Every finding on record at Evercare at Stearns

Based on interview and record review, the facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA) for one (R3) of three residents reviewed for abuse in the sample list of three. This failure resulted in psycho/social harm to R3 causing feelings of increased anxiety and R3 being admitted to a local hospital for bruising to the left eye socket and left forehead and cheek bone. This past non-compliance occurred from 08/18/2026 to 08/18/2026.Findings Include:On 8/20/26 at 09:45am V4, Hospital Registered Nurse (RN) stated R3 arrived in the emergency room of the local hospital on 8/18/26. V4 stated the report received from the facility and paramedic was R3 pulled the hair of a Certified Nursing Assistant (CNA) and the CNA (V20) punched the resident several times. V4 stated R3 arrived and was assessed for injury. V4 stated R3 was assessed to have discolorations (bruising) to the left forehead above the left eye and discolorations (bruising) to the left eye socket/orbital area.On 8/20/26 at 09:54am V3, R3's family, stated in the afternoon of 8/18/26 V3 was informed R3 had been punched in the face several times by a CNA who had been caring for R3. V3 stated V3 arrived at the facility and noted R3's left eye/forehead area was reddened/bruising and swollen. V3 stated V3 would be pressing charges against the alleged perpetrator for hitting/abusing R3. V3 stated R3 would be extremely upset to be treated like that.On 8/20/2026 at 10:00 AM, V6, License Practical Nurse (LPN), stated there was an incident a day or so ago where R3 stated V20 struck R3. V6 stated V6 observed a knot on R3's forehead. V6 stated V6 reported this to V1 immediately. V6 stated V20, CNA was taken to the Human Resources office and then was walked out in handcuffs by the police. V6 stated R3 was sent to the hospital for an evaluation. V7 LPN stated the abuse coordinator is the Administrator, and all abuse and suspicions of abuse are to be reported immediately.On 8/20/26 at 10:31am V24, Nurse Practitioner (NP), stated V24 gave an order for R3 to have a one time dose of Alprazolam (anti-anxiety medication) due to V24 being told R3 was having increased anxiety related to a staff member hitting R3 in the face.On 8/20/26 at 10:57am V20, CNA, was unavailable for interview.On 8/20/26 at 11:26am V25, Activity Assistant (AA), stated V25 was in the Memory Care Unit performing activities when V25 heard V20, who was in the dining room with R3, asking for help due to R3 pulling the hair of V20. V25 stated V25 went to assist V20 and was able to remove R3's hands from V20's hair when V20 then using V20's right hand made forceful contact and pushed R3's face back into the recliner R3 was sitting in. V20 then reached for R3's hand to transfer R3 into the wheelchair, R3 resisted pulling away. V25 stated V25 then assisted and was able to transfer R3 into the wheelchair. V25 stated V20 then made forceful contact to the shoulder of R3 before pushing R3 to R3's room. V25 stated at this time V25 did not see any injury to R3.V25 continued stating V25 returned to the nurse's station, V20 went to R3's room. V25 stated V6, LPN, then brought R3 out of the room and V25 noted R3 having bruising to the left eye and left forehead. V25 stated V6 took R3 to V2's (Director of Nursing) office, and V25 stated V25 reported what V25 observed to V1.On 8/20/26 at 12:02pm V1, Administrator, stated V1 cannot get a copy of the police report due to the report being an ongoing investigation.On 8/20/26 at 12:51pm V26, NP, stated V26 had assessed R3 on 8/17/26 and R3 did not have any discolorations to R3's face. V26 stated on 8/18/26 V26 observed R3 with discolorations/bruising to the face and forehead after an alleged incident involving a staff member hitting R3 in the face.On 8/20/26 at 1:20pm V27, Physician Assistant- Certified (PA-C), stated on 8/18/26 V27 was the treating practitioner at the local emergency room when R3 arrived from the nursing facility. V27 stated V27 received report of R3 being assaulted by a staff member of the nursing facility. V27 stated V27 assessed R3 for injury noting bruising to the left forehead, and left eye/orbital areas. V27 stated the injuries were consistent of forceful contact from a fist/hand or blunt object.On 8/21/26 at 09:20am V1 stated on 8/18/26 in the afternoon, it was reported to V1 that R3 stated to V6 R3 had been hit several times. V1 stated V1 observed R3 to have bruising to the left forehead and left eye area. V1 stated V1 immediately removed V20 from the breakroom and kept V20 separated from all residents in the social service office. V1 stated when V1 observed R3, V1 knew that something had happened and R3 was unable to tell V1 what happened. V1 stated V1 phoned the police and R3's family. V1 stated R3's family wanted R3 assessed for further injury at the local hospital.On 8/21/26 at 09:20am V1 continued stating the police officer (V23) arrived at the facility, reviewed video footage of the incident, and interviewed V20. V1 stated V23 then went outside to make a phone call to his supervisor, upon returning inside the facility V23 arrested V20.On 8/21/26 at 09:43am V23 Police Officer (PO) stated V23 received a dispatch to the nursing facility due to an alleged abuse. V23 stated V23 observed R3 with bruising to the left forehead and left eye socket indicating R3 had been struck with a blunt object like a fist. V23 stated R3 was unable to report what had happened. V23 stated V23 reviewed video footage of V20 standing over R3 in the dining room/common area and V20 striking R3 several times. V23 stated V23 placed V20 under arrest for aggravated battery. V23 stated the V20 was transferred to the County jail charged with felony aggravated battery.V27 hospital PA-C, documented on 08/19/26 at 09:05am R3's Chief Complaint: facial bruising ADM (Admission) Date: 08/18/26 R3 is a (age) y/o (year/old) (gender) with a past medical history of Dementia, Hyperlipidemia, Major Depressive Disorder, Anemia and Hypertension. R3 comes from a local nursing facility (memory care) where R3 has resided since 2023 after R3 allegedly pulled a CNA's hair yesterday evening and the CNA punched R3 multiple times in the face before being arrested before patient being transported to the emergency department. The document continues History of Present Illness: HPI narrative: This is a (age) year old (gender) that presents to the ER (Emergency room) as a victim of physical assault. Reportedly (R3) was hit in the face multiple times by a CNA at (R3's) facility. (R3) presents with bruising about the left eye. Reports headache.R3's Electronic Progress Note dated 8/18/2026 at 2:01pm by V26 Nurse Practitioner, documents (R3) found to have bruising and swelling to left side of (R3's) face along (R3's) cheekbone and on the left-side of (R3's) forehead above (R3's) eyebrow following incident.R3's Nurse's Progress Notes dated 8/18/26 at 3:18pm, documented by V2 Director of Nursing (DON), spoke with Psych (Psychiatric) NP and an order received for one (1)-time extra dose of current Alprazolam (Anti-Anxiety Medication). In-house X-ray discussed with POA (Power of Attorney) and all parties in agreement.R3's Electronic Medication Administration Record documents V6, LPN, administered Alprazolam 0.25mg (milligrams) to R3 on 8/18/26 at 3:31pm.The facility's Abuse Prevention and Prohibition Program policy dated 8/10/26 documents, Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. Or misappropriation of resident property. Prior to the survey date of 08/21/2026, the facility had taken the following action to correct the non-compliance:1. On 08/18/2026 an all staff inservice was given to review the Facility Abuse Policy. 2. The facility implemented and performed skin checks on all residents. Administrator & DON in-serviced on the abuse & neglect policy & procedure by the regional director of operations. IDT (Interdiscplinary Team) team in-serviced on abuse & neglect policy and procedure. Staff on shift were in-serviced by the IDT team. Staff will not work until in-serviced on the abuse & Neglect policy & procedure. An Initial audit of the 24-hour report over the last 7 days will be reviewed to ensure that no reports of abuse & neglect were not reported. Residents were interviewed to ensure that no allegations of abuse or neglect have not been reported. Residents that were not interviewable on the dementia unit had skin checks completed. 3. The facility Quality Assurance tool with a start date of 8/19/26, quality assurance tool was implemented: On-going Audit: The Administrator/Designee will review the 24- hour report 5x(times)/wk(week) x 4wks to ensure that there were no reports of abuse or neglect. If abuse was noted and not reported 1 :1 in-servicing will be completed. On-going audit: The DON/ Designee will audit grievances or any injury of unknown origin to ensure that abuse or neglect are not suspected.

