on the request of the PCP (primary care provider) for skin ulcers/lesions. Skin problem site- coccyx, wound #4 coccyx un-staged, there is no exudate, infection or inflammation is none, the wound is 12 days since first recorded. Assessment and plan abnormal posture- monitor skin PROM, muscle weakness-low air loss mattress, reposition every 2 hrs (hours) and PRN, offload heels, heel protectors to both feet. Pressure ulcer sacral region, unstageable, frequency of treatment- daily and PRN, site should be cleaned with with normal saline, primary dressing-Medi honey, adaptic, ZN (zinc) oxide around, secondary dressing - foam island dressing, secure with off load, additional notes- please call me when the edges open so that I can debride and get the consent for debridement. Plan of care #5 continue with skin ulcer prevention protocol of the facility including daily skin check. #7 dressing change and plan discussed with treatment nurse. Avoid bony prominences under pressure, provide stage appropriate mattress, off load with heel protectors or pillows, repositioning in the bed and w/chair as needed, or per facility protocol, if patient cannot do it, education of staff and nurse assistant about prevention and treatment and repositioning as needed. Comments seen with WCC (wound care coordinator) (V8). Page 4 wound #4, coccyx, un-staged, pressure, date reported 5/18/23, size 8x11x0, 100% necrotic, undefined margins, treatment done 5/30/23. R6 wound assessment completed by V38 (wound doctor) dated 6/9/23 denotes in-part patient seen on the request of the PCP (primary care provider) for skin ulcers/lesions. Removal of necrotic tissue, slough, and biofilm and reduced bioburden, to promote healing and prevent infection. Tissue debrided was necrotic subcutaneous, necrotic muscle, percentage area was debrided 51-75%, viable wound bed was exposed. Page 5 denotes MDS stage 4, pressure, post debridement size- 9x11x2.5. Post debridement volume 247.5 centimeters squared. Necrotic/ escar color 90%, intact 10%. Treatment done 6/9/23, topical application gentamicin, calcium alginate, ZN( zinc) . Treatment has been changed. On 6/9/23 at 12:37pm V38 (wound physician) said R6 was readmitted to the facility with the wound on 5/17/23, V38 said R6 wound has deteriorated, V38 said R6 has deep tissue injury. V38 said when there's deep tissue injury it takes about 72 hours or 4 days for the injury to present on the skin (show up). V38 describe deep tissue injury happens when pressure from bony prominences cause tissue to die due to lack of oxygen. V38 said it takes about 4 days for the injury to show on the skin because the injury happens deep inside. R6 admitted s were reviewed with V38 of 5/17/23, when 4 days is added to 5/17/23 the date is now 5/21/23, R6 wound assessment and images dated 5/24/23 reviewed with V38, R6 wound to coccyx measured the same as the 5/18/23. V38 was asked should the deep tissue injury should have come to the surface by then. V38 said R6 had a deep tissue injury. V38 said R6 deteriorated wound was debrided today to reveal a stage 4 pressure ulcer. V38 said wound debriding removes the necrotic tissue. V38 said the low air loss mattress assist pressure prevention. V38 was made aware that during the observation on 6/6/23 at 12:37pm R6 did not have the low air loss mattress in place, V38 said oh no that not good. V38 said not having that low air loss mattress in place can contribute to R6 wound deteriorating. V38 said cultures were sent today and R6 wound treatment was changed from honey to gentamicin. V38 said R6 previous wound healed. Facility policy tilted pressure injury and skin condition assessment with last review date 1/17/2018 denotes in-part to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. The resident care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. Physician ordered treatments shall be initiated by staff on the electronic treatment administration record after each administration. Other nursing measure not involving medications shall be documented in weekly wound assessment or nurse noted. Facility policy titled pressure ulcer prevention with last revision date 1/15/2018 denotes in-part to prevent and treat pressure sores/pressure injury. Pressure reducing (foam) mattress are used for all residents unless otherwise indicated. Specialty mattress such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattress are typically used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. Facility policy titled comprehensive care plan dated 11/17/17 denotes in-part to develop a comprehensive care plan that directs the care team and incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental psychosocial well-being. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. 2.R8 care plan denotes R8 has diagnosis of chronic respiratory failure, obesity, DVT, glaucoma, long term use of anticoagulants, pressure ulcer left elbow, anemia, chronic kidney disease, atherosclerotic heart disease, acute embolism, long term use of insulin, protein calorie deficits. R8 Braden assessments dated 4/27/23 denotes score of 9 (very high risk). On 6/7/23 at 11:30am R8 observed for wound care with V9 (wound care coordinator) and V8 (wound care nurse), V9 (wound care coordinator), R8 left elbow noted with granulated tissue covering the wound bed, V9 said R8 only had preventive measures in place for the right elbow. On 6/8/23 V9 presents R8 wound documents denoting R8 has pressure wound to the right elbow, and R8 MAR denotes preventive dressing to the right elbow. On 6/9/23 at 9:50am skin check/wound care observation conducted with V8 (wound nurse), R8 noted with open area to the right elbow, wound bed observed moist and redden, with little yellow tissue inside wound bed. V8 said R8 has a stage 3 to the right elbow. V8 said R8 right elbow wound is facility acquired. On 6/9/23 at 1:50pm V9 (wound care coordinator) said she was not aware that R8 had an open wound to the right elbow. Review of R8 wound assessment completed by V35 (wound physician) on 5/23/23 denotes in-part right elbow, un-staged, pressure date reported 3/24/23, size- length (2 centimeters) by width (2 centimeters) by depth (0.2 centimeters). Post debridement measurements (2 centimeters) in length by (2 centimeters) in width by 0.4 centimeters in (depth). 60% granulation, 10% necrotic, and 30% slough. Pressure ulcer of right elbow, frequency of treatment- daily and PRN (as needed), site should be cleaned with normal saline, primary dressing- iodosorb adapatic, secondary dressing-4x4, secure with loose kerlix, wound debrided 5/23/2023. Plan of care #5 continue with skin ulcer prevention protocol of the facility including daily skin check. #7 dressing change and plan discussed with treatment nurse. Comments seen with WCC (wound care coordinator) V9 and wound nurse (V8). Facility wound report presented by V9 on 6/9/23 dated 6/9/23 denotes in-part R8, right elbow, date identified 6/9/2023, facility acquired (yes), pressure/ulceration, last assessed 6/9/23, stage 4, Length 2.50, width 2.50, depth 2.00, epithelia (pale pink or red) 100%, erythema, scant exudate, serosanguineous. Facility failed to present weekly skin assessments following the week of 5/23/23 for R8 during this survey. On 6/9/23 at 3:15pm V8 said weekly wound assessments include measurements, descriptions, including restaging the wounds by the physician. V8 said wound changes would be documents weekly or as needed, V8 said wound changes are necrotic tissue, slough, infection, change wound bed, and if the wound is purple, pale, if there's concerns for flow to the wounds, V8 said all residents admitted to facility with wounds will be seen by the wound doctor regardless of the stage of the wound. V8 said this allows for them to contact the wound doctor when there is a change int the wound. V8 said the wound doctor sees all residents with sacral wounds, stage 3 and stage 4 wound weekly. V8 said he can stage wounds and the wound physician will follow up with staging the wound. Facility policy titled pressure injury and skin condition assessment with revision date of 1/17/18 denotes in-part the purpose to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, atrial, venous) will be assessed and measured at least every seven (7) days by licensed, and document in the resident's clinical record. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Resident identified will have a weekly skin assessment by licensed nurse. A wound assessment will be initiated and documented in the resident's chart when pressure and/or other ulcers are identified by licensed. A disposable measuring device (one time use) will be used to measure dimensions, and if necessary, a clean cotton tipped applicator to measure wound depth/ tunneling/ undermining. Pressure injuries and other ulcer (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. A wound assessment for each open area will be completed and will include: site location, size( length x width x depth), stage of pressure ulcer, odor, drainage, description, date and initials od each individual performing the measurements.

Based on observations, interviews, records reviewed the facility failed to develop and implement individualized and effective fall prevention interventions to prevent or reduce the incidents of falls with injury. This affected 2 of 3 residents reviewed for falls with injury. This failure resulted in R2 having an unwitnessed fall being transported to hospital with a change in condition post fall. R2 was admitted to the hospital for abnormal with a complex left cerebral subdural hematoma containing significant acute hemorrhage. R2 expired 14 days related to complication of the fall. This failure also resulted in R1 having an unwitnessed fall sustaining a comminuted right femoral intertrochanter fracture Findings include: 1.R2 was [AGE] years old with diagnosis including but not limited to Fibromyalgia, History of Falling (Onset [DATE]), and Weakness. Cognitive patterns dated [DATE] documents he has modified independence for daily decision making. On [DATE] at 11:54AM V22, Restorative Nurse, said the purpose of the CNA charting is to know how many people assist the residents and for the staff to know how much assistance the patient needs. V22 said CNAs are told to document every shift and every time they assist the residents. V22 said blanks in the charting means it (the care) did not happen. V22 said the residents should have bed mobility charted on all shifts. V22 said if the charting is not documented then it did not happen. V22 said a fall is a change in plane. V22 said unless I saw them fall then it is a fall. V22 said she updates the care plan after a fall but she does not document the root cause. V22 said the purpose of the root cause analysis is to know what caused the fall. On [DATE] at 1:32PM V18, Registered Nurse, said R2 usually did not try to get out of the bed. V18 said standard care included to round frequently and offer R2 help. V18 said R2 had a call light but I am not sure if he would use it. On [DATE] (morning) R2 was having normal behavior, he was non-verbal. V18 said R2 would sit up in the bed in the middle of the bed with his legs out. V18 said on [DATE] 9:00AM when I was rounding I saw him on the floor by his bed. V18 said I had seen R2 prior to the fall, R2 was sleeping. V18 said when I walked in the room R2 was laying on the floor on the mat. V18 said R2 was flat on his back. V18 said R2 could not stand but was able to pull himself up into a sitting position. V18 said I did not ask R2 what he was trying to do. V18 said I did not see him fall and the roommates said they did not see anything. The surveyor asked V18, did R2 hit his head and V18 said I don't know if he hit his head V18 said it is possible for the patient to have an injury without signs of injury. V18 said there was a night stand next to the bed on the side R2 fell . V18 said usual rounding is every 2 hours. V18 said I was checking R2 every 30 minutes. V18 said I reported to the oncoming nurse that R2 had a fall and had no signs of pain and the nurse practitioner saw him. V18 said when a resident falls we do a head to toe assessment and make sure there is no injury. V18 said we make sure they did not hit their head. On [DATE] at 1:53PM V10, Assistant Director of Nursing, said when a resident falls immediately the nurse develops a new intervention. V10 said the nurse communicates the intervention verbally to the next shift and then adds the new intervention to the careplan. During a phone interview on [DATE] at 11:08AM V28, Nurse, said on the evening shift [DATE] R2 fell and he was more anxious so she reported it to the doctor. V28 said R2's baseline is alert, but he can't talk or have conversations and can't communicate his needs. V28 said I don't know how R2 got on the floor on ,d+[DATE] (evening). V28 said at the start of her shift she was told R2 had a fall earlier. V28 said the intervention was to do more frequent rounding and keep an eye on him. V28 said we tried to check on R2 to make sure he was ok. V28 said she was notified R2 was on the floor by V34, Certified Nursing Assistant (CNA). V28 said on [DATE] she last saw R2 around dinner time, 5:00PM and could not recall if she saw R2 prior to the fall. On [DATE] at 10:19AM V13, Director of Nursing (DON), said V22 is the fall coordinator and she follows the falls in the building. V13 said V22 makes sure the interventions are in place. After V13 reviewed R2's incident report with the surveyor, V13 said on [DATE] at 9:00AM R2 was attempting to reach items from the floor. R2 said the intervention following R2's fall was to provide a reacher. V13 said when she interviews the staff following a fall she does not document it and she only documents the interviews if the incident is a reportable that goes to IDPH. V13 said the nurse's statement will be documented in the nurse's notes. The surveyor asked if the reacher was provided to R2 and V13 said I need to check with V22 if the reacher was provided. V13 said as a whole, R2 is difficult to redirect, very impulsive, and he does not ask for assistance. V13 said due to R2's cognitive status he is difficult to educate even with the use of an interpreter. The surveyor asked V13 how R2 was going to retain the information to use a reacher? V13 said R2 could do a return demonstration. V13 said R2 was told if you need assistance please call, but that was difficult for him to retain. V13 said