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions were in place and followed to prevent weight loss for 1 of 4 residents (R63) reviewed for nutrition in a sample of 59. This failure resulted in a significant weight loss of -13.38% in one month and -17.2% in a six-month period.Findings Include:On 06/22/26 at 12:00 PM, R63 is sitting at the dining table dressed in appropriate clothes. His shirt is hanging on him, he doesn't have any teeth, and his face is thin with facial hair noted. He picked up his piece of chicken and tried to eat it before the staff could cut it up for him. He was served his food on a divided plate, plastic silverware, and his drinks are in Styrofoam cups with no lids. He had a piece of chicken, vegetables, and rice. No house supplement was given to R63.06/23/26 at 12:10 PM, R63 is up in his wheelchair in the dining room. His shirt is hanging loosely on him, his face is thin, and he is thin and frail in appearance. His meal is being served on a divided plate, he has plastic utensils, and his liquids are served in Styrofoam cups with no lids. He was not seen given or drinking any house supplement. R63's Face Sheet, dated 06/25/25, documents he was admitted to the facility on [DATE] and has diagnoses of but not limited to unspecified dementia, unspecified severity, with psychotic disturbance and unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, and homicidal ideations.R63's Minimum Data Set (MDS), dated [DATE] documents R63 is severely cognitively impaired and requires supervision or touching assistance with eating.R63's Care Plan, admission date of 07/21/25, documents R63 has a nutritional problem or potential nutritional problem related to (r/t), interventions include but are not limited to Occupational Therapy (OT) to screen and provide adaptive equipment for feeding as needed, Provide diet as ordered, Registered Dietician (RD), to evaluate and make diet changes recommendations as needed (PRN). It also documents R63 has a swallowing problem, interventions include but not limited to diet to be followed as prescribed and refer to speech therapist for swallowing evaluation.R63's Progress Notes, dated 10/23/2025 at 3:23 PM, documents Nutrition/Dietary Note: Weight Note: Monthly/current weight of 139# (87%IBW; BMI 20.5) triggered significant weight gain of 7.42%/3 months (reviewed in IDT weight meeting; see RD note 10-13-25). Current diet is regular, NAS (No Added Salt), finger food preference. Offered divided plate, 2 handled cup with lid. Fair-good intakes at most meals per chart review. ST (Speech Therapy) ordered.R63's Physician's Orders, dated 11/21/25 at 2:38 PM, documents NAS (No Added Salt) diet, Regular texture, regular/thin consistency, finger foods, divided plate, handled cups with lids andSkilled speech therapy (ST) to evaluate and treat as indicated. Skilled ST to treat 4 times per week for 8 weeks for a minimum of 15 minutes of week and may include dysphagia treatment and speech and language therapy.R63's Physician's Orders, dated 06/19/26 at 2:21 PM, documents House Supplement before meals.R63's weights for the past six months document the following:1/5/2026 at 12:47 PM 138.4 Lbs (pounds)2/5/2026 at 04:39 PM 136.2 Lbs 3/5/2026 at 06:00 PM 132.4 Lbs4/3/2026 at 02:38 PM 133.7 Lbs5/6/2026 at 10:48 AM 132.3 Lbs6/5/2026 at 06:53 PM 114.6 Lbs R63's Electronic Medical Record (EMR) was reviewed and has no further documentation the Registered Dietician has been contacted to see R63 regarding his weight loss.On 06/30/2026 at 7:50 AM, V2, Director of Nursing they normally weigh the residents once a month and depending on if there is a trigger and where they fall, they will then do weekly weights and contact the dietician especially with someone who has wounds or is having weight loss. She said they also have a Nurse Practitioner (NP) who is in house who sees them often. She said they will start someone on house supplements and do other interventions as needed. V2 said the dietician they have now is new and has only been working for the facility for just a couple of weeks now. She said the old dietician was just coming to the facility staying for a few hours and then leaving and not really seeing the residents. She said the dietician was writing orders to put the residents on a supplement who were already on a supplement. V2 said they also had one person who was designated to weigh the residents and that person is no longer here, so they have had different staff weighing them and then they found out the scale wasn't working properly and had that fixed. V2 said in R63's case when the new owners took over R63 didn't have the right kind of insurance that would cover the Occupational Therapy (OT), Physical Therapy, (PT) and Speech Therapy (ST) but after his falls they were able to get him approved for the right insurance which is in the email she provided. V2 said if someone didn't have the right insurance and they needed a swallow evaluation done then the facility would just pay for that and if they needed PT and OT the facility would cover six visits for the residents. On 06/29/2026 at 1:32 PM V52, Medical Doctor/Director said when it comes to weight loss there is protocol the facility is supposed to follow. He said they will place the resident at the table and have him assisted with his meals, they will start them on the house supplement, and sometimes even an appetite stimulant. He said if he ordered for ST, OT, and PT to be completed he would expect for them to be completed. He said speech therapy would evaluate them and would see if the person would need a modified barium swallow. He said he didn't believe he was contacted regarding R111'a weight loss and the facility knows about the protocol regarding it and should have initiated it. He said they have talked about this in the Quality Assurance and Performance Improvement (QAPI) meetings.The facility's Significant Weight Gain or Loss Policy, undated, documents Purpose: To ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate interventions provided. Responsibility: Licensed Nursing Personnel/Dietician/Dietary Manager, Guidelines: 1. Dietary/Nursing team determine significant weight changes.After review a request for reweights will be determined.2. Dietician/Nursing will determine significant weight changes.A. Gain or Loss of 5% in the last month.B. Gain of Loss of 7.5% in the last three months.C. Gain or Loss of 10% in the last six months.3. Dietician will review these clients and document the change.4. If recommendations are indicated, they will be communicated to nursing to notify the provider of the significant changes and recommendation.

Based on interview and record review the facility failed to monitor vital signs, notify the physician, and send a resident out for evaluation and treatment in a timely manner for a change in condition for 1 of 3 residents (R111) reviewed for quality of care in a sample of 59. This failure resulted in R111's family member calling 911, having him sent out to the local hospital, and R111 being admitted to the Intensive Care Unit (ICU) at the local hospital with a diagnosis of Septic Shock, pneumonia, severe dehydration, and a urinary tract infection (UTI).Findings Include:R111's admission Record, dated 06/25/26, documents R111 was admitted to the facility on [DATE] and has diagnoses of but not limited to Chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute kidney failure, and major depressive disorder.R111's Minimum Data Set (MDS), dated [DATE], documents R111 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 08 out of 15 and he requires substantial/maximal assistance or is dependent on staff for most of his activities of daily living (ADLs).R111's Care Plan, admission date of 10/04/23, documents R111 is at risk for breathing complications related to (r/t) diagnosis (dx) of COPD, emphysema, and sleep apnea. Interventions include but are not limited to providing oxygen as ordered, observe for signs and symptoms (s/s) of exacerbation such as shortness of breath, restlessness, chest breathing, anxiety, cough, changes in skin/nail color, and monitor 02 (Oxygen) status as needed.R111's Facility Vital Signs (v/s), dated 04/12/26 at 4:44 PM, Blood Pressure: 124/84, Temperature: 102.2, Pulse Rate: 93, Respiratory Rate: 18, Pulse Oximetry 91% on room air. V/S for 21:45 were documented as the the same as the previous vital signs. (R111 was already in the hospital.)R111's Progress Notes, dated 4/12/2026 at 10:27 PM, documents Resident noted to have cough and fever this evening, and I gave him Tylenol. The sister came with other relatives and proposed to take him to the hospital. I contacted the MD (Medical Doctor) and DON (Director of Nursing). It was agreed after consultation that we do in house management of the problem. I communicated the same to sister who had since left the facility and seemed to have understood. Shortly, we saw the EMT (Emergency Medical Technician) team come to pick him up. He was taken to the local hospital for further care.R111's Physician's Orders, dated 11/26/25, documents Acetaminophen (Tylenol) 325mg (milligram) give 650mg by mouth every 6 hours as needed (PRN) for pain.R111's Medication Administration Record (MAR), for the month of April 2026 was reviewed and has no documentation Tylenol was given on 04/12/26.R111's Hospital Vital Signs, dated 04/12/26 at 6:11 PM, Temperature: 99.7, Pulse Rate: 83, Respiratory Rate: 22, Blood Pressure 109/80, and Pulse Oximetry (Sp02) 91%. V/S at 9:16 PM, Pulse: 57, Respirations: 22, B/P 9blood pressure): 76/54, and Pulse Oximetry 92%.R111's Hospital admission Record, admission date of 04/12/2026 (11:11 PM) and discharge date of 04/16/2026, documents the patient presented with a one-week history of a cough. Upon arrival, the patient met clinical criteria for septic shock, presenting with persistent hypotension (abnormally low blood pressure), leukocytosis (a condition characterized by a higher-than-normal number of white blood cells (WBC) in the blood), and tachypnea (rapid, shallow breathing). Documented on admission due to a high probability of clinically significant, life-threatening deterioration, the patient required admission to the highest level of care. The patient was admitted directly to the ICU (Intensive Care Unit) and initial treatment included aggressive intravenous fluids (IVF) and the initiation of Levophed (norepinephrine) to manage severe, acute hypotension. Diagnostic imaging revealed left lower lobe pneumonia, which is the primary source of the patient's septic shock and severe dehydration was identified as a secondary, contributing factor to the patient's persistent hypotension. The patient denied acute urinary symptoms. However, a Computed Tomography (CT) scan showed bladder wall inflammation, and urinalysis was positive for 4+ bacteria with trace leukocyte esterase. Acute cystitis cannot be entirely excluded. Lab results indicated elevated troponin levels. The patient was asymptomatic for acute myocardial infarction ([NAME]) and the elevated troponin is secondary to demand ischemia caused by septic shock.On 06/25/2026 at 11:05 AM, V29, Registered Nurse (RN), said if he has a resident who is having a change in condition and the family wants them sent out to the hospital to be evaluated, he will go and assess the resident to see how they are doing. He said if he feels like the resident can be managed in house then they will try to take care of it here instead of sending them out to the hospital. He said he would call the family/ (Power of Attorney) POA and explain it to them and if they still wanted them sent out, he would send them out. He said if it was a person who can make their own decisions, he would do what they wanted. V29 said he spoke with V52, Medical Doctor and they got orders to give R111 Tylenol and to use cold compresses to try and bring down the temperature. He said when the fever didn't break then he was sent out. V29 said he documented in R111's progress notes what was going on with him. On 06/29/2026 at 1:34 PM, V54, R111's Family Member said talked with R111 the day before this incident (4/11/26) when he called her and asked her if she would bring him some chocolate candy. She said R111's voice sounded hoarse. She said when she came in on 04/12/26 at around 3:00 PM, she bent down to give R111 a hug and she could feel he was hot, and his gown was soaking wet. V54 said she went up to the nurse's station and informed the nurse of what was going on and told him R111 needed his vital signs checked. She said the CNA came down and took R111's v/s and his temp was 102.5 and his Sp02 was 88% to 90% and she told the nurse R111 needed to be sent out to the hospital because he was at high risk. V54 said the nurse then asked her what she wanted him to say what was the reason for sending him out for? V54 said she went back to R111's room and waited about 20 minutes before returning to the nurse's station and the nurse told her he had talked with the doctor, and they had decided to treat R111 in house. V54 said she then left the facility to take some individuals home, and she waited for about an hour before she attempted to call the facility and got no answer. She said she then called the number R111 had called her from the day before to check and see what was going on and that was when she decided to call 911 herself and have R111 sent out to the hospital, and she met him up there. She said she was glad she had sent him out when she did because about 30 minutes or so later, he went into septic shock and had to have a central line placed. On 06/29/2026 at 1:32 PM, V52, Medical Doctor/Director said when nursing staff notifies him of someone who is running a temperature, he has a standard work up he would initiate for them. He said he would have ordered a Complete Blood Count (CBC), Blood Cultures, chest x-ray, and a urine culture to be done. V52 said if those things weren't ordered then he probably wasn't notified about R111's change in condition. V52 said if the family had requested for R111 be sent out to the hospital he would have respected the family's wishes and sent that person out. V52 said the nurses should have notified him of this change in condition it's the law. The facility's Change of Condition Policy, not dated, documents Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. It further documents Guidelines: The facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is: B. A significant change in the residents' physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. It also documents D. A decision to transfer or discharge the resident from the facility.

Based on interviews, observation and record review, the facility failed to prepare food at the required temperatures reviewed for Food and Nutrition Serves. This failure has the potential to affect all 101 residents residing in the facility.Findings include: On 6/22/26 at 10:50 AM, V7 (dietary manager) stated they are having brownies, chicken, steamed veggies, and rice. V7 stated they will take the food out of oven in about 10 minutes to place on the steam table to be served. At 11:02 AM, temperatures were as follows in degrees Fahrenheit with V8 (Cook): mechanical chicken 105 degrees, steamed veggies 203 degrees, rice 180 degrees, chicken 156.4 degrees, pureed meat 132 degrees, gravy 119 degrees. The following were placed back in the oven to heat up more: pork loin with gravy 76 degrees, pureed veggies 99.5 degrees and mashed potatoes 117.5 degrees. At 11:14 AM the pork loin was reheated to 156.3 degrees and placed on the steam table, at 11:19 AM the pureed veggies were reheated to 123.1 degrees and placed on the steam table and at 11:27 AM the mashed potatoes were reheated to 130.5 degrees and placed in the steam table. V7 stated to V8 we are good as long as the food temps good before we serve.On 6/25/26 at 1:52 PM, V7 (dietary manager) stated chicken is supposed to be at least 157-160 degrees prior to serving, veggies should be 159-160 degrees prior to serving and pork should be at least 160 degrees.The facility's Food Preparation: Temperatures policy undated documented the minimum final cooking temperature for poultry is 165 degrees Fahrenheit and port is 155 degrees Fahrenheit. The policy continued to document cook foods to the proper temperatures and reheat foods in the oven and check temperatures before placing on a steam table or holding unit.The Long-Term Care Facility Application for Medicare and Medicaid, dated 6/22/2026, documents 101 residents living in facility.

Based on observation, interview, and record review, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 101 residents residing in the facility.Findings include: 1. On 6/22/2026 at 8:27 AM observed R32 lying in bed with a clear medication cup containing 6 pills on table next to the bed. No nurse in room. On 6/22/2026 at 8:27 AM R32 stated that they always leave his medication there. R32 stated that he will take it after he wakes up.On 6/22/2026 at 9:00 AM 100 back hall medication carts were inspected. The medication cart contained the following. 2. R69's open and partially used multidose Lantus vial. No open date on vial. 3. 2 multidose open and partially used multidose Lantus pens. No name or open or expired date. 4. 4 Budesonide 0.25mg/2ml vials. The vials were loose in the cart. No name on vial and no box or package in cart for medication. Expiration date 9/25.On 6/22/2026 at 9:08 AM V11, Licensed Practical Nurse (LPN), stated that all expired medication should be removed from the cart, returned or disposed of. V11 stated that she does not know who the Lantus belongs to. V11 stated that each medication should be labeled with a resident's name. V11 stated that when opening multi dose vials and pens an open and expiration date is placed on it. V11 stated that the medication has a shortened expiration date. V11 stated that the open date alerts you to when the expiration date is. V11 stated that it's 28 days after opening. On 6/22/2026 at 9:10 AM the 100-medication room was inspected. The unlocked refrigerator located in the medication room contained the following:5. An open and partially used multidose vial of Tubersol. No open date on vial or box.6. R74's multidose vial of Lorazepam 2mg/ml.On 6/22/2026 at 2:15 PM V18, LPN, stated that the TB solution is to have an open date when opened. V18 stated that the TB is a stock medication and can be used for everyone. V18 stated that when performing a TB test, the medication is obtained from the refrigerator in the medication room. V18 stated that the refrigerator should be always locked unless you are in it. V18 stated that Lorazepam is a controlled medication and must be stored under double lock. V18 stated that the medication room door lock and the refrigerator lock are the double lock system. V18 stated that if either is unlocked then there isn't a double lock system.On 6/22/2026 at 9:18 AM 100-Hall Front medication cart was inspected. The medication cart contained the following:7. 1 open and partially used multidose vial of Lantus. No name or open date on the vial.8. R7's open and partially used multidose Basaglar pen. No open or expiration date on pen. On 6/24/2026 at 2:00 PM V2, Director of Nursing, stated that all medications should be labeled with a resident's name. Multidose vials should be labeled with the resident's name, open and expiration date. V2 stated that controlled medications are under a double lock system. V2 stated that expired medications are to be removed from cart, returned to pharmacy or discarded. No medications are to be left at the bedside. The facility's Medication Storage policy, dated 8/1/25, documents that Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. Guidelines: 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier.5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. 12. Controlled Substances Storage: 1. Facility should ensure that Schedule II - V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 2. After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law) and double locked (i.e. l locked narcotic drawer inside locked medication cart or locked box in locked medication room). 3. Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security.The facility's Medication Administration policy, dated 6/15/26, documents Purpose: To provide practice standards for safe administration of medications for residents in the Facility. Policy: VIII. Medications will not be left at bedside.The Long-Term Care Facility Application for Medicare and Medicaid, dated 6/22/2026, documents 101 residents living in facility.