there could have been more effective prevention interventions for R2. V13 said each resident fall should be addressed in the care plan or the care plan updated. V13 said I expect the interventions on the care plan to be carried out. At 11:26AM V13 said we did not do a monitoring sheet for R2 after his fall on [DATE] at 9:00AM, we did not do that intervention. On [DATE] at 2:58PM V22 said I don't know why there is a sign on R10's room (R2's former room mate) to keep the door closed. V22 said a person who has had previous falls should not have the room door closed. V22 said she discussed implementing the reacher with the staff but she did not physically provide it to R2. On [DATE] at 3:02PM V13 and V22 were asked together who is the fall coordinator for the facility. V12 said V22 is. V22 adamantly said I am not the fall coordinator. On a follow up in person interview on [DATE] at 3:28PM V28 said I could not tell if R2 hit his head, V28 said she was informed of R2's fall by the CNA who said the call light was on. V28 said I don't recall if the door to R2's room was closed. V28 said R2 does not usually wear shoes and I can't recall if he had socks on. V28 said I was not told anything about a reacher device to be used for R2. V28 said when she saw R2 he was on the floor, next to his bed, on a mattress and his head was near the footboard of his bed. V28 said I called the ambulance right away. On [DATE] at 3:15PM during in person interview V34, CNA, said I can't remember about R2's fall. V34 was unable to answer any of the surveyor's questions regarding R2 or his shift on [DATE]. V34 said he remembers entering R2's room because the call light was on and then saw R2 on the floor mattress but that was all he could remember. On [DATE] at 2:49PM The surveyor asked V39, LPN, about the sign on R10's door that reads keep door closed at all times. V39 said let me ask about the sign on the door and V39 approached R10. R10 (speaking in Korean to V39) said he does not recall his former room mates or anything else. R10 said he requested his door be kept closed since last fall because he feels a chill from the hall way. R10 told V39 who told the surveyor R10 requested the sign be put up on his door sometime last fall. R10 told V39 who told the surveyor the sign was put on his door by the Korean Manager. (Based on the interview is reasonable to conclude the door was closed when R2 fell .) On [DATE] at 11:53PM V40, Nurse Practitioner, said R2 was a fall risk because he as Dementia and he was not able to comprehend his safety needs. V40 said all fall precautions that could have been initiated, were initiated. V40 said I don't believe R2 could retain any information given to him by staff. V40 said the purpose of fall precautions is to prevent falls. V40 said if a patient's condition worsens, I expect the staff will check on the patient frequently. V40 said patients who are acute should be checked on more frequently. V40 said a significant hit on the head can cause a subdural hematoma. Incident Reports document R2 had a fall on [DATE] a fall on [DATE] at 9:00AM and a fall on [DATE] at 9:35PM. Behavior assessment dated [DATE] documents no behaviors related to psychosis, physical or verbal symptoms, or behaviors directed towards others. R2 had rejected care during ,d+[DATE] days of the assessment. R2's Functional Status assessment dated [DATE] documents he requires extensive assistance with bed mobility and transfers between surfaces. R2's Incident Report dated [DATE] documents R2 was sitting next to bed. Notes sections denotes encouraged R2 to ask for assistance and staff reminded to anticipate needs. R2's Incident Report dated [DATE] 9:00AM documents observed on the floor next to his bed. Root cause dated [DATE] notes R2 with history of falls, very impulsive, difficult to redirect. Attempting to reach items on floor/nightstand etc. R2's Incident Report dated [DATE] 9:35PM documents R2 had unwitnessed fall. Observed at the side of the bed. In supine position with head on the footboard side of the bed. R2's Behavioral Symptoms Code denotes 0 behaviors on [DATE] - [DATE]. R2's Documentation Survey Report dated [DATE] has no entry for day or evening shift. This includes Bed Mobility and Dressing. R2's Fall Scale Evaluation dated [DATE] notes R2 has a fall risk scale of 55. Scoring indicates high risk is a score of 45 and higher. Mental Status notes R2 overestimates or forgets limits. Careplan initiated on [DATE] documents R2 is a at risk for falls related to impaired cognition, limited mobility, weakness, incontinence, poor safety awareness, and history of fall. Intervention dated [DATE] denotes: staff to anticipate resident's needs. Encouraged to ask for assistance. Intervention dated [DATE] keep needed items water, etc. in reach. Assess ability to use and provide reacher. Intervention initiated on [DATE] denotes past falls and attempt to determine cause of falls. Record possible root cause. Careplan focus dated [DATE] denotes R2 has a right hip fracture related to a fall. R2's progress notes written by Nurse Practitioner dated [DATE] document fall precautions. R2's progress notes dated [DATE] at 10:53AM R2 had a recent fall. Progress notes at 11:12am written by nurse practitioner document status post fall follow up. Fall precautions to be maintained. On [DATE] at 9:52pm R2 had a fall. R2's progress notes dated [DATE] 3:06PM document R2 admitted for subdural hematoma. At 3:19AM R2 being admitted to the hospital with diagnosis of fall. R2's record including a head CT denotes result time [DATE] at 2:02AM examination is abnormal with a complex left cerebral subdural hematoma containing significant acute hemorrhage. R2's hospital record [DATE] at 10:45PM denotes R2 has known history of falls Hospital record on [DATE] documents R2 was intubated during operation and remains so. Post op drain and dressing indicated on R2's head. Procedures listed: cerebral angiogram for embolization, left die burr holes with placement of drain, and intubation. R2's death certificate dated [DATE] documents cause of death 1. Complications of closed head injury 2. Fall. 2. R1 is [AGE] years old with a diagnosis including but not limited to Fracture of Right Femur ([DATE]), History of Falling ([DATE]), Long Term Use of Anticoagulant, Lack of Coordination, Abnormal Posture, and Difficulty in Walking. R1's Fall Scale Evaluation dated [DATE] notes R1 has a fall risk scale of 51. Scoring indicates high risk is a score of 45 and higher. On [DATE] at 12:26PM the surveyor observed R1 in his room, laying on his bed, no socks or shoes on his feet, and no floor mats in place. On [DATE] at 11:27AM R1 observed sitting in his room in his wheelchair. R1's floor being mopped and wet floor sign in the room. No floor mat observed in the room. On [DATE] at 11:40PM V13, DON, said R1 has only 1 fall incident report dated [DATE]. V13 said I did the investigation for this fall. V13 said R1 only complained of pain on [DATE] while in the facility. V13 said it was written in his hospital file that while in the hospital he reported that he fell in the facility. At 12:03PM V13 said the nurse at the hospital told me R1 fell and it is in the record. V13 said [DATE] is the only other fall R1 had. At 12:26PM V13 said I was verbally told when R1 went to the hospital he self reported the fall at the hospital. On [DATE] at 1:09PM V26, LPN, said when I started my medication pass on [DATE] I noticed R1 was not comfortable. V26 said I noticed R1's right leg with swelling at the hip and upper leg. V26 said R1's overbed table was at the foot of the bed and that was unusual because the table was usually next to him. V26 said there were no floor mats in the room when he was assessing R1. V26 said after the X-ray was completed I was notified R1 had a right leg fracture. V26 said R1 was not acting at his baseline. V26 said R1 was often self transferring without assistance from staff and often seen reaching under his bed. V26 said R1 would sometimes take himself to the bathroom. V26 said R1 would remind him and tell him to ask for help. V26 said R1 never used the call light. V26 said R1 needs at least supervision for transfers because he was unsteady before the fracture. V26 said he used an interpreter when talking to R1 about his pain. V26 said R1 said he did not know what happened to his leg. V26 said R1 was a fall risk before [DATE]. V26 said if a patient is on the floor it is a fall. On [DATE] at 1:33PM V27, Certified Nursing Assistant (CNA), said she spoke with R1 on [DATE] in Spanish and he only said he had pain in his leg and she told the nurse what R1 said. On [DATE] 3:15PM V32, CNA, was assigned to R1 on [DATE] evening shift. V32 said R1 tries to get out of bed. V32 said R1 thinks he can get up and assist the room mate, he sits up and tries to stand. V32 said R1 never fell on my shift. V32 said R1 tries to go from bed to wheelchair on his own and sometimes he is successful. V32 said if you see a resident on the floor it is a fall. V32 said if I saw a resident crawling around. I would report it as a fall, because I don't know how you (the person) got on the floor. On [DATE] at 10:19AM V13, DON, said via a phone conversation with the hospital staff I was told R1 said he fell in the facility. V13 provided a record from the hospital that reads I usually take steps in my wheelchair. The surveyor questioned the document because the document does not denote R1 said he fell . V13 said I used the wrong wording on the incident report. I worded it incorrectly. The surveyor reviewed R1's previous falls and incident reports with V13. V13 said I don't want to comment on R1's fall on [DATE]. V13 said I can't answer the root cause. V13 said a fall is a change in plane. V13 said we have some residents with behaviors that lower themselves to the floor. V13 said if it is a behavior there will a progress note and a careplan for the behavior. V13 said the plane is majority of the time the floor. On [DATE] at 10:12AM V14, Social Services Director, said behaviors are care planned. V14 said we document behaviors on a form in the record. V14 said crawling on the floor is a behavior that would be care planned. V14 said we would collaborate with the other departments and develop interventions. On [DATE] at 10:57AM V22 said the floor mat interventions for R1 was implemented. V22 said I don't know when we took the floor mats out. V22 said staff should be following the care plan. V22 said R1's episodes of crawling in the room should have been investigated. On [DATE] at 11:53PM V40, Nurse Practitioner, said R1's baseline is confused and he sometimes follows commands and his answers may or may not be appropriate. V40 said R1 was able to transfer himself prior to the fall. V40 said R1 did not understand the risk of his movements. V40 said it is an assumption that R1 fell because no fall was reported. V40 was asked if R1 was a fall risk and V40 responded of course, he was dementia and patient getting in and out if bed numerous times. V40 said everyone should be following the documented list of actions and precautions for the residents. V40 said The staff should be checking in on him constantly, make sure he is safe and in good condition. V40 said no staff saw what happened to R1, he was just complaining of pain. V40 said I can't recall if I was notified of the fall investigation results. R1's X-Ray dated [DATE] denotes X-Ray Right Hip, Unilateral Impression: acute moderately comminuted intertrochanteric fracture of the proximal right femur with deformity. R1's Incident Report dated [DATE] denotes observed lying on the floor. Notes: Sent to ER for further evaluation, Bilateral floor mats and low bed and continue therapy. R1's Incident Report dated [DATE] denotes R1 with complaints of pain to right leg. No witnesses found. (There is no mention this report is related to X-ray results from [DATE].) This incident was reported to IDPH. Final incident report denotes per hospital notes cause of injury related to unwitnessed fall, resident informed staff at hospital, I usually take steps to my wheelchair. The facility provided a document dated [DATE] (during R1's hospitalization period) Occupational Therapy I usually take steps to my wheelchair. Review of the facility Documentation Survey Reports dated [DATE]-[DATE] day shift have no documentation that assistance was provided with Activities of Daily Living (ADLs), including dressing and transferring. Review of the facility provided monthly fall Logs indicate R1 had a fall on [DATE] and on [DATE]. R1's progress notes dated [DATE] denotes R1 is a Very High Fall Risk due to impaired cognition and mobility. Review of R1's progress notes dated [DATE] denotes checked by the CNA patient is crawling on the floor R1's care plan denotes he is a high risk for falls. Interventions include on [DATE] review information on past falls and attempt to determine root cause of falls. The facility provided a 13 page care plan and there is no mention R1 has a behavior of crawling on the floor. R1's hospital record dated [DATE] denotes patient unable to provide meaningful history. Per EMS and nursing home report, patient had an unwitnessed fall today with persistent right hip pain. Hospital X-ray report dated [DATE] denotes x-ray hip 2 views right and pelvis impression: comminuted right femoral intertrochanter fracture. The facility Fall Prevention Policy effective date [DATE], in part denotes the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program, includes the following immediate change in in interventions, communication with direct care staff members, documentation requirements. Care plan incorporates: addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Accident/Incident reports involving falls will be reviewed by the team to ensure appropriate care and services were provided and determine possible safety interventions. Residents will be assigned approximately every 2 hours. The fall risk interventions will be identified on the care plan. Foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid. In addition to these of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk. The frequency of safety monitoring will be determined by the risk factors and the plan of care. In the event safety monitoring is initiated for ,d+[DATE] minute periods, a documentation record will be used to validate observations. Safety monitoring will be discontinued when the risk factors requiring monitoring is no longer evident.