Based on observation, record review, and the facility failed to ensure infection control guidelines were in place and implemented, related to staff using appropriate personal protective equipment, appropriate hand hygiene and glove changes during care, meal service and medication pass, cleaning of blood spill on floor and preventing contamination from surface to surfaces for 6 of 21 (R3, R23, R27, R72, R98, 107) reviewed for infection control in a sample of 59.Findings include: 1. On 6/23/26 at 9:00 AM V25, Wound Nurse and V26, Nurse Practitioner, performed treatment to R3's skin tear on right arm. R3 was observed sitting in wheelchair with a dressing dated 6/22/2026. The dressing was heavily soiled with various shades of red and brown drainage. V25 removed the old dressing and dropped it on the floor. V25 picked up the dressing leaving brown and red substance on floor. On 6/23/2026 at 9:29 AM brown and red substance remains on the floor. On 6/23/2026 at 11:39 AM brown and red substance, now dried, remain on the floor. On 6/23/2026 at 1:30 PM dried brown and red substance remain on floor. On 6/23/2026 at 1:31 PM V25 verified that the brown and red substance on the floor was from R3's wound. V25 stated that the dried substance was blood and wound drainage. V25 stated that she thought she got it up. On 6/29/2026 at 11:15 AM V2, Director of Nursing, stated that she does not have a process regarding how to complete treatments. On 6/29/2026 at 11:21 AM V29, Registered Nurse, stated that when changing a dressing the old dressing is removed and discarded. V29 stated if the dressing falls on the ground and blood or drainage was on the ground it would be initially cleaned by him and then V29 would call for housekeeping to disinfect. V29 stated that they have blood kits depending on the amount and it sits for about 3 to 5 minutes and then cleaned up. V29 stated that this is completed immediately. 2. On 6/22/26 at 12:05 PM during a lunch observation in the TCU (transitional care unit)/small dining room V23, Certified Nursing Assistant (CNA), was seen feeding both R107 and R98. V23 was seen standing between the two residents, feeding each one with a fork full of food, one after another, with no hand hygiene seen done before or between residents. 3. On 6/23/26 at 9:42 AM, V10, CNA, was seen performing incontinent care on R72, with V2, Director of Nursing (DON), in the room observing. V10 failed to don Personal Protective Equipment (PPE) as R72 was on Enhanced Barrier Precautions (EBP). There were PPE supplies and a sign on the door. On 6/23/26 at 10:13 AM, V25, Wound Care Nurse, and V26 NP (Nurse Practitioner), provided wound care on R72's toe with both of them donning PPE. When asked about R72 being on EBP, V25 stated (R72) is on EBP for her wound. Anyone with a wound is automatically placed on EBP and the staff should be wearing PPE when caring for that resident. On 6/23/26 at 10:20 AM, V27, CNA, and V10 entered to get R72 out of bed to her wheelchair. V27 donned appropriate PPE, while V10 failed to don any PPE. 4. On 6/24/26 at 8:10 AM, V12, Licensed Practical Nurse (LPN), was seen passing medications to R27. While popping R27's Lisinopril out of the card, she missed the medicine cup and the pill landed on the unclean/soiled medication cart. V27 then picked it up with her bare hand and put it into the medicine cup, then administered it to R27. On 6/29/26 at 9:05 AM, V49, LPN, stated Any time a resident is on EBP, all staff should wear PPE when providing care to that resident. On 6/29/26 at 9:10 AM, V50, CNA, stated If a resident is on EBP, a sign is posted on the door outside their room and PPE should be hanging on the door. They should wear PPE any time they are providing care to that resident, especially if that resident has any wounds, lines, or colostomies. On 6/29/26 at 9:17 AM, V51, CNA, stated If a resident is on EBP, I wear PPE any time I am doing care to that resident. On 6/30/26 at 9:30 AM, V2, Director of Nursing (DON), stated I would expect all staff to perform hand hygiene and glove changes when appropriate. I would expect all staff to don PPE before caring for any resident who is on EBP or isolation. I would expect the nurses to maintain sanitary conditions during medication administration, including discarding any medication dropped onto the medication cart. If a nurse drops a pill on the medication cart, they should not be picking it up with their bare hands and giving it to the resident. The facility's EBP Policy, undated, documents in part Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug- resistant organism status. EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, etc) Infection or colonization with a novel or targeted MDRO when contact isolation does not apply (see CDC listed MDRO list) At discretion of the Infection preventionist. Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: Dressing, Bathing/Showering, Providing Hygiene, Changing Linens, Incontinence Care, Medical Device Care, Wound care. Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled. Sign will be posted to door to notify that on EBP to notify family and visitors. 5. On 06/22/26 at 11:54 AM, during a lunch observation in the dining room on the locked dementia unit V14, CNA seen taking trays to the residents two at a time. Coming back to the food cart without preforming hand hygiene and then getting two more trays and taking them to the residents. On 06/22/26 at 12:30 PM, V14, CNA was seen picking up the resident's dirty trays from the tables in the dining room. She would sit them on the nurse's station while she was cleaning them off into the trash barrel, then she would put them on the cart and go and get more. When they were all picked up the nurse's station was not seen being wiped down or cleaned in any way. 6. On 06/23/26 at 11:39 AM, V14, CNA went into the unit kitchen/clean room and came out with plastic knives and placed them in the pocket of her scrub top. On 06/23/26 at 11:42 AM, V6, CNA was passing out plastic silverware to the residents. She pushed her hair behind her ear and then gave R23 her silverware without doing hand hygiene. She again used her hand and put her hair behind her ear and then gave R61 her plastic silverware without hand hygiene. On 06/23/26 at 11:48, V14, CNA was seen cutting up a sandwich on one of the resident's trays with a knife from her pocket prior to taking the tray to the resident. The facility's Hand Hygiene policy, not dated, documents Definition: Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel).

Based on interviews, observations and record review, the facility failed to serve food at a preferred temperature for 5 of 5 residents (R8, R44, R51, R69, and R72) reviewed for Food and Nutrition Services in a sample of 59.Findings include:1.R8's Facesheet with a print date of 6/25/26 documented she was admitted on [DATE] with diagnosis of, in part, chronic obstructive respiratory disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder.R8's Minimum Data Set (MDS) dated [DATE] documented R8 was cognitively intact.On 6/22/26 at 9:05 AM, R8 stated the food is cold when it gets to her room.2.R44's Facesheet with a print date of 6/28/26 documented they were admitted to the facility on [DATE].R44's minimum data set (MDS) dated [DATE] documented he was cognitively intact.3.R51's Facesheet with a print date of 6/28/26 documented he was admitted to the facility on [DATE].4.R69's Facesheet with a print date of 6/28/26 documented she was admitted to the facility on [DATE].R69's MDS dated [DATE] documented she was cognitively intact.5.R72's Facesheet with a print date of 6/28/26 documented she was admitted to the facility on [DATE].R72's MDS dated [DATE] documented she was cognitively intact.On 6/24/26 at 10:00 AM, R44, R51, R69 and R72 stated that the food is late and cold. All stated that they eat in the dining room and the food is cold. All stated that they like for their hot food to be hot and cold foods to be cold. R51 and R69 stated that they eat on the hall for meals at times and it is always cold and worse than when sent out in the kitchen. All stated that the kitchen will not serve unless the CNAs (certified nursing assistants) are in the dining room. All stated that the CNAs are always late, sometimes they wait for 30 to 40 minutes for the staff to get there and then maybe the nurse will show up and starts serving.On 6/22/26 at 12:56 PM, after all trays were served; sample tray tested with V9 (cook) with the following readings in degrees Fahrenheit: chicken 106.1, rice 119.8 and steamed veggies at 126.3. The chicken was not warm to the bite but cool, the rice and veggies were cool to the bite and bland. On 6/25/26 at 1:52 PM, V7 (dietary manager) stated chicken is supposed to be at least 157-160 degrees prior to serving, veggies should be 159-160 degrees prior to serving and pork should be at least 160 degrees. V7 stated holding temperatures should remain around 157 and would have to look at the policy to know what that says. The facility's Food Preparation: Temperature policy undated documented hold hot foods 135 degrees Fahrenheit and check temperatures frequently.

Based on interviews, observations and record review, the facility failed to provide complete incontinent care for 4 out of 5 residents (R8, R3, R19, R36); reviewed for incontinent care in a sample of 59.Findings include: 1.R8's Facesheet with a print date of 6/25/26 documented she was admitted on [DATE] with diagnosis of, in part, chronic obstructive respiratory disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder. R8's Minimum Data Set (MDS) dated [DATE] documented R8 was cognitively intact, has upper extremity impairment on one side, lower extremity impairment on both sides, is dependent on staff for toileting hygiene, and always incontinent of urinary and bowel. R8's Care Plan dated 5/21/25 documented she has bowel incontinence with interventions of, in part, for staff to provide pericare after each incontinent episode. On 6/24/26 at 9:46 AM, V42 (licensed practical nurse/LPN) and V14 (certified nursing assistant/CNA) came to assist R8 with getting ready for therapy. V15 stated R8 had a bowel movement and will need to be cleaned up. V15 wiped R8's front vaginal region but did not wipe in between her thighs, then turned her on her left side and wiped her right buttock and anal region off. 2. R19's Care Plan, dated 4/22/26, documents that the resident has bladder incontinence. It also documents Clean peri-area with each incontinence episode. R19's [NAME] Data Set (MDS), documents that R19 is severely cognitively impaired, frequently incontinent of bowel and bladder and requires Substantial/maximal assistance with toileting. On 6/22/2026 at 8:41 AM R19 observed sitting on toilet with urine soiled incontinent brief. V23, Licensed Practical Nurse, assisted R19 with toileting. V23 removed urine soiled incontinent brief. V23 then assisted R19 into standing position and R19 had a bowel movement. V23 then cleansed R19's anal area and buttocks. V23 then applied a clean incontinent brief and pulled up R19's pants. V23 did not cleanse or rinse R19's groin, outer labia or inner labia, upper thighs or buttocks. V23 did not separate R19's labia and wipe each side separately. 3. R3's Care Plan, dated 5/21/25, documents that the resident has bladder incontinence. It also documents clean peri-area with each incontinence episode. R3's MDS, dated [DATE], documents that R3 is severely cognitively impaired, always incontinent of urine and bowel and dependent on staff for toileting. On 6/22/2026 at 1:50 PM observed R3 sitting in the doorway of room with pants visibly soiled. V6, Certified Nurse Assistant (CNA), performed incontinent care. R3 was incontinent of urine. V6 and V22, CNA, assisted R3 into bed using a full body mechanical lift. V6 then applied gloves, pulled tabs back and rolled the incontinent brief down in between R3's leg. Using a wet wipe V6 then wiped each side of R3's groin and inner labia. V6 then turned R3 onto her left side and cleansed R3's right buttock and partial left buttock. V6 then rolled R3 onto her right side, placed R3 on her back, pulled clean brief between R3's legs and fastened it. V6 did not cleanse R3's outer labia, upper thighs and entire left buttock. V6 did not separate R3's labia and wipe each side separately. V6 washed R3's groin before labia. 4. R36's Care Plan, dated 5/14/2025, documents that the resident has bladder incontinence. It also documents clean peri-area with each incontinence episode. R36's MDS, dated [DATE], documents that R36 is severely cognitively impaired, always incontinent of urine and bowel and dependent on staff for toileting. On 6/23/2026 at 10:09 AM V31, CNA, and V12, LPN, assisted R36 with incontinent care. V31 and V12 assisted R36 onto her right side revealing the incontinent brief had a green stripe and foul urine odor. V31 then rolled R36's soiled incontinent brief and lift pad beneath R36. V31 and V12 then rolled R36 onto R36's back. V31 then using a wet wipe cleansed R36's groin and inner labia. V31 then rolled R36 onto R36's left side and pulled clean brief under R36. V31 and V32 assisted R36 onto her back and pulled brief up and applied. V31 did not cleanse or rinse R2's outer labia, upper thighs or buttocks. V31 did not separate R36's labia and wipe each side separately. V31 wash R36's groin before labia. On 6/25/26 at 11:26 AM, V28 Licensed Practical Nurse (LPN) stated incontinent care on a female with a bowel movement would involve fully wiping from front to back, on both buttocks, in between thighs and then after cleaned to apply a new brief. On 6/25/26 at 11:54 AM, V41 (CNA) stated incontinent care on a female resident involves fully wiping in between the thighs and both buttocks. The facility's Incontinent Care policy, dated 12/28/25, documents Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. Procedure: 3. Assist the resident to lie on back and expose the perineal area. 4. Soap one cloth at a time to wash genitalia using clean part of the cloth for each swipe. In the female, separate labia was with strokes from top downward (with gloved hand), each side separately with a clean cloth or clean area of the cloth. Keep labia separated with one hand. A. Wash the labia first then groin area. C. Clean/rinse inner/upper thigh areas to remove urine moisture.

Based on interview, observation, and record review, the facility failed to Implement fall interventions to reduce falls for 2 of 5 residents (R3, R7) reviewed for resident safety in the sample of 59. The findings include:1. R7's admission Record, dated 6/25/26, documents R7 was admitted to the facility on [DATE] with diagnosis of Dementia, Alzheimer's Disease, Generalized anxiety disorder, Bipolar disorder, Major depressive disorder, Seizures, Metabolic encephalopathy, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN) Asthma, Osteoarthritis, and Obesity. R7's Care Plan, dated 5/28/26, documents R7 is at risk for falls and has experienced falls related Poor Balance, Unsteady gait and failure to use her assistive device. Interventions: 1/5/26: Encourage resident to propel in wheelchair (w/c) independently. If resident requests assistance, encourage use of bilateral foot rests during staff assisted propulsion in wheelchair. 10-15-25: Staff to assist resident with repositioning in wheelchair when resident is not sat back into the chair as resident tolerates. 10/23/25: Medication and lab review- resident to be on enhanced monitoring when noted to have an infection. 11-8-25: Staff to offer resident a snack in the night if noted awake and encouraged resident to utilize call light and ask for assistance with getting something to eat. 11/20/25: Ensure call light and personal items are within easy reach to reduce unsafe reaching or leaning. 5/6/26: (non-slip pad) to wheelchair. 6-8-25: The bed was adjusted so wheels not touching the floor. Staff to ensure that the bed is in this position as much as possible and only to have wheels down when moving the bed. 6/12/26: Staff to assist resident with diversional activities of choice between mealtimes. 8/23/25: Staff to assist resident to preferred destination as she tolerates when resident does not get what she wants and appears to be upset about the situation. resident is independent with transfers. Toileting schedule: Offer to assist resident to the bathroom Q3H (every 3 hours) at night between 8p-7a. Toileting schedule: Staff to offer to assist resident to restroom Q4H (every 4 hours) as tolerated 6a-8p daily. R7's MDS, dated [DATE], documents R7 has a moderate cognitive impairment and is dependent on staff for most ADLs and for sit-to-stand transfers. Facility's Fall Log for the past six months documents R7 had falls on 1/5/26, 5/6/26, and 6/12/26. On 6/23/26 at 10:27 AM, R7 seen asleep in her wheelchair with no foot rests on the chair. On 6/24/26 at 2:20 PM, R7 stated she has had a few falls. R7 stated she has fallen out of her bed when trying to get into her wheelchair, and she has fallen out of her wheelchair. Unable to see if there is a non-slip pad in her wheelchair at this time. On 6/25/26 at 8:10 AM, R7 was assisted by staff to stand up. R7's wheelchair has a cushion on the seat with no (non-slip pad) seen on top of the cushion or under it. R7's Nursing Note, dated 1/5/26 at 2:26 PM, documents Resident was refusing to let CNA (Certified Nursing Assistant) push her to her room to change her soiled clothes when she put her legs out while being pushed towards her room when she fell forward out of her chair landing face down causing a nosebleed with a small laceration across the top of her nose. Resident was still alert and oriented during body assessment, no other complaints of pain or injury to any other parts of her body. Nose immediately stopped bleeding once pressure was applied. Resident was given Tylenol and PRN (as needed) Xanax for pain. R7's Fall Investigation, dated 1/7/26, documents (R7) 64 y/o (year old) female, wheelchair bound, alert with confusion. Dx. (diagnosis) Alzheimer's disease, Bipolar disorder, COPD, Asthma, severe obesity, Type 2 DM, anxiety, mood disorders, developmental disorders, HTN, insomnia, osteoarthritis, vitamin deficiencies, depression, and anxiety. Monday 1/5/26 resident had a fall with slight pain and small cut to bridge of nose noted upon assessment, MD (medical doctor) notified, and PRN treatment initiated along with fall protocol. Resident c/o (complain of) increased pain to the area on 1/6/26 MD notified, and x-ray obtained. Results 1/7/26 revealed a fx. (fracture) MD updated. Please find this as the initial report with final to follow. Incident Summary: On the afternoon of Monday 1/5/26, while attempting to assist the resident (R7) to change her clothing after an incontinent episode staff was propelling the w/c (wheelchair) when the resident started having behaviors about not wanting to change and slammed her feet down onto the floor. The staff propelling the resident could not anticipate the abrupt stop at which time the resident went forward from the w/c landing in a prone position on the floor. Staff immediately initiated the fall protocol, and this DON (Director of Nursing) was notified. This DON assessed the resident at which time a small laceration was noted to the bridge of the resident's nose, some bleeding was present easily stopped without concern. The resident was offered treatment further and refused stating she was fine and going to bingo. The facility house NP (Nurse Practitioner) present was notified. The resident has no RP (representative person) but was aware herself of the fall and her decisions