Based on interview and record review, the facility failed to provide adequate supervison for 3 of 3 residents (R1,R2,R6) reviwed for supervision. This failure resulted in R2 being physically aggressive with R1 and R2 physically attacking R6 which resulted in R6 being bit by R2 on the stomach and hand resulting in R6 bleeding and being sent out to the hospital due to human bite of right hand by R2. Findings include: (R1 and R2) Facility's (6/22/22) FINAL Incident Investigation Report regarding R1 and R2 documents in part: R1 diagnosis of Dementia and R2 Alzheimer ' s Disease, dementia with behavioral disturbances. On 6/15/2022 @ approximately 4 pm, resident alleges physical altercation with another resident. Administrator interviewed R1 who stated, I was just sitting and talking with some of the other ladies when I heard R2 talking loudly, and I told him to stop. He started walking toward me and attempted to hit me. I blocked him and tried to hit him back. Administrator interviewed R2 and was unable to recall incident and what occurred leading up to the alleged abuse. Per C.N.A (V14) stated, I was assisting residents by the nurse ' s station when I heard residents calling for help. I ran to the dining room and saw R1 sitting in a chair and R2 standing next to her trying to hit each other and swinging arms. I immediately separated the residents. Per C.N.A (V15), I was around the corner assisting a resident in the hallway when I could hear noise coming from the dining room. I immediately went toward the dining room when I saw R1 and R2 trying to hit each other. I immediately separated each of them and had the nurse come an assess each of them. Per nurse on duty (V16), I was called to the dining room from the C.N.A. Both residents had been separated. I completed a body assessment on both residents. Resident (R1) stated her arm were scratched along with her face was hit. Noted no markings on her arms and small swelling under her left eye. Resident (R2) body assessment noted 2 small scratches on his chest and small scratch noted on right ear. Basic first aid was applied. Residents were assisted to their rooms. (R1 no longer residents at the facility) (R2 and R6) Facility's (8/13/22) Preliminary 24-hour Abuse Investigation Report regarding R2 and R6 documents in part: (R2)Alzheimer's disease, Dementia with behavioral disturbances, [CONDITION(S)], Lack of Coordination, A/Ox1, BIMS=3. (R6) Dementia, chronic a-fib, [CONDITION(S)] A/Ox2, BIMS=8. On 8/13/2022 at approx 2 am, Administration was notified by staff of an physical altercation between 2 residents. Body assessment completed and pain assessment has been initiated. Small lacerations were noted on R6. On 8/13/22 at 9:00 am, V12 (HR Director) was observed sitting in the hallway, V12 said she is watching both the dining room and observing R2 because he is being sent out to hospital and needs to be monitored. V12 said, this is not R2's room (surveyor observed R2 in room next to dining room), he is just here for monitoring. On 8/13/22 at 9:02 am, V13 (CNA) said there needs to always be a staff member watching the dining room when residents are there. V13 said, staff need to be in the dining room to monitor the residents and to supervise them. V13 said, the unit is Dementia and memory care and the residents need supervision. On 8/13/22 at 9:06 am, V10 (RN) said there needs to be always a staff present over the residents in the dining room because this unit is memory care. On 8/13/22 at 9:07 am, V11 (CNA) said, right now the dining room is being monitored by V12 (HR Director). V11 said, the staff take turns monitoring the dining room. On 8/13/22 at 9:31 am, V14 (CNA) said, on 6/15/22 she was working the floor when the incident happened with R1 and R2. V14 said, when she was taking care of residents, someone called out for help. It was another resident. V14 said, she ran to dining room and saw R1 and R2 were fighting. V14 said, her and V15 (CNA) separated the residents. After they were both separated the residents (R1 and R2) and calmed them down, we called the nurse. R1 was angry with the situation. V14 further stated, the unit is memory care unit, and there should be a staff present all the time in the dining room if residents are there, however that time no staff were in the dining room, On 8/13/22 at 9:44 am V15 (CNA) said, on 6/15/22 she was at the corner (not in the dining room), and heard someone yelling for help. V15 stated, R7 was yelling for help and she (V15) went to the dining room and saw R1 and R2 fighting. R2 was holding R1 hands and she separated the residents and called the nurse. R2 had a scratch on the ears and R1 had red hands from R2 holding her. V16 was the nurse. V15 said, no staff member was present during the altercation. V15 said, when she got to the dining room, there was no staff present and staff should be present to monitor residents. V15 further stated, someone needs to be there (referring to dining room) all the time to supervise the residents. On 8/13/22 at 10:15 am V2 (DON) said, 4 south is a locked unit. V2 stated, it is a memory and psychiatric unit. V2 said, there should always be staff in the dining room to oversee the residents, to prevent falls, watch for change of conditions, aspiration, and behavior acts including fighting. V2 said, today V12 (HR Director) was watching R2 because he is being sent out to the hospital for psychiatric evaluation because he attacked R6. V2 said, R6 was sent out to the hospital for medical evaluation and is back now. On 8/13/22 at 11:02 am, R6 was observed with V2 (DON). R6 had a dressing on the right thumb. R6 said, he was involved in a fight with another resident, but is unsure who that was. R6 said he was unsure if he was in pain because it is normal for him to forget. R6 said, he forgets and is unsure what happened. V2 said, R6 was hit in the stomach that is why he was sent out to the hospital. On 8/13/22 at 11:46 am, V1 (Administrator) said she is the abuse coordinator and she was called around 2 am by V18 (LPN). V18 said he called to report a physical altercation between 2 residents. V1 said, it was between R2 and R6. V1 said, R2 was being physically aggressive and R6 got a bite mark on his hand. It happened in R6's bed. V1 said, CNA were rounding on the unit, and heard commotion in R6's room. V1 said, she instructed V18 to separate the residents, make sure they are ok. 1 to 1 supervision was started with R2, and V18 alerted the police. V1 said, R6 was requesting to go to hospital because he wanted to have bite mark looked at on his hand. V1 said, she wanted to have R2 sent to hospital when they have a bed available to have a psychiatric evaluation completed. R2 was being 1 to 1 monitored until he was sent out to the hospital. Reportable was sent to the state. V1 said, regarding the incident in June he (R2) was sent out for psychiatric evaluation, it was determined he had [CONDITION(S)] and this was associated to his confusion. On 8/14/22 at 3:36 pm, V18 (LPN) said he was the nurse working for the night shift on 8/13/22. V18 said, he was doing round and CNA came to get him because R2 was attacking another resident. V18 said, it was after 1 am, when V18 got to R'6 room. V18 stated, he (V18) saw the resident (R6) in bed and R2 was next to the bed, bent over like 90 degrees and R2 had his face on R6's abdomen biting the resident. V18 said, he immediately got R2 off R6 and separated the residents. V18 said, there was blood on R2's face but it was from R6's right thumb because R6 was bleeding and R2 was not. V18 said, R6 had bite/teeth marks on his abdomen and was bleeding from right thumb due to R2 biting him. V18 said, he sent R6 out for medical evaluation because he was bit and wanted to make sure his abdomen was ok. V18 further stated, R2 was being monitored because he needed a psychiatric evaluation and a bed was not available yet. V18 also said, he called the police and made a police report and made doctor and family aware. R6's (8/13/22) hospital discharge documents in part: diagnosis Human bite of right hand. R2's progress note (6/16/2022 at 3:51 pm) documents: This writer heard the CNA shouting on the dining room, writer run toward the dining room and saw residents was having fight with each other. This writer separated the residents right away and redirected to their room. NP was informed, Family was made aware, Admin, social service and, DON was notified about the situation with orders to strictly monitor both resident and keep their distance with each other. R2's (6/25/21) care plan documents for Interpersonal Behavior : (focus) resident exhibits behavior symptoms including irritability, physical and verbal aggression towards others. his history includes physical behavior (hitting, pushing, punching) and verbal, cursing behavior. (6/15/22) R2 involved in an incident involving, however no updated interventions from 6/15/22 are noted on R2's care plan. On 8/15/2022 at 12:21pm during exit conference, V1 stated, I (V1) was not aware interventions were not updated for R2 and I (V1) will let social services know. Facility's (11/28/16) Abuse Prevention and Reporting policy documents in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. Facility's Facility Assessment Tool documents in part: Part 2: Services and Care We Offer Based on our Residents' Needs: Prevent abuse and neglect Identify hazards and risks for residents

Based on interview and record review, the facility failed to follow their policy and failed to report critical kidney function level labs to the nurse practitioner or physician for approximately one week for one (R2) resident reviewed for abnormal labs out of four residents in a total sample of seven. This failure resulted in R2's sent to the local hospital with kidney function worsening causing acute renal failure, and R2 needing to be admitted to the intensive care unit in the hospital where emergent [CONDITION(S)] was performed. Findings Include: R2 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 admitted to the facility on [DATE] and discharged on [DATE]. The Chemistry Lab Report dated 2/9/22 documents the following levels: blood urea nitrogen (BUN) of 22 mg/dL and creatinine of 0.6 mg/dL. These are kidney functioning labs to tell how well the kidneys are waste from the blood. Both the BUN and creatinine are within a normal range on this day. Normal range for BUN is 7 to 20 mg/dL, and normal range for creatinine is 0.6 mg/dL to 1.3 mg/dL. The Laboratory Report dated 2/23/22 documents the blood specimen was collected on 5:50 AM, the blood specimen was received at 2:10 PM, and the final results were reported at 5:49 PM. This report documents the following levels: sodium of 164, potassium of 5.5, BUN of 141 (this is considered a critical level, anything higher than this would also be considered critical), and creatinine of 3.3. The Laboratory Report dated 2/24/22 documents the blood specimen was collected at 5:45 PM, the blood specimen was received at 7:25 PM, and the final results were reported at 9:41 PM. This report documents the following levels: sodium of 162, BUN of 146, Creatinine of 3.3. There is no documentation in any notes that the critical lab levels were reported to a nurse practitioner or physician on 02/23/22 or 02/24/22. A Nursing note dated 2/24/22 documents R2's pulse rate is elevated to 118. The nurse practitioner was notified and a new order was given for a blood pressure machine medication and stat complete blood count and complete metabolic panel (lab work). A Nurse Practitioner note dated 2/25/22 documents the nurse practitioner assessed R2 on this day. No acute distress was noted. R2 was resting comfortably in bed. There is no mention of any abnormal lab work in this note. A Nurse Practitioner note dated 3/1/22 documents R2 was seen and examined today for follow up abnormal lab values. R2 is not in any acute distress. R2 has critically high lab values noted on 2/24, ordered IV hydration but unable to insert IV due to [CONDITION(S)] in both arms. It will take hours to wait for midline insertion and repeat of lab exams. R2 was transferred to the hospital for IV hydration and further treatment. These lab results were done on 2/24 but was reported only today by the nurse. Per nursing, the results were in unmatched lab section of the chart. A Lab note dated 3/1/22 documents the nurse relayed lab results to the nurse practitioner. A new order for intravenous fluids were ordered due to high level of creatinine, BUN, and sodium. An IV was attempted to be inserted but was an able to find a vein. The nurse practitioner order to send R2 to the hospital. The Nursing Home to Hospital Transfer Form dated 3/1/22 documents the reason for transfer as abnormal lab values - BUN 146, creatinine 3.3, and sodium 162. The Hospital Records dated 3/1/22 document R2 arrived to the emergency room for electrolyte abnormalities. The labs from the nursing home showed a sodium level of 162 (normal is 135-145 mmol/L). R2 is at baseline with a history of [CONDITION(S)] [CONDITION(S)], chronic [CONDITION(S)], and G-tube. Lab work was ordered in the emergency room and showed the following: sodium of 150, potassium of 9.2 (normal 3.4-5.1 mmol/L), BUN of 288 (normal is 6-20 mg/dL), creatinine of 7.43 (normal is 0.67-1.17 mg/dL). R2 has multiple electrolyte derangements and chemistry shows acute renal failure. Nephrology was consulted for emergent [CONDITION(S)]. R2 was admitted to the intensive care unit given the critical nature of R2's condition. R2's emergency room diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/27/22 at 11:10AM, V6 (Nurse) stated, I do work doubles on Wednesdays so if my name is documented as taking R2's vital signs that I probably did work with R2 that day. When you get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They come and they do the lab draw and send it back to the lab. We wait for the results and when they call with the results you relayed them to the doctor. If they are normal then you normally don't call but if they are abnormal you do call. The results are automatically uploaded into the computer so the doctors can take a look at them too. They will know that they're there even if we don't call them. I don't recall any call or results from the lab for that resident. With results that critical, it should be reported to the doctor immediately. This was the scheduled nurse working with R2 on 2/23/22 when the lab worked was documented as being reported. On 05/27/22 at 11:27AM, V7 (Nurse) stated, If a resident has a lab draw and the results are in then we relay them to the nurse practitioner or the doctor. You always call the nurse practitioner or doctor with critical results and document that you called them. You should always call them. There is not a reason that they should not be called. V7 denied remembering sending R2 out to the hospital for critical lab values. On 05/27/22 at 2:50PM, V13 (Nurse Practitioner) stated, I cannot tell you the exact days that I ordered the labs on but if they were done on those days then I probably told the nurses to do them. I know we tried to IV fluids on R2 but we ended up having to send R2 out the same day. I know that R2's BUN and other kidney function levels were critically high. When they are that high and not treated it, can lead to a need for [CONDITION(S)] due to renal failure. The longer you wait to treat something like that the more damage that is done to the kidneys and it is harder for them to get back to prior functioning. I know that with all R2's other comorbidities and with R2's wound that is where R2 could've been losing the hydration from. R2 only gets R2's nutrition and hydration through the G-tube so it is likely that with that worsening R2 was losing more fluid through that. If the nurses didn't tell me about the critical level then I likely would not have put in an order to address them. I've mainly relied on the nurses to tell me the critical level of the resident. I have six nursing homes that I oversee patients with so I understand when something like this could have been missed. I now make sure that it is a team effort and then I go in and I check all the labs for my residents. It is the expectation that the nurses still call either me or the doctor of the critical level. On 05/31/22 at 1:54PM, V16 (Nurse) stated, I normally work the night shift so if I have lab values that are called in I usually wait until morning unless they are critical. If they're a critical level then I will call the doctor immediately. We getting reports there was a lab draw and we know to watch out for the call or to check back to see if they were entered in. You always call when they're critical. I don't know why this one was not called in. I do not remember. The Admission Hospital Records dated 2/7/22 document R2 presented to the hospital in November for unresponsiveness and was found in [CONDITION(S)]. Lab work on 2/4/22 document a creatinine of 0.6 mg/dL and a BUN of 28 mg/dL. There is no documentation of concerns with kidney function upon discharge. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Section I dated 2/14/22 documents R2 does not have any renal failure or end-stage renal diagnoses. There is no care plan related to any renal concerns for R2. The policy titled, Physician-Family Notification- Change in Condition, dated 11/13/18 documents, Purpose: to ensure that medical care problems are communicated to the attending physician or authorized designee in family/responsible party in a timely, efficient, and effective manner. Responsibility: license nursing personnel/social services. Guidelines: the facility won't inform the resident; consult with the residence physician or authorized designee such as nurse practitioner; and if known, notify the residence legal representative or an interested family member when there is: (A) an accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the residence physical, mental, or psychosocial status (i.e., A deterioration in health, mental, or cycle social status in either life-threatening conditions or clinical complications); . (C) I need to alter treatment significantly (i.e., I need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); o A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., do use of any medical procedure, or therapy that has not been used on that resident before). The policy titled, Physician Notification of Laboratory/Radiology/Diagnostic Results, dated 3/14/18 documents, Purpose: to assure physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: a licensed nurse is responsible for ensuring the laboratory is notified of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Test results should be reported to the physician or other practitioner who ordered them. Guidelines for Reporting Abnormal Results: . In the event the physician does not respond promptly to attempts to convey critical laboratory results, the alternate physician or medical Director will be notified. Promptly may be defined based on the clinical condition of the resident and the judgment of the nurse in each individual situation . should the alternate physician or medical director not respond, the director of nursing will be notified. The director of nursing intervention should include: assessment of the residence clinical condition (in person or by phone); further attempt to contact the physician, alternate physician, or Medical Director; an emergency transfer based on clinical judgment. Unless other parameters are ordered by physician: . sodium <130 or >145, potassium <3.0 or >1.5, blood sugars <64 > 400 in diabetes, BUN > 60 .

Based on interview and record review, the facility failed to follow their policy and failed to report critical kidney function level labs to the nurse practitioner or physician for approximately one week for one (R2) resident reviewed for abnormal labs out of four residents in a total sample of seven. This failure led to R2's kidney function worsening causing acute renal failure, and R2 needing to be admitted to the intensive care unit in the hospital where emergent [CONDITION(S)] was performed. Findings Include: R2 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 admitted to the facility on [DATE] and discharged on [DATE]. The Chemistry Lab Report dated 2/9/22 documents the following levels: blood urea nitrogen (BUN) of 22 mg/dL and creatinine of 0.6 mg/dL. Normal range for BUN is 7 to 20 mg/dL, and normal range for creatinine is 0.6 mg/dL to 1.3 mg/dL. The Laboratory Report dated 2/23/22 documents the blood specimen was collected on 5:50 AM, the blood specimen was received at 2:10 PM, and the final results were reported at 5:49 PM. This report documents the following levels: sodium of 164, potassium of 5.5, BUN of 141 (this is considered a critical level, anything higher than this would also be considered critical), and creatinine of 3.3. The Laboratory Report dated 2/24/22 documents the blood specimen was collected at 5:45 PM, the blood specimen was received at 7:25 PM, and the final results were reported at 9:41 PM. This report documents the following levels: sodium of 162, BUN of 146, Creatinine of 3.3. There is no documentation in any notes that the critical lab levels were reported to a nurse practitioner or physician on 02/23/22 or 02/24/22. A Nursing note dated 2/24/22 documents R2's pulse rate is elevated to 118. The nurse practitioner was notified and a new order was given for a blood pressure machine medication and stat complete blood count and complete metabolic panel (lab work). A Nurse Practitioner note dated 2/25/22 documents the nurse practitioner assessed R2 on this day. No acute distress was noted. R2 was resting comfortably in bed. There is no mention of any abnormal lab work in this note. A Nurse Practitioner note dated 3/1/22 documents R2 was seen and examined today for follow up abnormal lab values. R2 is not in any acute distress. R2 has critically high lab values noted on 2/24, ordered IV hydration but unable to insert IV due to [CONDITION(S)] in both arms. It will take hours to wait for midline insertion and repeat of lab exams. R2 was transferred to the hospital for IV hydration and further treatment. These lab results were done on 2/24 but was reported only today by the nurse. Per nursing, the results were in unmatched lab section of the chart. A Lab note dated 3/1/22 documents the nurse relayed lab results to the nurse practitioner. A new order for intravenous fluids were ordered due to high level of creatinine, BUN, and sodium. An IV was attempted to be inserted but was an able to find a vein. The nurse practitioner order to send R2 to the hospital. The Nursing Home to Hospital Transfer Form dated 3/1/22 documents the reason for transfer as abnormal lab values - BUN 146, creatinine 3.3, and sodium 162. The Hospital Records dated 3/1/22 document R2 arrived to the emergency room for electrolyte abnormalities. The labs from the nursing home showed a sodium level of 162 (normal is 135-145 mmol/L). R2 is at baseline with a history of [CONDITION(S)] [CONDITION(S)], chronic [CONDITION(S)], and G-tube. Lab work was ordered in the emergency room and showed the following: sodium of 150, potassium of 9.2 (normal 3.4-5.1 mmol/L), BUN of 288 (normal is 6-20 mg/dL), creatinine of 7.43 (normal is 0.67-1.17 mg/dL). R2 has multiple electrolyte derangements and chemistry shows acute renal failure. Nephrology was consulted for emergent [CONDITION(S)]. R2 was admitted to the intensive care unit given the critical nature of R2's condition. R2's emergency room diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/27/22 at 11:10AM, V6 (Nurse) stated, I do work doubles on Wednesdays so if my name is documented as taking R2's vital signs that I probably did work with R2 that day. When you get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They come and they do the lab draw and send it back to the lab. We wait for the results and when they call with the results you relayed them to the doctor. If they are normal then you normally don't call but if they are abnormal you do call. The results are automatically uploaded into the computer so the doctors can take a look at them too. They will know that they're there even if we don't call them. I don't recall any call or results from the lab for that resident. With results that critical, it should be reported to the doctor immediately. This was the scheduled nurse working with R2 on 2/23/22 when the lab worked was documented as being reported. On 05/27/22 at 11:27AM, V7 (Nurse) stated, If a resident has a lab draw and the results are in then we relay them to the nurse practitioner or the doctor. You always call the nurse practitioner or doctor with critical results and document that you called them. You should always call them. There is not a reason that they should not be called. V7 denied remembering sending R2 out to the hospital for critical lab values. On 05/27/22 at 2:50PM, V13 (Nurse Practitioner) stated, I cannot tell you the exact days that I ordered the labs on but if they were done on those days then I probably told the nurses to do them. I know we tried to start a IV on R2 but we ended up having to send R2 out the same day. I know that R2's BUN and other kidney function levels were critically high. When they are that high and not treated it, can lead to a need for [CONDITION(S)] due to renal failure. The longer you wait to treat something like that the more damage that is done to the kidneys and it is harder for them to get back to prior functioning. I know that with all R2's other comorbidities and with R2's wound that is where R2 could've been losing the hydration from. R2 only gets R2's nutrition and hydration through the G-tube so it is likely that with that worsening R2 was losing more fluid through that. If the nurses didn't tell me about the critical level then I likely would not have put in an order to address them. I've mainly relied on the nurses to tell me the critical level of the resident. I have six nursing homes that I oversee patients with so I understand when something like this could have been missed. I now make sure that it is a team effort and then I go in and I check all the labs for my residents. It is the expectation that the nurses still call either me or the doctor of the critical level. On 05/31/22 at 1:54PM, V16 (Nurse) stated, I normally work the night shift so if I have lab values that are called in I usually wait until morning unless they are critical. If they're a critical level then I will call the doctor immediately. We getting reports there was a lab draw and we know to watch out for the call or to check back to see if they were entered in. You always call when they're critical. I don't know why this one was not called in. I do not remember. The Admission Hospital Records dated 2/7/22 document R2 presented to the hospital in November for unresponsiveness and was found in [CONDITION(S)]. Lab work on 2/4/22 document a creatinine of 0.6 mg/dL and a BUN of 28 mg/dL. There is no documentation of concerns with kidney function upon discharge. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Section I dated 2/14/22 documents R2 does not have any renal failure or end-stage renal diagnoses. There is no care plan related to any renal concerns for R2. The policy titled, Physician Notification of Laboratory/Radiology/Diagnostic Results, dated 3/14/18 documents, Purpose: to assure physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: a licensed nurse is responsible for ensuring the laboratory is notified of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Test results should be reported to the physician or other practitioner who ordered them. Guidelines for Reporting Abnormal Results: . In the event the physician does not respond promptly to attempts to convey critical laboratory results, the alternate physician or medical Director will be notified. Promptly may be defined based on the clinical condition of the resident and the judgment of the nurse in each individual situation . should the alternate physician or medical director not respond, the director of nursing will be notified. The director of nursing intervention should include: assessment of the residence clinical condition (in person or by phone); further attempt to contact the physician, alternate physician, or Medical Director; an emergency transfer based on clinical judgment. Unless other parameters are ordered by physician: . sodium <130 or >145, potassium <3.0 or >1.5, blood sugars <64 > 400 in diabetes, BUN > 60 .

Based on interviews and record reviews, the facility failed to keep residents free from physical and sexual abuse. This failure affected two (R50 and R187) of four residents reviewed for abuse and resulted in R50 being physically abused by another resident and R187 experiencing fear while being touched inappropriately by another resident. Findings include: R187 is a [AGE] year old female, admitted in the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) dated 03/18/2022 under Section C indicated that R187 has BIMS (Brief Interview for Mental Status) score of 15 which means intact cognition. According to abuse report dated 04/24/2022, R143 admitted to inappropriate touching R187 above clothing and flashing without her (R187) consent. On 05/10/2022 at 11:40 AM, R187 was asked regarding incident with R143. R187 stated, It happened in my room. He went to my room and got into my bed, put his hand into my mouth so I couldn't scream. He started touching me, my breasts. I started crying and told him to stop. It was a little scary at that time. He stopped and left the room. I went to the nurse and report it right away. The nurse checked me. I don't have any injuries or anything. I am not scared of him. Final Investigation report dated 04/29/2022 read: R143 stated during interview: I sometimes go into her room and I want to touch her. I attempted to touch on top of her pants and her breasts, but she pulled away and told me to get out of the room. R187's Progress notes dated 04/26/2022 authored by V16 (Nurse Practitioner) documented: Assessment/Plan: 12. Incident with another resident: Patient (R187) was touched inappropriately by another male resident at night while she was sleeping; patient reports no health concerns resulted from above. V8 (Registered Nurse, RN) was interviewed on 05/11/2022 at 10:24 AM regarding R187 incident with R143. V8 verbalized, The incident happened on 04/24/2022, around noon. I was doing my medication pass, I saw him (R143) with her (R187) in her (R187) room. He was talking to her but I was not listening. I remember she was feeling uncomfortable, she was looking at me like she was asking for my help to tell him (R143) to leave the room. I escorted him out of the room. He has [CONDITION(S)] disorder, sometimes he says intrusive thoughts out loud, or talks to himself. She is always calm, nice and cooperative. As a nurse, we don't allow male residents to come into female residents' rooms for safety precautions. Sexual advances may occur. We do rounds every hour to check, talk to residents and redirect them. R143 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/11/2022 at 11:32 AM, V21 (Director of Social Services) stated in an interview that R143 admitted that he went to her room and tried touching her (R186) private parts. V21 continued, I asked her (R187) about the incident and she told me that it happened earlier in the day. She said she was sleeping, she woke up and he was standing there and was trying to touch her private areas, the breasts and was trying to put his hand inside her pants. She was assessed, I told V1 (Administrator) everything. I called paramedics and local authorities also came. During interviews by local authorities, she stated that he (R143) had his genitalia out while he was trying to touch her which she did not tell me during the interview. She said she did not say anything to me or to the nurse because she is afraid that he would kill her if she said anything. It makes sense because she did not tell me everything until I asked her. I am not aware of any rules in the facility that male residents are not allowed in female residents' rooms. Residents have rights but there should be some kind of boundaries between male and female residents when male residents going into female residents' rooms. Activities, CNAs (Certified Nurse Assistants) rand nurses need to be inserviced of the boundaries of male entering female rooms and vice versa, privacy, redirection, supervision and monitoring from staff. CNAs are supposed to do rounds as often as necessary to ensure privacy and safety of other residents. Involuntary Petition dated 04/24/2022 documented in part but not limited to the following: R143 was displaying sexually inappropriate behaviors and language towards a female peer. R143 confessed to exposing his genitalia and attempting to touch peer's breast and vaginal area. R143 often displays sexually abusive language, sexually threatening language and explicit/inappropriate language towards female peers. R143 expressed having overthinking, and auditory hallucinations stating, voices in my head are telling me to do bad things. R143 is a danger to peers and requires immediate hospitalization . On 05/11/022 at 1:13 PM, V3 was asked regarding interventions in preventing sexual abuse among residents in the facility. V3 stated, We need to set boundaries on female residents being visited or male residents coming into room; inform residents regarding interaction in the room or with supervision. Staff needs to intervene, ask if it was an invitation, especially if there are other residents residing in the room. Staff needs to monitor residents every two hours or as needed to ensure residents' needs are met and for safety purposes. V3 also added, He (R143) has [CONDITION(S)] disorder. We need to monitor behavior and management for [CONDITION(S)]. We need to supervise him and monitor regardless if there is a behavior or not because of his mental illness, medical illness and for psychotic episodes. He is alert, oriented and easily redirectable and can understand instructions. Just need guidance and monitoring. V1 (Administrator) also mentioned during interview on 05/11/22 at 2:43 PM, We always have an adequate amount of staff supervising and monitoring residents to ensure patients' needs are met, male residents roaming around or going into female residents' rooms without permission. Staff is constantly doing rounds in a shift and they do redirect residents when needed. We need to monitor and supervise residents with mental illness and redirect them. We monitor all residents and supervise them as needed and as frequent as possible for safety and prevention of incidents and redirection as necessary. R187's Care Plan dated 04/12/22 documented: The resident may voice allegations of mistreatment or exploitation. Interventions: assess the resident that they are safe and secure. Assure them that their needs will be addressed by trained caregivers. Keep the resident's representative informed about the behavior and staff interventions strategies, as appropriate; Investigate statements/allegations. Facility's policy titled Abuse Prevention and Reporting - Illinois reviewed date 12/17/2021, documented in part but not limited to the following: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, 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 abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. R50 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to MDS (Minimum Data Set) dated 02/15/2022 under section C, R50 has BIMS (Brief Interview of Mental status) score of 14 indicating intact cognition. On 05/09/22 at 12:17 PM surveyor interviewed R50 about an incident that happened on 05/06/2022, R50 stated upon an interview, Couple of days ago, around 10:00 PM, another resident came into my room and started calling me names, and then he started punching my right forearm. He also hurt other people before. Somebody came in and told him to leave. Then they looked at me and my arm, and I got an x-ray couple of days later, but nothing is wrong with my arm. I believe the perpetrator is still here. I talked to the V3 (DON) the same night, I told him what I just told you. On 05/11/2022 at 10:24 AM Surveyor interviewed V3 (DON - Director of Nursing) regarding an incident that happened on 05/06/2022 involving R50, V3 stated, I was told by the nurse that R171 came into R50's room and hit him. V32 (LPN - Licensed Practical Nurse) then evaluated R50, no injury was noted, and x-ray was ordered. Notified family and the medical director. R171 was sent to the hospital for further evaluation for increased confusion, which resulted in hitting R50. Neither of them are violent, R171 is easily redirectable and it was very unusual for him to hit someone, that's why he was sent for further evaluation. V3 further stated, That floor (four south - dementia unit) needs more supervision, residents are demented, we're trying to keep them occupied but two demented patients walking into each other sometimes results in an altercation. On 5/11/2022 at 12:10 PM surveyor asked V21 to characterize R50, V21 stated, R50 has been here for a while, he rarely leaves the room. He gets a lot of packages but never opens them. He has a Power of Attorney who's involved in his care. Surveyor asked V21 to characterize R171, V21 stated, R171 is a very sweet but he's a sundowner, he wanders into residents' rooms but is easily redirectable. On 5/11/2022 at 12:10 PM Surveyor asked V21 why are there several altercation incidents in the four-south unit, V21 stated, Four south is a locked unit. There are a lot of residents with dementia, and a lot of them are not easily redirectable, wandering into others' room, getting into others' belongings, or just their personal space. Four south has expansive activity program. Activities keep residents engaged, prevent altercations, falls, and keep residents in one area. That allows us to monitor and supervise them easily. Four south is usually staffed with one nurse, two CNAs and one activity staff. More activities would benefit the unit.