to forgo an x-ray post fall. Neuro checks were initiated as tolerated, fall f/u (follow-up) in place, staff provided Tylenol PRN for discomfort reported and resident proceeded to participate in the scheduled activity. The resident reported increased pain and was noted with increased swelling to the facial area on 1/6/26 during fall follow up assessments. No neurological changes identified and therefore an in-house x-ray was initiated when provider was updated on progression of edema and pain. The resident remained on fall f/u and assessments while awaiting completion of mobile radiology. PRN Tylenol and ice offered as needed with no major COCs (changes of condition) noted. This AM 1/7/26 the facility was informed via fax of a positive nasal bone fracture. The MD has been updated, resident care plan reviewed and revised. Based on all evidence and information available the resident behavior leading to the fall from w/c was the root cause of this fall with fracture. Staff education and care plan updates completed as resident to be encouraged to self-propel and when requests for assistance are made or assistance is needed foot pedals to be provided on w/c to ensure safety during assisted propulsion in w/c. The resident will continue to be monitored in house r/t (related to) the nasal bone fracture with no acute concerns noted at this time. Please find this as the initial reporting as well as the final investigation findings for this fall with fracture. Several in-service sheets with documented staff signatures were included in this investigation. R7's Fall Investigation, dated 5/6/26, documents Resident was sitting on the floor between the two beds with w/c behind her. Resident has a small, raised area to right forehead. Resident stated that she slid out of her w/c and she hit her head, but she doesn't know what she hit it on. 5/6/26-IDT (interdisciplinary team) met to discuss resident and (non-slip pad) added to w/c. 5/8/26: No post fall negative outcomes noted. Care plan interventions remain in place and resident is tolerating well. No concerns noted at this time. Refusal of VS (vital signs) continues to encourage resident to allow full assessments. 5/9/26: Fall f/u completed. No late injuries or concerns noted at this time. Fall interventions in place and resident tolerating well. No concerns at this time. R7's Nurse Note, dated 5/6/26 at 7:25 AM, documents VS 36.3, 90, 22, 137/67. I was called to this resident room by the CNA, and I found resident sitting on the floor between the 2 beds with wheelchair behind her, the lighting is good, the bathroom floor was wet from resident attempting to get on toilet and wet the floor. There is no change in medications and no change in medication. Resident does AROM (active range of motion) at command without difficulty. The resident also has an abrasion to right forehead. Call placed to Dr. (doctor) and orders received to monitor resident; the MD was informed that resident does take Aspirin 81 MG (milligrams) 1 tablet every day. M.D. stated she will be ok. R7's Fall Investigation, dated 6/12/26, documents Heard resident yelling out upon entering room resident was noted on floor laying on her right side. Resident states she was trying to get in her w/c from her bed and missed the chair and fell down. 6/12/26: IDT completed review of the incident with care plan implemented per orders. Care plan reviewed. Staff to assist resident to participate in diversional activity of choice between meals. Resident and MD in agreement with plan of care. On 6/29/26 at 9:05 AM, V49, LPN, stated Any resident on fall precaution may have a sign posted on their wall, they are discussed in report, they will have fall precaution equipment in their room, and we can always review the resident's care plan. On 6/29/26 at 9:10 AM, V50, CNA, stated If a resident is on fall precautions, I makes sure the bed is low, I review the fall interventions in the care plan, and sometimes we will talk about that resident in report. On 6/29/26 at 9:17 AM, V51, CNA, stated For residents who are on fall precautions, I look at the resident's Kardex or care plan, sometimes the report sheet, and/or the report sheet to find out what interventions that resident has. On 6/30/26 at 9:30 AM, V2, DON, stated I would expect all staff to follow all fall interventions put in place to help keep the resident safe. The facility's Fall Evaluation and Prevention Policy, dated 6/1/25, documents in part To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. 2. R3's Care Plan, dated 6/16/2026, documents that I am at increased risk for skin issues r/t (related to) dx (diagnosis) dementia, incontinence of bowel and bladder. I am at increased risk for bruising r/t use of anticoagulant/ASA (aspirin). I have active skin tears to my BUE (bilateral upper extremities) with treatments in place. 6/5/26 (R3) is at risk for falls and has a history of actual falls r/t Confusion, Gait/balance problems, Psychoactive drug use, Unaware of safety needs, impulsivity and wandering. 2/4/2026 IDT MEETING: DYCEM WILL PLACE IN RESIDENT'S WHEELCHAIR UNDER CUSHION. 6-25-25-Anti thrust cushion to wheelchair to assist resident to define the edge of the wheelchair seat when scooting in wheelchair seat. This is an enabler for positioning not a restraint and resident is able to transfer in and out of the w/c if she chooses to do so. 6/16/2026 (R3) at risk for skin impairment r/t fragile skin, poor skin integrity. 5/27/26 Left hand 5/31/26 Right leg 6/16/26 resolved 6/5/26 left breast 06/15/26 resolved 6/9/26 Right arm. 4/23/26-discuss moving from high stimulated area to less stimulated area to decrease physical contact with objects 4/24/26-daughter and resident agreed to move from memory unit high stimulated area to North Hall less stimulated area to decrease physical contact with objects when self-wheeling. Assist with repositioning. Identify potential causative factors and eliminate/resolve when possible. R3's Self Inflicted Injury Report, dated 4/13/2026, documents that R3 was wheeling herself in the dining area when she got a skin tear on top of her right hand from her wheelchair. Resident alert to person only and unable to give description of event. The wheelchair was observed and replaced. R3's Physical Contact with Object Report, dated 4/23/2026, documents called to resident room. Upon entering noted to have a skin tear to left outer arm. Above the elbow. Area cleansed, and dressing applied. Skin slight area of blood noted to shirt that just had been removed. Shirt very tight sleeved. Resident alert to person only and unable to give description of event. 4/24/26 resident and daughter agreed to move from memory unit high stimulated area to North Hall less stimulated area to decrease physical contact with objects when self-wheeling. R3's Injury Report, dated 5/31/2026, documents resident obtained skin tear to right shin during transfer, lower extremity hit on areas of wheelchair leading to tear. R3's Injury Report, dated 6/5/2026, documents Resident noted to have bruising during care, reported to nurse. DON and staffing director performed assessment. Bruising noted to left side of upper chest between arm, skin tear to left forearm noted. Upon review occurred during 2 person transfer with gait belt, resident dropped her weight during the transfer causing the belt to shift and cause bruising and skin tear. On 6/22/2026 at 1:45 PM R3 sitting in wheelchair. Foot pedals in place. No foot buddy in place. R3 moving feet on pedals, under pedals bumping legs with movement. Short sleeve shirt and no Geri sleeves in place. V11, Licensed Practical Nurse (LPN) and V18, LPN, applied R3's sling to the full body lift. V6, CNA, entered room and V11 and V18 exited. With R3 attached to the sling V6 then leaves the room. R3 noted to be rocking back and forth hitting forehead on mechanical lift. V6, and V22, CNA, assisted R3 into the bed. No dycem in wheelchair. On 6/23/2026 at 9:00 AM observed R3 sitting in wheelchair foot pedals in place with R3's legs behind. R3 moving legs freely behind pedals and bumping pedals. On 6/29/2026 at 9:36 AM observed R3 propel self in hallway bumping into arm rail. No foot pedals, pillows or foot buddy in place. On 6/22/2026 at 1:50 PM V6 stated that R3 has thin skin. V6 stated that R3 is to wear long sleeves to prevent skin tears. V6 stated that R3 does not have sleeves but should. V6 stated that R3 rolls her chair around and bumps into stuff causing skin tears. V6 stated that the foot pedals on the wheelchair have foot pedals that are in place but R3 bumps into them. V6 stated that this can cause a bruise or skin tear. V6 stated that R3 had a large bruise to her chest. R3 stated that she reported it to the nurse. V6 stated that she does not know how it got there. On 6/23/2026 at approximately 1:00 PM V18, LPN, stated that V6 reported to V18 that R3 had a bruise. V18 stated that she is not sure how the bruise was obtained. V18 stated that R3 has thin skin and bumps into things in her path. On 6/29/2026 at 10:30 AM V52, Physician, stated that any resident that has tears in the skin would experience pain from the injury. V52 stated that the facility should be pro active and not reactive. On 6/30/2026 at 10:30 AM V2, Director of Nursing, stated that with every incident they put interventions in place. V2 stated that R3 has had multiple skin tears, and the facility has tried multiple interventions after injury occurred. V2 stated that R3 is to have a foot buddy in place to wheelchair. V2 stated that R3 obtained 2 new skins from transfers on 6/23 and a bruise to leg from bumping padding on wheelchair. V2 stated that R3 picks at skins and does not like tight things on skin. V2 stated that Geri sleeves were applied and R3 attempted to remove them. V2 stated that she would expect the interventions to be in place. V2 stated that when R3 is in the hall and moving towards items she would expect the staff to redirect R3 away from objects. When asked about investigations related to bruises and skin tear. V2 stated that she did not provide the complete investigation and would provide. When asked about R3's falls V2 stated that she was aware of R3's falls in the past and would provide investigations. As of 1:00 PM on 6/30/2026 V2 had not provided fall investigations or complete investigations for skin tears and falls. The facility's Fall Evaluation and Prevention Policy, review date of 6/1/25, documents that Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents.