Based on observation, interview, and record review, the facility failed to 1.) prevent a resident (R98) from developing moisture associated skin [CONDITION(S)] related to incontinence and 2.) failed to assess and treat a neck wound for a resident (R173) at the time of admission. These failures affected two out of 10 residents reviewed for pressure ulcers and resulted in R173 having a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R98 is a [AGE] year-old female admitted to the facility 07/05/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R98 is alert and oriented but is unable to make needs known to staff as noted during observation and interview attempts. On 05/09/22 at 12:18PM R98 was observed in bed, with bilateral lower leg contractions, and heels resting on the mattress. The right heel was red in color and had noticeable skin peeling. R98 had on a disposable brief and sheets were observed to be soiled from underneath. On 5/10/22 at approximately 10:50 AM V22 Wound Care Coordinator said, the nurses are supposed to look at the skin and document on days that the residents get showers. The Certified nursing assistant will put if there is a skin issue in the electronic record and the nurse is supposed to follow up and assess. They should be documenting weekly on skin observation forms in the electronic record. It would not be beneficial for an air mattress to be covered with a bath blanket on the air mattress or a towel in between the resident and the air mattress because it will impede the healing process of the mattress. It should only be covered with a flat sheet. 5/10/22 at 11:40 AM R98 was observed receiving incontinence care before conducting a skin assessment with V22 Wound Care Coordinator. V28 and V29 Certified Nursing Assistants were observed changing R98 and there was a foul odor coming from the sheets, the brief was saturated and the sheets were soaked in urine and feces. V28 said I last changed her at 8am today. While repositioning for care, a soiled bath towel was noted in between the mattress and the flat sheet. The air mattress was saturated as well. R98's skin was observed to be reddened in color with multiple areas of open skin in areas of the sacrum, coccyx and labia. V22 said, I would assess this as moisture associated skin [CONDITION(S)] in the perianal and scattered open areas caused by incontinence. R98 being wet for an extended period of time will certainly have accelerated this skin breakdown. It could have been prevented with frequent changes and repositioning. R98's Care Plan for Wound Care documents that R98 is high risk for skin breakdown related to immobility; Bowel and Bladder Incontinence and use of anti-coagulation therapy. Facility did not present weekly skin assessment notes upon request. R173 is a [AGE] year-old woman admitted to the facility 03/04/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R173 was admitted with a [CONDITION(S)] and required a ventilator for primary respiration. R173 was not able to be interviewed as she is not alert or oriented. She is unable to make her needs known to staff. Initial comprehensive nursing assessment dated [DATE] documents that R173 had 1 skin alteration, a Stage IV pressure ulcer to the sacrum. In an initial respiratory note written for the same day, 3/4/22, it was noted that R173 also had a wound on the neck, and that nursing would be advised of the wound. There was no further assessment by nursing or wound care noted until 3/17/22. On 3/17/22 at 11:47AM, a wound assessment and details report documents that R173 had a Stage III pressure ulcer of the back of neck bright pink or red in color with serous exudate measuring 3.0 x 1.50 x 0.20 cm^2 (length x width x depth). The assessment states that the wound was present on admission. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan initiated 3/7/22 and revised 3/17/22 said that R173 required wound care due to pressure injury to sacrum and back of neck upon admission. On 05/12/22 10:27 AM V22 Wound Care Coordinator said, the nursing and wound care team did not assess the wound on the back of the neck until 3/17/22. Although the wound was noticed by the Respiratory Therapist, they are not able to assess a skin issue. The nurse is supposed to assess. Since there was no assessment, there is no way of determining what type of wound was present and therefore did not have any treatment orders in place. By the time the wound care team saw R173, the wound was a Stage III. 05/12/22 12:45 PM V31 Wound Care MD said, The back of the neck wounds, when they open up, the skin opens very fast. I have no idea how old the wound was. Once a wound was identified, the treatment should be placed with urgency. Moisture Associated Skin [CONDITION(S)] (MASD) cause is secondary to exposure of body fluids including feces and urine. This could certainly transform into a pressure ulcer without treatment. MASD could have open skin with undefined edges and any moisture causes the skin to swell and skin breaks down. Facility Pressure Ulcer Prevention policy revised 1/15/18 reviewed and states in part; Purpose: to prevent and treat pressure sores/pressure injury. 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Facility policy titled Wound Care Program: Pressure injury and Skin Condition Assessment revised 11/29/20 states in part, 2. Residents identified will have a weekly skin assessment by a licensed nurse; 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse; 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment; 6. Care givers are responsible for properly notifying the charge nurse of skin breakdown; 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

Based on interviews and record reviews, the facility failed to provide required supervision and monitoring of residents assessed to require staff supervision. This failure affected three of three (R143, R174, and R171) residents reviewed for accidents and supervision and resulted in one resident (R143) from going into another resident's room (R187) and touching her inappropriately without consent; the facility also failed to supervise and monitor a resident according to their plan of care and the resident subsequently had a fall which resulted in one resident (R174) having to be transferred to the hospital for a laceration to the forehead that required sutures; and the facility failed to provide supervision to keep one resident (R171) from physically abusing another resident. Findings include: R143 is a [AGE] year old male, admitted in the facility on 12/30/2021 with diagnosis of [CONDITION(S)] Disorder, Depressive type. MDS (Minimum Data Set) dated 04/08/2022 under Section C documented that R143 has BIMS (Brief Interview for mental Status) score of 13 which means intact cognition. According to abuse report dated 04/24/2022, R143 admitted to inappropriate touching R187 above clothing and flashing without her (R187) consent. On 05/10/2022 at 11:40 AM, R187 was asked regarding incident with R143. R187 stated, It happened in my room. He went to my room and got into my bed, put his hand into my mouth so I couldn't scream. He started touching me, my breasts. I started crying and told him to stop. He stopped and left the room. I went to the nurse and report it right away. I was okay, the nurse checked me. I don't have any injuries or anything. I am not sacred of him. V8 (Registered Nurse, RN) was interviewed on 05/11/2022 at 10:24 AM regarding R187 incident with R143. V8 verbalized, The incident happened on 04/24/2022, around noon. I was doing my medication pass, I saw him (R143) with her (R187) in her (R187) room. He was talking to her but I was not listening. I remember she was feeling uncomfortable, she was looking at me like she was asking for my help to tell him (R143) to leave the room. I escorted him out of the room. He has [CONDITION(S)] disorder, sometimes he says intrusive thoughts out loud, or talks to himself. She is always calm, nice and cooperative. As a nurse, we don't allow male residents to come into female residents' rooms for safety precautions. Sexual advances may occur. We do rounds every hour to check, talk to residents and redirect them. R143 has a diagnosis of [CONDITION(S)] Disorder, Depressive Type, per his face sheet. On 05/11/2022 at 11:32 AM, V21 (Director of Social Services) was asked for interventions in preventing incidents of going into another resident's room without permission. V21 stated, I am not aware of any rules in the facility that male residents are not allowed in female residents' rooms. Residents have rights but there should be some kind of boundaries between male and female residents when male residents going into female residents' rooms. Activities, CNAs (Certified Nurse Assistants) and nurses need to be inserviced of the boundaries of male entering female rooms and vice versa, privacy, redirection, supervision and monitoring from staff. CNAs are supposed to do rounds as often as necessary to ensure privacy and safety of other residents. On 05/11/022 at 1:13 PM, V3 was asked regarding R143 and supervision among residents in the facility. V3 stated, We need to set boundaries on female residents being visited or male residents coming into room; inform residents regarding interaction in the room or with supervision. Staff needs to intervene, ask if it was an invitation, especially if there are other residents residing in the room. Staff needs to monitor residents every two hours or as needed to ensure residents' needs are met and for safety purposes. V3 also added, He (R143) has [CONDITION(S)] disorder. We need to monitor behavior and management for [CONDITION(S)]. We need to supervise him and monitor regardless if there is a behavior or not because of his mental illness, medical illness and for psychotic episodes. He is alert, oriented and easily redirectable and can understand instructions. Just need guidance and monitoring. V1 stated on 05/11/22 at 2:43 PM, We always have an adequate amount of staff supervising and monitoring residents to ensure patients' needs are met, male residents roaming around or going into female residents' rooms without permission. Staff is constantly doing rounds in a shift and they do redirect residents when needed. We need to monitor and supervise residents with mental illness and redirect them. We monitor all residents and supervise them as needed and as frequent as possible for safety and prevention of incidents and redirection as necessary. R143's care plans documented: Care plan 03/17/2022: R143 has diagnosis of [CONDITION(S)] Disorder and [CONDITION(S)] Disorder. He exhibit symptoms of auditory hallucinations, [CONDITION(S)], [CONDITION(S)], feelings of helplessness/hopelessness, poor insight/logic/judgment and contact with reality. Interventions: As warranted, conduct, carry out daily monitoring and supervision of resident; room safety checks; personal wellness check; mouth check during medication pass; behavior monitoring of the resident, looking especially for any change; evaluation of mental status, mood state, and thought content. Care plan 03/01/2022: R143 has a diagnosis of and history of Severe Mental Illness. Interventions: Explain facility rules, resident behavioral expectations and resident rights. Facility's Contract Between Resident and Facility stated in part but not limited to the following: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community, nor shall a resident forfeit any of the following rights: 1. The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. Facility's policy titled, Incidents and Accidents dated 04/07/2019 does not specifically address any guidelines regarding residents' going to other residents' rooms without permission. R174 is [AGE] years old. Current diagnoses include but are not limited to: Cognitive Communication Deficit, Symptoms and Involving Cognitive Functions Following Unspecified [CONDITION(S)] Disease, [CONDITION(S)], Unsteadiness on feet, and Other Abnormalities of Gait and Mobility. The facility reported incident of 4/27/22 states: Resident (R174) observed crawling on floor by bedside with a laceration to the forehead. Resident (R174) unable to explain what happened. Sent to hospital and sutures applied to the laceration on the forehead. On 05/10/22 at 10:46 AM, Resident # 174 is in lying in bed awake, opening and closing eyes when spoken to. Noted a handrail on the right side of the bed and a half side rail on the left side of the bed. The call light is wrapped around the handrail hanging in front of Resident # 174 while in bed within his reach. R174 has a BIMS score of 3 which indicates cognitive impairment' may be unable to understand how to use the call light. No fall mat noted on either side of his bed. Resident # 174 is wearing yellow non-slip socks. Review of R174's care plan indicates: Resident # 174 is utilizing half side rails to serve as enabler during repositioning and bed mobility 8/4/2021 Ensure that the mattress is appropriately sized for the selected bed frame Evaluate resident level of independence in repositioning Show to resident or staff how to take full advantage of the side rail for positioning, turning and transfer Resident # 174 is high risk for falls d/t generalized weakness and cognitive impairment secondary to AMS, [CONDITION(S)], [CONDITION(S)], history of [CONDITION(S)] (Cardiovascular accident) CKD (Chronic Kidney Disease), [CONDITION(S)] (Hypertension), [CONDITION(S)] ([CONDITION(S)]) and Depression. 