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for 4 of 21 (R29, R72, R11, R61) reviewed for resident care plans in the sample of 59. The findings include:1. R29's admission Record, dated 6/24/26, documents R29 was admitted to the facility on [DATE] with diagnosis of Assault by firearm discharge, Paraplegia, Contracture of right lower leg, Contracture of muscle of right shoulder, Contracture of muscle of right hand, Contracture of muscle of right upper arm, Contracture of muscle of right forearm, Contracture of muscle left lower leg, Epilepsy, Dysphagia, Osteomyelitis, Type 2 Diabetes Mellitus (DM), Emphysema, Hypertension (HTN), Malnutrition, and Adult failure to thrive. R29's Care Plan, dated 1/2/25, documents R29 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Paraplegia to right side. R29 is moderate risk for falls r/t Gait/balance problems, Paralysis. 5/14/25: R29 has paraplegia. Interventions: ADLs and locomotion as required. Encourage resident to perform as much as possible of these activities. Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Give medications as ordered. Monitor/document for side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Pain management as needed. See MD orders. Provide alternative comfort measures PRN (as needed). PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) evaluate and treat as ordered. R29's Care Plan does not address his restorative care needs, including Range of Motion (ROM) and the use of splints. R29's Minimum Data Set (MDS), dated [DATE], documents R29 has a moderate cognitive impairment and is dependent on staff for all ADLs and transfers. Section O: Restorative Nursing Programs: Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). A. Range of Motion (passive) - 1. B. Range of Motion (active) - 1. C. Splint of brace assistance - 1. R29's Therapy Notes, dated 1/11/25, documents Training and Education Log: Splinting: Assist pt. (patient) with stretching right elbow and to apply splint. Blue beanbag splint to be worn for elbow extension for up to 5 hours at a time. This document has 7 staff signatures. R29's Therapy Notes, dated 2/2025, documents Training and Education Log: Splinting: 1. Pt. to don beanbag splint to right knee for up to 4 hours. 2. Pt. to don resting hand splint for up to 3 hours. 3. Pt. to don beanbag splint to right elbow for up to 5 hours. Stretching/Exercise: 1. Maintain PROM (passive ROM) to right shoulder, elbow, wrist and digits 1x/day. 2. Maintain PROM to right knee. Sitting Tolerance: 1. Pt. to sit up in chair 4x/week and up to 4 hours each time. Pt. prefers sitting up after lunch. 2. R72's admission Record, dated 6/24/26, documents R72 was admitted to the facility on [DATE] with diagnosis of Cerebrovascular Accident (CVA) affecting right dominant side, Hemiplegia/Hemiparesis, Dysphagia, Dysarthria/Anarthria, Generalized anxiety disorder, Major depressive disorder, Type 2 DM, Chronic Obstructive Pulmonary Disease (COPD), and HTN. R72's Care Plan, dated 1/28/25, documents R72 has hemiplegia/hemiparesis r/t diagnosis of Cerebral Infarction. Interventions: Discuss with R72 and family any concerns, fears, issues regarding diagnosis or treatments. Educate R72 to use scanning (move eyes across affected side) to prevent neglect/injury to affected side. Give medications as ordered. Monitor/document for side effects and effectiveness. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Reposition/Ambulate as tolerated and at least every two hours. R72's Care Plan does not address her restorative care needs, including ROM and the use of splints. R72's MDS, dated [DATE], documents R72 has a moderate cognitive impairment and is dependent on staff for most ADLs. Section O: Restorative Nursing Programs -Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). A. Range of Motion (passive) 0, B. Range of Motion (active) 0, Splint of brace assistance 0. R72's Therapy Notes, dated 7/1/25, documents Training and Education Log: Right hand splint: Pt. to wear right hand splint when in bed/wheelchair. Wear up to 8 hours at a time. Place in bag and hang on hook when not in use. Pt. requires assist to put on splint. Provide verbal encouragement to Pt. for propelling w/c (wheelchair) forward in hallway. This document has 14 staff signatures. There are also two signs that documents Place Splint in bag and hang on hook and another sign that documents Pt. to wear splint on R (right) hand when in bed & wear up to 8 hours at a time. Please assist (R72) with putting splint on R hand. R72's Functional Maintenance Program, dated 7/17/25, documents Goals: 1. Manage R hand contracture and maintain ROM and strength in BUE (bilateral upper extremities). 2. Demonstrate safe forward w/c mobility. Approaches: 1. R hand splinting program - wear R hand splint for up to 8 hours/day. 2. Verbally encourage pt. with LUE (left upper extremity) help. 3. Verbally encourage pt. with forward w/c propelling. On 6/30/26 at 9:30 AM, V2, Director of Nursing (DON), stated I would expect the Care Plans to be updated as needed to include all areas of the resident care, such as Restorative Care, ROM, and the use of splints. Our Corporate level staff was supposed to be keeping up with these while our MDS Nurse, who usually does them, was out on leave. 3. R11's admission Record, dated 06/25/26, documents R11 was admitted to the facility on [DATE] with diagnoses of but not limited to unspecified dementia, unspecified severity, with agitation, Post-Traumatic Stress Disorder (PTSD), Chronic, and cognitive communication deficit. R11's MDS, dated [DATE], documents R11 is severely cognitively impaired and requires staff assistance of setup or clean- up assistance with eating, partial/moderate assistance with personal hygiene, dependent on staff for assistance with toileting hygiene and shower/bathe, and he is incontinent of bowel and bladder. R11's Care Plan, admission date of 05/04/26, documents R11 advanced directives general: Do Not Attempt Resuscitation (DNR), R11 requires long term care services for ongoing support with activities of daily living, medical needs, and overall well-being, R11 is at risk for falls related to dementia, PTSD, Cerebrovascular disease, cognitive communication deficit, insomnia, lack of coordination, history (hx) of malignant neoplasm of prostate and incontinence, R11 is an elopement risk/wanders related to (r/t) disoriented to place. History of attempts to leave facility unattended. Impaired safety awareness. Resident wanders aimlessly, resident has diagnosis (dx) PTSD r/t hx of active combat during military service (WW2), which may cause distressing memories, or emotional triggers. He is at risk for emotional distress, and R11 is at risk for impairment of skin integrity r/t dementia, lack of coordination, incontinent of bowel and bladder. There is no mention of any issues related to R11's weight loss/nutrition issues. On 5/12/2026 at 1:12 PM, R11's Nutrition/Dietary Note, documents RD (Registered Dietician) review this date for admit assessment. PMH (Patient Medical History) includes dementia. Mechanical soft diet is served as ordered with intake noted to be adequate per intake records. He receives senna, Remeron as ordered. No recent labs to review. No skin breakdown/edema noted. Wt (weight) on 5-4-26 was 187#; BMI (body mass index) @22.8. Estimated nutritional needs are approximately 2380kcal (kilocalorie) (28kcal/kilogram (kg)), 85g protein (1g (gram)/kg), 2550cc (30cc (cubic centimeter)/kg). Diet is appropriate. No recommendations. Continue present diet order. Goal is for intake to remain stable as evidenced by no significant weight change. Monitor and assess as needed. On 05/04/26 R11's admission weight was documented as 187.0 Lbs. (pounds). On 06/05/26 R11's weight was documented as 141.8 Lbs. 4. R61's admission Sheet, dated 06/25/26, documents R61 was admitted to the facility on [DATE] and has diagnoses of but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified fracture of shaft of right radius. R61's MDS, dated [DATE], documents R61 is severely cognitively impaired and requires supervision or touching assistance with eating and requires substantial/maximal assistance or is dependent on staff for other ADLs. R61's Care Plan, admission date of 05/21/26, documents R61 is a DNR, R61 is at risk for falls, uses psychotropic medication, is prescribed antidepressant medication, and has a potential for alteration in skin integrity. There is no documentation regarding weight loss/nutrition. On 5/27/2026 at 4:08 PM, R61's Nutrition/Dietary Note documents RD Note: Initial nutrition assessment completed. Resident with medical history of right radius fx, dementia, laceration of head. Weight 5/22/26- 142.4lb. No height- unable to determine BMI. Diet Regular, Regular Texture, Thin Liquids. PO intake avg 50%. Meds/supplement reviewed- donepezil, amlodipine. Skin- right eyelid laceration, right forearm edema. No labs. Estimated Nutritional Needs: 1625-1950kcals (25-30kcal/kg), 65g protein (1.0g/kg), 1950 milliliters (ml) fluids (30ml/kg). Variable appetite. Recommend house supplement 60ml three times a day (TID), Multiple Vitamins- Minerals (mvi with mins) every day (QD). R61's Physician's Orders, dated 06/08/26 at 9:18 AM, documents House Supplement three times a day give 60ml TID. R61's admission weight on 05/22/26 was 142.4 Lbs. R61's last weight on 06/19/26 was 132.2. The facility's Care Planning Policy, with a reviewed date of 09/02/25, documents Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.