10/26/21 Falling leaf provided. o 2/18/22 Continue PT and OT o 4/20/22 Sent out for evaluation. Fall evaluation at hospital. To resume screening from therapy upon return. o 5/1. Sent to ER for evaluation. o Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. o Be sure call light is within reach and encourage resident to use it for assistance as needed Shows on Kardex. o Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. There are no appropriate individualized interventions documented regarding R174's ability to use the call light. There is no documentation of need for frequent monitoring or supervision. R174's MDS Minimum Data Set, dated dated dated [DATE] documents a BIMS Interview for Mental Status score of 03 out of 15. A score of 0-7 indicates the resident has severe cognitive impairment. Resident # 174's Restorative Care plan states: Resident # 174 presents with a functional deficit in Ambulation, due to: Generalized weakness 8/10/2021. Interventions-Explain program goals and procedure to resident. Shows on Kardex. o Ensure resident is wearing proper footwear. Shows on Kardex. o Apply gait belt to resident's waist. Shows on Kardex. o Resident to continue gait sequence to cover goal distance, as tolerated. o Allow for rest periods, as needed. o Observe for signs/symptoms of fatigue, SOB, pain, discomfort, or intolerance. o Resident to continue gait sequence, with rest periods as needed, until the dining room is reached. No updates were made after his fall on 4/22/22. Resident # 174 presents with a functional deficit in Transfers, related to: Generalized weakness 4/5/2022. Interventions- Review goal and procedure to resident o Apply gait belt to resident's waist. o Cue & assist resident to place hand(s) on wheelchair arms or edge of bed and place feet flat on the floor. o Cue & assist resident to scoot forward to edge of bed, wheelchair or toilet seat. o Cue resident to lean forward. o Cue resident to push up with hands and feet to come to a stand. Assist as needed. o Pivot on feet until back of knees touch edge of bed, wheelchair or toilet seat. o On standing, cue resident to take short steps toward stronger side to turn until back of knees touch edge of bed, wheelchair or toilet seat. o Staff to assist as needed. No updates were made to this care plan area after the fall on 4/22/22. Review of the risk assessment for fall completed by V3 DON Director of Nursing was reviewed, indicates no injuries noted. On 05/12/22 at 12:24 PM, interview with V3 DON Director of Nursing regarding Resident 174's fall incident facility reported 4/27/22. V3 stated, The restorative nurse is the fall coordinator, but I am over all the falls for the residents. R174's BIMS score is 3, he's only alert and oriented to himself. He is ambulatory, but his gait is not steady. He shuffles and has poor posture. The incident happened on 4/20, but I reported it on 4/27. He was sent out due to the fall and had a laceration to his forehead. His interventions are low bed, he was screened by PT (physical therapy) for gait mobility and strength. He is on the falling leaf program. He is monitored closely with frequent rounding around the clock by all staff. The rounding is not documented. His aide that night was V35 CNA Certified Nurse Assistant, and the nurse was V34 RN Registered Nurse. There was another aide on the floor. I have statements from all of them. What was determined to be the cause of the fall? V3 DON stated, It occurred in his room on the floor crawling by the V35 CNA and he went to get the V34 Nurse to see what was wrong with him. R174 had a laceration to his forehead. He got out of bed and fell . It was late at night; his gait was unsteady so I'm not sure the exact cause. He has dementia, his BIMS is 3 and he can only be redirected. He paces and wanders into other rooms. What are the possible interventions to prevent R174 from falling? V3 stated, Monitoring and supervision R174 every 2 hours. He has a behavior of wandering, unsteady gait. We did labs a urinalysis t check for possible urinary tract infection. His medications were reviewed, and he was referred to physical therapy for evaluation again. On 05/12/22 at 01:04 PM, interview with V33 Rehab Director regarding R174's fall. V33 stated, R174 was evaluated upon readmission. He went to the hospital on 4/20/22, we were seeing him before that. He was on therapy at that time when he fell . Right now, he's on restorative. His functional limits are decreased safety awareness, unsteady gait he's not able to follow therapy with using the walker because of his dementia. I wasn't able to educate him with the walker. Staff have to watch him. We provided a wheelchair, but he just gets up and walks. He doesn't know how to use the wheelchair. His bed mobility is contact guard. He can move himself, transfer in bed, get out of bed but with unsteady gait. He has a restorative program. We recommended a low bed, no floor mat because if he tries to stand up he is high risk for falls. He is close to the nursing station. To observe him when walking to give him handheld assistance. He needs monitoring due to decreased safety awareness and decreased cognition. At 2:29 PM V3 stated, The nurse did the assessment for R174, but I did the risk assessment for the fall. V3 was inquired if he was at the facility on the date and time of R174's fall incident. V3 stated, No, I wasn't here, I just wrote what the nurse told me happened. Upon review of the change in condition evaluation completed on 4/20/22 at 8:49 PM by V3 DON indicates he completed the assessment. The initial report sent to IDPH Illinois Department of Public Health states the facility reported incident took place on 4/27/22. V3 DON did not present the requested nurse assessment of R174 after his fall incident on 4/22/22. R174 does not have a medical diagnosis of Dementia documented. V3 DON did not provide any documentation regarding frequent every 2 hour rounding on R174. R174's 4/19/22 Fall Risk Evaluation indicates a score of 17: At Risk. The revised 11/21/17 Fall Prevention Program states: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The fall prevention program includes the following components: methods to identify risk factors, methods to identify residents at risk, assessment time frames, use and implementation of professional standards of practice, immediate change in interventions thaw were successful, notification of physician, family/legal representative, communication with direct care staff members, documentation requirements, adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. Fall/safety interventions may include but are not limited to: Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. R171 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Vascular Dementia, Essential Hypertension, Personal History of [CONDITION(S)], and Cerebral Infarction. According to MDS (Minimum Data Set) dated 04/18/2022 under section C, R171 has a BIMS (Brief Interview of Mental status) score of 3 indicating severe cognitive functioning. 05/11/2022 at 10:24 AM Surveyor interviewed V3 (DON - Director of Nursing) regarding an incident that happened on 05/06/2022 involving R50, V3 stated, I was told by the nurse that R171 came into R50's room and hit him. V32 (LPN - Licensed Practical Nurse) then evaluated R50, no injuries found, x-ray was ordered. Notified family and the medical director. R171 was sent to the hospital for further evaluation for increased confusion, which resulted in hitting R50. Neither of them are violent, R171 is easily redirectable and it was very unusual for him to hit someone, that's why he was sent for further evaluation. V3 further stated, That floor (four south - dementia unit) needs more supervision, residents are demented, we're trying to keep them occupied but two demented patients walking into each other sometimes results in an altercation. On 05/12/2022 at 1:35 PM attempted to interview V32 via phone, no answer. Care plan Wandering/Pacing/Roaming dated 04/18/2022 reads in part, R171 should be assessed for unauthorized departure risk; if staff see that resident is attempting to go into another resident room, gradually show him where his room is and ask him to show you a personal item from his room; and make rounds/room checks to minimize chance of unauthorize leave.

Based on observation, interview and record review, the facility failed to follow the resident Kardex (Patient Care Summary) as based on the Minimum Data Set (MDS) assessment to use 2 or more staff members when repositioning a resident, this was for 1 of 3 residents (R1) reviewed for repostioning and fall prevention. This failure resulted in R1 falling from from the bed sustaining a laceration to the head, and being sent to the local hospital for treatment. Findings include: On 1-8-21 at 9:10 AM, surveyor observed R1 in bed with old laceration to bridge of nose and front aspect of the scalp. Surveyor observed R1's Room Tag with 2HL next to her name. On 1-9-21 at 1:03 PM, V8 (Certified Nurse Aide/CNA) said R1's 2HL means R1 requires 2 persons assistance with care (repositioning) and requires mechanical lift for transfers. On 1-8-21 at 9:15 AM, V6 (Certified Nurse Aide/CNA) said she was giving R1 morning care by herself. She rolled R1 on her right side, the bedrail went down, and R1 fell off the side of the bed. R1 was bleeding from her nose and her head. V6 immediately notified the nurse on duty. On 1-8-21- at 9:22 AM, V7 (Registered Nurse) said she was informed that R1 fell on the floor. V7 assessed and treated R1's bleeding. V7 said she was not aware of another CNA in the room when V6 was giving R1 morning care. On 1-8-21 at 10:25 AM, V4 (Restorative Nurse) said V6 was providing care, turned R1 to her right side, the siderail dropped, and R1 fell out of bed. Per V6's statement, there was no mention of another staff on the other side of R1's bed. The rail dropped. R1 requires 2-3 persons to provide care. Any CNA can talk to other staff for assistance. V4 said 2 persons should have done bed mobility (based on R1's Minimum Data Set, Assessment Reference Date 10-9-20)). On 1-8-21- at 10:40 AM, V2 (Director of Nursing/DON) said CNA can ask for help from all nursing and restorative aides. V2 is not aware of another staff present to assist V6 during R1's am care/repositioning. R1 requires 2 person assistance for bed mobility/repositioning. R1's Minimum Data Set (Assessment Reference Date 10-9-20) documents Bed Mobility (Support) = 3 (two+ persons physical assist). R1's Kardex Report documents Special Instructions: Bed Mobility & Transfer with 2+ Person Assist. R1's Fall Assessments dated 1-1-21 reads NA, 1-5-21 reads 12 (at risk), 10-7-20 reads 11 (at risk). R1's Hospital Medical Record dated 1-1-21 documents R1 was being changed when she fell out of bed landing on her face. Four cm (centimeter) laceration to forehead at hairline. One cm flap laceration to nasal bridge. Both lacerations were closed with cyanoacrylate glue.

Based on interview and record review, the facility failed to implement interventions to ensure the safety of a wheelchair bound resident, who was identified at high risk for falls and totally dependent on facility staff for transfers. (R436) is one of one residents in the sample of 62 who sustained a [MEDICAL CONDITION] trochanter and a head injury, as a result of a fall related incident. This facility failure resulted in the residents transfer to the hospital for emergency medical treatment. Findings include: R436's Admission Record documented that R436 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R436's MDS (Minimum Data Set) dated 1/2/2020, documents that R436 has a BIMS (Brief Interview for Mental Status) score of three, which indicates severe impaired cognition. R436's bed mobility and transfer status was listed as 3/3, which indicates extensive assistance of two person physical assist. Fall Risk assessment dated [DATE], documents a total score of eight, which means Moderate Risk for falls. Clinical Admission Evaluation dated 12/28/19 indicate that R436 is confused, disoriented and had short-term memory loss. Under Safety, Call light within reach was the only intervention to be implemented for R436. On 1/29/2020 at 3:55 pm, V3 (Director of Nursing, DON) stated that the Clinical Admission Evaluation was the baseline care plan for R436 and includes the interventions. R436's progress note dated 12/29/19 at 7:47 pm, documented that V14 (Certified Nursing Assistant, CNA) assisted R436 to the bathroom. V14 lowered R436 to the floor, because R436 lost balance and was about to fall. This was R436's first recorded fall in the facility. The Progress note dated 1/2/2020 at 12:15 am, documented that R436 was noted by staff on the floor next to bedside. A head to toe assessment was done. Vitals were taken and on assessment, R436 felt pain in left hip. 911 was called and R436 was transferred to the hospital as ordered. This was R436's second recorded fall in the facility. Hospital records dated 1/2/2020, indicated that R436 had an X-ray of the hip for possible fracture. CT (Computerized [NAME]ography) of the head notable for small 6 mm (millimeters) possible intraparenchymal posttraumatic bleed. Hospital record - Diagnostic Imaging dated 1/2/2020 indicated that R436 had a [MEDICAL CONDITION] greater trochanter. A Progress note dated 1/3/2020, documented that R436 was admitted to the community hospital with a [DIAGNOSES REDACTED]. On 1/29/2020 at 3:24 pm, V12 (Registered Nurse, RN) stated that R436 is a fall risk and confused based on the information that she received from another long term care facility. V12 said she was the admitting nurse and she did the Fall Assessment on 12/28/19. V12 stated that R436 is wheelchair-bound. On 1/29/2020 at 3:55 pm, V3 (DON) stated that when a resident comes with a [DIAGNOSES REDACTED]. For residents who are admitted to the facility without fall diagnosis, then the falling leaf is placed on resident for 72 hours. If residents are high fall risk then the bed is placed to the lowest position, no floor mat if resident is ambulatory because it will be a fall hazard; if patient is not ambulatory then floor mat should be placed. There were no floor mats in place for R436 per V3. Facility's policy Fall Prevention Program revised 11/21/17 states Purpose: To assure the safety all residents in the facility, when possible. The Fall Prevention Program includes the following components: Methods to identify risk factors, Methods to identify residents at risk. Care plan incorporates: Identification of all risk/issue. Addresses each fall. Intervention are changed with each fall, as appropriate. Preventative measures. A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. Safety interventions will be implemented for each resident identified at risk. Each resident will be screened by a specialist therapist at the time of admission, after each fall, as appropriate, and with significant change in the resident's mental and functional abilities. Facility's policy Baseline Care Plan revised 11/17/17 states Upon admission, the admitting nurse will initiate the development of the baseline care plan as part of the admission assessment.

Based on observation, interview and record review, the facility failed to ensure that a pressure sore did not increase in size/decline; failed to follow interventions in preventing deterioration of pressure sore related to turning/repositioning and failed to ensure proper functioning of low air loss mattress for two (R2 and R3) of three residents reviewed for pressure ulcers. These deficient practices resulted in deterioration of R3's Stage 4 pressure ulcer on the sacrum and R2 to develop an Unstageable pressure ulcer on the right heel. Findings include: 1. R2 is a [AGE] year old, female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) dated 09/11/2018 documented: Sec. C - has memory problem for short and long-term memory; severely impaired cognition for daily decision making Sec. G - totally dependent from one person physical assist during dressing, eating, hygiene; has impairment no impairment on both upper and lower extremities Sec. H - always incontinent of bowel and bladder Sec. M - M0300: Has one Unstageable Pressure Ulcer Sec. M1200: Skin and Ulcer Treatments - pressure reducing device for bed; pressure ulcer care R2's POS (Physician order [REDACTED]. R2's care plan date initiated 06/13/18 documented interventions: Educate resident family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; Needs monitoring/reminding/assistance to turn/reposition every two hours, or as needed; Requires pressure relieving/reducing device on bed/chair. R2's Wound Assessment Details on the Right Heel Unstageable documented the following: 08/09/18: measurements 5cm (centimeters) x 4cm 08/16/18: measurements 5.1cm x 4cm 08/23/18: measurements 5cm x 4cm 08/30/18: measurements 4.5cm x 3.5cm 09/06/18: measurements 4.3cm x 3.5cm 09/13/18: measurements 4cm x 3.5cm 09/20/18: measurements 4cm x 3.5cm 09/27/18: measurements 4cm x 3.5cm x 0.3cm (debridement was performed) 10/04/18: measurements 3.8cm x 3.5cm x 0.3cm R2's Wound Care Evaluation Notes documented: 09/27/18: Right Heel Unstageable - 4cm x 3.5cm Preventive measures: heels offloading; turning schedule 10/04/18: Right Heel Unstageable - 3.7cm 3.5cm x 0.1cm Preventive measures: heels offloading; turning schedule On 10/09/18 at 10:15AM, morning care and incontinence care were observed on R2. R2 was lying supine on bed, on a low air loss (LAL) mattress. R2's LAL mattress was covered with flat, top sheet. A white blanket folded into fours was placed under R2's lower back. R2 was wearing an incontinent brief. A pillow was placed under R2's left upper back. The foot of the bed by R2's lower extremities were elevated at 30 degrees angle but R2's right heel is resting on the bed and not offloaded. After the provision of morning and incontinence care on R2, she (R2) was placed on a supine position in bed with a pillow placed on her (R2) left upper back. There was no pillow placed on R2's right heel for off-loading. On 10/09/18, the following were observed regarding R2's position while on bed: 10:25 AM - lying on her back position with a pillow placed on left upper back; heels not offloaded 10:40 AM - lying on her back position; heels not offloaded 10:55 AM - lying on her back position; heels not offloaded 11:10 AM - lying on her back position; heels not offloaded 11:25 AM - lying on her back position; heels not offloaded 11:40 AM - lying on her back position; heels not offloaded 11:55 AM - lying on her back position; heels not offloaded 12:10 PM - lying on her back position; heels not offloaded 12:25 PM - lying on her back position; heels not offloaded On 10/10/18 at 10AM, R2 was observed in lying supine on bed, on LAL mattress. R2's LAL mattress was covered with a fitted sheet. A white blanket folded into 4s was placed under R2's lower back. R2 was wearing an incontinent brief. A pillow was placed under R2's right shoulder and another pillow placed under left shoulder. R2's both feet were elevated to pillows but the right heel was resting on the pillow. At this time also, V7 (Wound Care Nurse) and V8 (Wound Care Nurse) were about to do wound care on R2. V7 and V8 were asked regarding R2's right heel and how many sheets are needed to cover the mattress. V7 stated, Her (R2) right foot should be elevated at all times. The CNAs (Certified Nurse Aides) are supposed to check and elevate her (R2) feet. V8 continued, There should only be a top sheet covering her (R2) LAL mattress. V7 mentioned, There should be no fitted sheet because it diminishes the distribution of pressure. CNAs turn and reposition residents with pressure ulcers every two hours. V3 (Assistant Director of Nursing) came into R2's room and observed that R2's right heel resting on the pillow and was not off loaded. V3 stated that R2's right heel should be offloaded at all times. At 10:20 AM, wound care was observed on R2. It was observed that R2's pressure ulcer on the right heel looked bigger than a Quarter in size. V7 measured the pressure ulcer on R2's right heel, measuring 3cm x 2.5cm., 50% necrotic and 50% slough. There were no issues noted during wound care observation. R2's progress notes dated 08/20/18 documented: MDS notes: (R2's) previous Stage 1 on right heel deteriorated to Unstageable pressure. According to V6 (Wound Care Coordinator), R2's pressure ulcer on the right heel is a facility acquired pressure ulcer which started 08/09/18. 2. R3 is a [AGE] year - old, male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per facility's census report, R3 was transferred to the local hospital on the following dates: 05/26/18 - transferred to hospital 06/02/18 - return date to facility 06/23/18 - transferred to hospital 06/26/18 - return date to facility 08/25/18 - transferred to hospital 08/30/18 - return date to facility R3's MDS (Minimum Data Set) dated 09/13/2018 documented: Sec. C - has memory problem for short and long-term memory; severely impaired cognition for daily decision making Sec. G - totally dependent from one person physical assist during dressing, eating, hygiene and bathing; has impairment on both upper extremities Sec. H -has indwelling urinary catheter and always incontinent of bowel Sec. M - M0300: Has one Stage 4 Pressure Ulcer and was present upon admission Sec. M1200: Skin and Ulcer Treatments - pressure reducing device for bed; pressure ulcer care R3's Wound Care Evaluation notes on Stage 4 Pressure Ulcer (P/U) on the Sacrum documented: 09/27/18 - measuring 5cm x 6cm x 1.6cm Dressing order: frequency - daily and PRN; clean with normal saline; [MEDICATION NAME] blue, dry dressing, zinc oxide in periwound Preventive Measures: bed off-loading, heels off-loading, turning schedule 10/04/18 - measuring 5cm x 6cm x 1.6cm Dressing order: frequency - daily and PRN; clean with normal saline; [MEDICATION NAME] blue, dry dressing, zinc oxide in periwound Preventive Measures: bed off-loading, heels off-loading, turning schedule R3's Wound Assessment Details documented: 08/30/18 - Stage 4 P/ Sacrum: measuring 5.5cm x 5cm x 1.8cm Treatment: Cleanse wound and periwound with noncytotoxic agent using Dakins ¼ strength solution (1); applied primary dressing using Calcium Alginate with Silver, foam 09/06/18 - Stage 4 P/U Sacrum: measuring 5.5cm x 6cm x 1.6cm. Assessment notes: (R3) is on wound vac for this wound. (R3) adherences to wound vac changes by the treatment nurse. Treatment: Cleanse wound and periwound with noncytotoxic agent using normal saline; applied negative pressure therapy dressing; support surfaces using low air loss mattress 09/13/18 - Stage 4 Pressure Ulcer Sacrum: measuring 5cm x 6cm x 1.6cm Treatment: Cleansed wound and periwound with noncytotoxic agent using normal saline; applied negative pressure therapy dressing; applied offloading device using pillows, support surfaces using low air loss mattress. 09/20/18 - Stage 4 Pressure Ulcer Sacrum: measuring 5cm x 6cm x 1.6cm Treatment: Cleansed wound and periwound with noncytotoxic agent using normal saline; applied primary dressing using foam, [MEDICATION NAME] blue, zinc oxide ointment, applied offloading device using pillows, support surfaces using low air loss mattress R3's POS (Physician order [REDACTED].>10/04/18: Turn and reposition at least every two hours and as appropriate for preventive measures. 09/20/18: [MEDICATION NAME] Blue Foam Dressing - apply to sacrum topically everyday shift for wound care irrigate with NSS (normal saline solution), cover with foam dressing. 09/20/18: Zinc Oxide ointment 20% apply to around wound sacrum wound topically everyday shift for wound care irrigate with NSS. R3's care Plan documented: 03/28/18: Pressure injuries that require wound care Interventions: Administer treatments as ordered and monitor for effectiveness; Educate (R3)/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 06/04/18: (R3) is ventilator dependent, has [DIAGNOSES REDACTED].>Interventions: Monitor for pressure ulcers. Preventive measures include turning (R3) at least every two hours; keep HOB (head of bed) <30 degree side-lying position; use pressure relief mattress or turning bed if indicated. Notify nurse and/or physician as indicated. On 10/09/18, the following were observed regarding R3's position while on bed: 10:55 AM - lying on back position with pillows placed under right and left shoulders. 11:10 AM - lying on back position 11:25 AM - lying on back position 11:40 AM - lying on back position 11:55 AM - lying on back position 12:10 PM - lying on back position At 12:20 PM, V12 (Respiratory Therapist, RT) was observed performing suctioning on R3. R3 was observed in bed, asleep, with trache tube and is on full vent support, R3 also has an ongoing tube feeding of Glucerna 1.2 running at 65 ml/hr (milliliter per hour). R3 has an indwelling urinary catheter connected to urine bag with 800 ml (milliliter) of yellowish urine output. R3 is on a low air loss mattress. The mattress was covered with a top sheet. On top of the top sheet, a colored blue blanket folded into 4s was placed. R3 was wearing an incontinent brief. There were two pillows observed placed under R3's right and left shoulders. R3's right and left upper arms were resting on the pillows. R3 was in a supine position. R3's lower back is also resting on the layers of sheets placed on the mattress. 12:25 PM - lying on back position 12:40 PM - lying on back position 12:55 PM - lying on back position 1:10 PM - lying on back position On 10/10/18 at 10:55 AM, V7 (Wound Care Nurse) and V8 (Wound Care Nurse) were about to perform wound care on R3. It was observed that R3 was turned halfway to (R3) left side. A wedge pillow was placed under R3's upper back and right shoulder and a regular pillow was placed under R3's right shoulder. According to V7, (R3) position shouldn't be like this. (R3) lower back and sacral area is not totally offloaded. He (R3) should be turned completely. Wound care observation on R3 was done. R3's pressure ulcer on the sacrum is like a size of a golf ball, beefy red in appearance, no tunneling observed with 100% slough and 90% granulation. V7 took the measurements: 7cm x 6cm x 3cm. R3's Wound Care progress note dated 10/11/18 documented: Late entry for 10/10/18. Upon daily dressing change the measurements for sacral wound are 7x6x3. V7 was asked regarding prevention of pressure ulcers. V7 stated that residents with pressure ulcers need to be repositioned at least every two hours. V8 also verbalized that there should be one sheet which is the top sheet that needs to be in the low air loss mattress. On 10/10/18 at 11:00 AM, V6 (Wound Care Coordinator) was asked regarding prevention of pressure ulcers. V6 stated, We do skin assessment, turning and repositioning of residents every two hours and as needed. Performing dressing change as ordered. To prevent the pressure ulcer from getting worse, the nurses' aides were told to do incontinence care when needed. V6 was also asked regarding the use of low air loss mattress. V6 verbalized, The mattress should have one flat sheet. Because with multiple layers of sheets, the pressure on the mattress is not redistributed. We constantly remind the nurses' aides regarding interventions to prevent pressure ulcers regarding turning and repositioning, incontinence care and the use of low air loss mattress and its covers. On 10/11/18 at 11:16 AM, V10 (Certified Nurse Aide, CNA) and V11 (CNA) were asked regarding ways in preventing pressure sores. V10 and V11 both stated that residents with pressure ulcers need to be turned and repositioned every two hours, check for changing of briefs when needed and if there is any change in the skin condition that the wound care nurses need to be notified. V10 and V11 further stated that only a flat sheet should be covering the low air loss mattress. On 10/11/18 at 12:37PM, V14 (Wound Physician) was interviewed regarding pressure ulcer prevention and management. V14 stated, First of all, residents with pressure ulcers should be provided with good hygiene, proper nutrition, the pressure ulcer wounds should be off-loaded at all times; turning and repositioning per protocol and be provided with low air loss mattresses. Staff in the facility should be following the wound protocol as well as wound policies. Facility's policy titled Pressure Ulcer Prevention dated 12/30/13 documented in part: Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. Purpose: The purpose of this policy is to establish and provide consistent measures for the prevention of pressure ulcers based upon the assessment of pressure ulcer risk. Procedure: I. This facility will implement interventions based upon the results of the risk assessment. A. Sensory deficits, mobility impairment and activity limitations 2. Residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. Facility's policy on Pressure Ulcer Prevention, dated 12/30/13 documented in part: Skin and Early Treatment: Protecting Against External Mechanical Forces - All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours. Manufacturer's guidelines on the low air loss mattress does not address on how many layers of sheets needed for proper functioning of the low air loss mattress.

Based on interview and record review, the facility failed to develop and implement elopement risk intervention to monitor and provide supervision to prevent elopement of an at risk resident 1 of 3 resident R7 reviewed for elopement and wandering. This failure resulted in R7 exiting from the 5th floor window on the locked dementia unit and found on the patio bleeding and unresponsive and taken to the hospital where R7 was later pronounced dead. Findings include: R7 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 8/9/16 at 10:45am, E2 (Director of Nursing) stated that on 8/7/16 at approximately 8:30am, R7 was found unresponsive on the patio after R7 jumped out of his bedroom window. E3 was a resident on the locked dementia unit. On 8/9/16 at 11:10am, E14 (Social Service) stated that R7 recently told him that he knows how to leave. E14 stated that R7 refused to talk about how he was going to leave. R7's care plan dated 7/22/16 reads Placed in alarmed unit for close monitoring. E14 stated that he would check on R7 daily but E14 noticed that there was a change in R7 within the past two weeks prior to his death. E14 stated that R7 did not want to be on the locked dementia unit and stated that he wanted to leave. R7's MDS (Minimum Data Set) dated 7/28/16 reads under section D - R7 verbalized feelings of depression, hopeless or down- frequency nearly every day for 12-14 days. On 8/10/16 at 2:30pm, E14 (Social Service) stated that he coded section D on R7's MDS on 7/28/16. E14 stated that R7 may have felt depressed, down, hopeless because he did not want to be on the locked dementia unit. On 8/9/16 at 12:30pm, Z3 (Attending Physician) stated that R7 had asked her if he could go out on pass. Z3 stated that she talked to Z4 (Psychiatrist) and they both decided not to give R7 a pass. Z3 stated that R7 had former alcoholi[DIAGNOSES REDACTED]. Z3 stated that R7 was rebellion type. Z3 stated that on 7/23/16, R7 ran away from the nursing home. Z3 stated that R7 was brought back to the facility by the local police and put in the locked dementia unit. Z3 stated that R7 was angry that we locked him up. Z3 stated that R7 was dangerous to himself. Z3 stated that R7 lived on impulses. Z3 stated that she thinks R7 was angry and that is why he jumped out of the window on 8/7/16. On 8/10/16 at 2pm, Z4 (Psychiatrist) stated that R7 had dementia and mental illness from a head trauma. Z4 stated that R7 was not suicidal. Z4 stated that he thought that R7 probably thought he was going out and didn't realize that he was on the 5th floor when he jumped out of the window. Surveyor asked Z4 if this incident on 8/7/16 of R7 jumping out of his bedroom window could have been avoided. Z4 stated Well, yes, the problem is that the facility should not have windows that can open enough to allow a resident to jump out of a window. That is the problem. On 8/11/16 at 10am, Z4 stated that he was not notified that R7 expressed feelings on depression, hopeless, down on 7/28/16. Z4 stated that if he was notified of R7's feeling of depression, hopeless or down, he would have talked to R7. Z4 stated that R7 always said he wanted to go home. The facility notes documented that R7 had 5 episodes of elopement on 2/17/16, 3/10/16, 6/28/16, 7/10/16 and 7/23/16. R7's social service progress notes dated 2/17/16 read R7 tried to escape the facility through the back door and alarm was activated by his motion. R7 was stopped at the parking lot by E14 and returned back to the facility. After that, E1 (Administrator) decided to transfer R7 to locked unit around 3pm but in 2 hours, R7 left the locked unit and returned to unlocked unit. R7 refused to return to locked unit. R7's social service notes dated 3/10/16 at 9:37 reads Informed by E1 that around 8:30am on 3/9/16, R7 was missing. R7 was absent for more than 3 hours. R7's social service notes dated 3/17/16 read E14 was informed that R7 was standing by the door, trying to go out. E14 stated that he wanted to walk around and get out away from the building. R7 stated per notes I don't want to be her anymore. R7's nursing notes dated 6/28/16 at 00:00 read R7 left facility without permission, was absent for about 30-40 minutes. Later found sitting on bus stop about a block away from facility- waiting for a bus to go home. R7 was escorted back to facility. Combative, verbally and physically abusive, makes threats against staff, swings arms trying to hit staff. On 8/9/16 at 12:30, E2 stated that R7 was found at local grocery store on 7/10/16 and brought back to the facility. R7's nursing notes dated 7/23/16 at 01:46 read R7 came back to facility, escorted by police. R7 alert, oriented x 3, uncooperative, agitated. E2 stated that R7 was transferred to locked dementia unit after the 7/23/16 episode of elopement. R7's screening assessment indicators of aggression and harmful behavior dated 5/4/16 reads score is 3, minimal aggression risk, potential interaction with peers. On 8/9/16 at 2:45pm, E3 (Social Service Director) stated that there is no range of scores for this assessment. R7's elopement/unauthorized departure risk assessment dated [DATE] reads score 12 (at risk- care plan recommended). On 8/9/16 at 2:45pm, E3 stated that there is no range for scores for this assessment. The facility's accident/incident report dated 8/7/16 at 8:35am reads Notified by staff member that R7 had fallen, ran down to patio and observed R7 lying on the ground not responsive and bleeding. 911 called. Paramedics on the scene. Police arrived.

Based on record review and interview, the facility failed to ensure appropriate transfer technique was followed for one (R4) resident of three residents reviewed for injuries during transfer. Improper transfer technique resulted in fracture of tibia. Findings include: Accident/incident report dated 1/13/14 for R1 documents, "Assigned C.N.A reported that resident complains of pain on right lower leg. According to C.N.A, he transfer resident to wheelchair 2 days ago and right leg got caught between side rail. He reported to nurse but no discomfort for 2 days. Now noted pain." Under description of incident, "Resident complained of pain to her right lower leg area, x-ray taken and showed degenerative arthritic changes with fracture of the distal shaft of the tibia." Employee report dated 1/13/14 documents, "transferred resident, resident leg got caught between foot/leg of wheelchair and 1/2 rails. resident sustained [REDACTED]. On 1/15/14 at 11:30 am with the help of an interpretor, R1 stated, "Hurt (fracture) occurred during transfer because foot was dragging under bed." On 2/14/14 at 10:05am E3(Certified Nursing Assistant at time of incident with R1) through interpretor) stated, "When stand she has no control over feet. When turning her, foot hooked. He didn't know hooked by wheel so when turning she said ah." On 2/14/14 at 1:15 pm Z1(Physician for R1) stated, "No weight bearing. Not able to control feet. Had spiral fracture of tibia. He tried to move and fracture occurred. Need remind/retaught how to transfer properly." On 2/14/14 at 9:30 am E2(Director of Nursing) stated, " She's alert. She can answer questions. On and off reliable. The way he described her leg got caught. Transfer from wheelchair to bed. Caught between wheel of wheelchair and foot of bed. You have to be aware of where feet are when transferring. He probably at that time not looking or aware of where her feet where during transfer. She loses control of her feet during transfer. 1/12 and 1/13 didn't get up. I believe break happened during transfer."

Based on observation, interview, and record review the facility failed to comprehensively assess, determine cause of weight loss, develop interventions and attempt alternative interventions to prevent further weight loss from occurring for three residents (R10, R16, R19) of 30 sampled residents. This has the potential to affect all 255 residents in the facility. Findings Include: 1. Record review on 12-28-10 notes on the nursing admission form that R10 re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the nutritional progress notes on 11-22-10 that R10 was readmitted at 160 pounds within acceptable parameters and to be given an 1800 calorie controlled diet. Record review of the nutritional progress notes on 12-3-10, R10 was assessed and denotes to change from 1800 calories controlled diet to a regular diet and that intake is good. Record review of weight /vitals signs sheet denotes R10 was weighted at 132 pounds on 12-5-10. Record review of R10's progress notes on 12-13-10 nursing staff contacted the nurse practitioner for R10's complaint of pain and sleepiness. Observed on 12-28-10 at 12:15 PM R10 eating chocolate from a box of chocolates while in his bed. Observation on 12-28-10 at 12:28 PM, R10 was weighed at 121 pounds in his room with an Hoyer lift by R15 (certified nurse assistant). Interview of R15 states that we and his family feed and encourage R10 to eat since he has been here. Interview of E12 (director of nursing) on 12-28-10 at 2:40 PM states staff should have notified the doctor when any significant change happens to a resident. R12 states R10 weight from 11-13-10 was not put into the weights ands vitals summary record for the dietary to see. R12 states that it is nursing responsibility to put the weight of R10 into the weights and summary record. Interview of E13 (registered dietician) on 12-28-10 at 2:44 PM states that R10 weight did not trigger her to evaluate him for weight loss because nursing did not put R10's weight in the weight and vitals record. E13 states she did not know R10 had a significant weight loss until today. Interview of Z5 (nurse practitioner) on 12-28-10 at 3:20 PM on the second floor, states she was not notified of R10's weight loss until a few minutes ago. Z5 states that she is going to his room now to evaluate him. Record review of the facilities policy on 12-29-10 states A) All residents will be weighed on admission and the weight will be recorded in the clinical record. B) A significant weight change of 5% in one month is cause to notify the attending physician and the consulting dietician for review and recommendations to change the diet order. 2. R19 is diagnosed with [REDACTED]. R19 weight record documents: October 122 lbs. November 115 lbs. Between October and November R19 lost 7 lbs, a significant weight loss of 5.7% in 1 month. Registered Dietician note is dated 10/2/10. No dietician note is present for moth of November. After facility was notified of weight loss during daily status on 12/29/10, the Registered Dietician reassessed R19 and Supercereal, fortified pudding is added. Yearly weight record was presented on 12/28/10, after numerous requests, but did not contain complete weights for November and December. R19 weight record in medical record is documented as 118 lbs for November while on final monthly weight grid presented by facility on 12/29/10 at 10:00 am November weight is 115. R19 has a care plan for dysphagia and requires supervision when eating. Last care plan for weight loss risk is dated 7/20/10. No updated care plan for weight loss is in medical record. R19 lost significant amount of weight from October to November without R.D. (Registered Dietician) intervention. Policy and Procedure for Weight Monitoring Program states significant weight change is cause to notify the Attending Physician and the Consulting Dietician for review and recommendation. 3. R16 is a [AGE] year old female with a [DIAGNOSES REDACTED]. Review of R16's weight record on 12/28/10 indicated the following: September 5, 2010- 146 pounds October 5, 2010- 120 pounds November 5, 2010- 113 pounds December 5, 2010- 107 pounds Nutritional assessment completed on 10/29/10 stated no weight change (0 points for weight status), although there was a 26 pound weight loss, and failed to consider R16's [DIAGNOSES REDACTED]. Per nutritional progress, swallow evaluation was completed on 11/12/10 and speech language pathologist recommendations were pending. Hospital records indicate [MEDICAL CONDITION] tube feeding were initiated during hospitalization at Advocate Lutheran General hospital on [DATE]. Per E19 (Risk Manager) on 12/30/10, R16's physician was aware of the weight change and had planned to convert R16 to a gastrostomy tube, however she was diagnosed pneumonia during hospitalization . There were no interventions completed for R16 for weight loss during the month of October. -Monthly weight grid for facility was requested daily throughout survey. On 12/29/10 facility presented a incomplete monthly weight grid with November and December weights missing for all residents. On 12/30/10 at 10:00 a.m the final day of survey facility presented additional weights of November and December for 4 residents. Facility census during entrance on 12/27/10 was 255. Facility failed to present weight record for 251 residents for November and December. Facility policy and procedure documents "if weight is inconsistent, reweigh the patient" and "The facility will maintain a tracking system to include the resident's height, admission weight, ideal body weight, weight change, 5%, 7.5%, or 10%, supplement (where appropriate). Additional information is recorded as needed, [DIAGNOSES REDACTED]." Facility tracking sheet was requested during daily status on 12/29/10. On 12/30/10 at 10:00 am (E19)) risk manager stated, "We're missing folder of documentation of tracking for weights." Review of monthly weight grid for January 2010 through December 2010 identifies weight discrepancy for 29 residents.