Based in interview, observation, and record review, the facility failed to provide appropriate services, equipment, and treatment to increase range of motion (ROM) and/or to prevent further decrease in ROM for 4 of 21 residents (R8, R29, R36, R72) reviewed for ROM in the sample of 59.The findings include: 1. R29's admission Record, dated 6/24/26, documents R29 was admitted to the facility on [DATE] with diagnosis of Assault by firearm discharge, Paraplegia, Contracture of right lower leg, Contracture of muscle of right shoulder, Contracture of muscle of right hand, Contracture of muscle of right upper arm, Contracture of muscle of right forearm, Contracture of muscle left lower leg, Epilepsy, Dysphagia, Osteomyelitis, Type 2 Diabetes Mellitus (DM), Emphysema, Hypertension (HTN), Malnutrition, and Adult failure to thrive. R29's Care Plan, dated 1/2/25, documents R29 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Paraplegia to right side. R29 is moderate risk for falls r/t Gait/balance problems, Paralysis. 5/14/25: R29 has paraplegia. Interventions: ADLs and locomotion as required. Encourage resident to perform as much as possible of these activities. Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Give medications as ordered. Monitor/document for side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Pain management as needed. See MD orders. Provide alternative comfort measures PRN (as needed). PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) evaluate and treat as ordered. R29's Care Plan does not address his restorative care needs. R29's Minimum Data Set (MDS), dated [DATE], documents R29 has a moderate cognitive impairment and is dependent on staff for all ADLs and transfers. Section O: Restorative Nursing Programs: Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). A. Range of Motion (ROM) (passive) - 1. B. Range of Motion (active) - 1. C. Splint of brace assistance - 1. R29's Therapy Notes, dated 1/11/25, documents Training and Education Log: Splinting: Assist pt. with stretching right elbow and to apply splint. Blue beanbag splint to be worn for elbow extension for up to 5 hours at a time. This document has 7 staff signatures. R29's Therapy Notes, dated 2/2025, documents Training and Education Log: Splinting: 1. Pt. to don beanbag splint to right knee for up to 4 hours. 2. Pt. to don resting hand splint for up to 3 hours. 3. Pt. to don beanbag splint to right elbow for up to 5 hours. Stretching/Exercise: 1. Maintain PROM (passive ROM) to right shoulder, elbow, wrist and digits 1x/day. 2. Maintain PROM to right knee. Sitting Tolerance: 1. Pt. to sit up in chair 4x/week and up to 4 hours each time. Pt. prefers sitting up after lunch. On 6/22/26 at 10:07 AM, R29 seen lying in his bed. R29 stated he is supposed to have splints on, but they never put them on him. There was no splint seen on his right arm/hand or leg. There were signs on the wall Please position me upright for all meals/snacks, Please assist me in getting up after lunch, Right resting hand splint to be worn for 5 hours a day with right elbow splint (PM/Afternoon). Right knee splint to be worn 5 hours a day (morning/noon). R29 stated no one works with his extremities for exercises or ROM. On 6/23/26 at 10:15 AM, R29 in his bed, no splints seen on his upper or lower extremities. R29 right arm contracted and both legs bent together in bed. On 6/24/26 at 10:10 AM, R29 seen lying in bed, right arm and hand contracted upwards, and his legs bent. There were no splints seen in bed. On 6/24/26 at 10:45 AM, R29 seen in wheelchair with no splints on him. When asked, R29 stated No I don't have them on, they're over there pointing to his side table. 2. R72's admission Record, dated 6/24/26, documents R72 was admitted to the facility on [DATE] with diagnosis of Cerebrovascular Accident (CVA) affecting right dominant side, Hemiplegia/Hemiparesis, Dysphagia, Dysarthria/Anarthria, Generalized anxiety disorder, Major depressive disorder, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), and Hypertension (HTN). R72's Care Plan, dated 1/28/25, documents R72 has hemiplegia/hemiparesis r/t diagnosis of Cerebral Infarction. Interventions: Discuss with R72 and family any concerns, fears, issues regarding diagnosis or treatments. Educate R72 to use scanning (move eyes across affected side) to prevent neglect/injury to affected side. Give medications as ordered. Monitor/document for side effects and effectiveness. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Reposition/Ambulate as tolerated and at least every 2 hours. R72's Care Plan does not address her ROM or restorative therapy. R72's MDS, dated [DATE], documents R72 has a moderate cognitive impairment and is dependent on staff for most ADLs. Section O: Restorative Nursing Programs -Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). A. Range of Motion (passive) 0, B. Range of Motion (active) 0, Splint of brace assistance 0. On 6/22/26 at 9:40 AM, R72 stated she had a stroke and is flaccid on her right side and is supposed to have braces on her right side, but they lost them when moving rooms. R72 stated she is not working with PT, and no one is working with her for exercises or ROM to her right side. There was no splint or brace seen on R72 or in the room. R72 was assisted out of bed and to her wheelchair by CNAs and there was no ROM seen done and no splint/brace was seen. On 6/23/26 at 9:42 AM, V10, Certified Nursing Assistant (CNA), was seen performing incontinent care on R72 with V2, Director of Nursing (DON), in the room observing. At no time during care was staff seen performing any ROM on R72 and no splint/brace was seen. On 6/23/26 at 10:20 AM, V27, CNA, and V10 was observed getting R72 out of her bed and into her wheelchair. At no time before, during, or after transfer was ROM seen done and no splint/brace was seen. R72's Therapy Notes, dated 7/1/25, documents Training and Education Log: Right hand splint: Pt. (patient) to wear right hand splint when in bed/wheelchair. Wear up to 8 hours at at time. Place in bag and hang on hook when not in use. Pt. requires assist to put on splint. Provide verbal encouragement to Pt. for propelling w/c (wheelchair) forward in hallway. This document has 14 staff signatures. There are also two signs that documents Place Splint in bag and hang on hook and another sign that documents Pt. to wear splint on R (right) hand when in bed & wear up to 8 hours at a time. Please assist (R72) with putting splint on R hand. R72's Functional Maintenance Program, dated 7/17/25, documents Goals: 1. Manage R hand contracture and maintain ROM and strength in BUE (bilateral upper extremities). 2. Demonstrate safe forward w/c mobility. Approaches: 1. R hand splinting program - wear R hand splint for up to 8 hours/day. 2. Verbally encourage pt. with LUE (left upper extremity) help. 3. Verbally encourage pt. with forward w/c propelling. On 6/24/26 at 9:45 AM, V36, Physical Therapy Assistant (PTA) stated (R72) had both PT and OT and had plateaued so was discharged from therapy. We send our discharge papers and recommendations to (V2, DON) and the MDS person and then we educate staff if needed. On 6/24/26 at 9:48 AM, V35, Therapy Director, stated When a resident is done with therapy or have plateaued, I write a restorative program for the staff to follow. We used to have a restorative nurse and a restorative CNA, but now the facility does not have restorative staff. I believe that (V2) is the one who does the restorative care. On 6/24/26 at 10:00 AM, V2, DON, stated (V27, CNA Manager) and I are the two people who will teach other staff what ROM or splints a resident requires. Staff is notified of such by their Tasks and there is not necessarily an order to do so. We do not have a specific Restorative Nurse or CNA at the facility. Sometimes what therapy recommends is not done because I feel the resident doesn't need it. On 6/29/26 at 9:05 AM, V49, Licensed Practical Nurse (LPN), stated the nurses and CNAs are responsible for performing ROM and restorative care because they don't have a restorative team here. On 6/29/26 at 9:10 AM, V50, CNA, stated there are no restorative nurses or CNAs here so the CNAs are responsible for doing ROM and exercises with the residents. V50 stated therapy will educate them on what to do with a resident or if the resident has a change in condition, staff will communicate with each other on what to do for that resident. On 6/29/26 at 9:17 AM, V51, CNA, stated she is not sure who is supposed to be doing restorative care on residents. V51 stated she does exercise the resident's arms/legs when she dresses them or is getting them up. On 6/30/26 at 9:30 AM, V2, DON, stated I would expect all staff to perform ROM and restorative care for residents as recommended by the therapy department. The facility's Restorative Nursing Services Policy, dated 5/23/26, documents Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but not limited to, programs in walking/ mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance. Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain. Develop and individualized program based on the resident's restorative needs, and include the restorative program on the care plan. Develop an individualized restorative program as appropriate based on the assessment information and update the resident care plan. The restorative nurse or designee will review the restorative program at least quarterly and as needed for appropriateness of that individual plan and will document a note on the appropriate form. This will include reviewing the program goals, interventions, patient tolerance, and any recommended changes to the plan. The resident care plan will also be reviewed and updated at least quarterly and as needed by the restorative nurse or designee. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, bathing, etc. Range of motion programs may include Active Assisted Range of Motion, Active Range of Motion or Passive Range of Motion. 3. R36's admission Record, dated 6/25/2026, documents R36 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction 11/01/2025. R36's Care Plan, dated 11/5/24, documents that the resident has an ADL self-care performance deficit r/t Disease Process and external devices. R36's MDS, dated [DATE], documents that R36 is severely impaired, dependent on staff for adls. Section O: Restorative Nursing Programs: Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). A. Range of Motion (ROM) (passive) - 7. B. Range of Motion (active) - 7. C. Splint of brace assistance - 7. R36's RESTORATIVE - Active ROM Program #1 Maintain ROM to Left upper/lower extremities does not document being performed 6/20 to 6/24. RESTORATIVE - Passive ROM Program #2 Maintain PROM to Rt upper extremity w/o any further contractures by next review date does not document being performed 6/20 to 6/24. Splint/Brace Assistance Program #3 Resident will [NAME] Rt elbow and wrist splints up to 4hrs as tolerated w/o any further contractures by next review date does not document being performed 6/20 to 6/24. R36's Occupational Therapy Training and Education Log, dated 1/7/2025, documents Splinting: Stretch hand, elbow, and shoulder of right arm prior to splint application. Blue beanbag splint in use for elbow extension up to 5 hours at a time. Blue 'carrot' style hand splint for up to 8 hours at a time. R36's Functional Maintenance Program, dated 2/26/2024, documents Goals: To maintain ROM and manage contractures un right upper extremity. To manage pain and promote ease of hygiene in right upper extremity. Approaches: Staff to provide PROM to right shoulder, elbow and hand prior to splint application. Elbows extension splint worm on right for up to 8 hours at a time. Right resting hand splint worn daily for up to 8 hours at a time. On 6/22/2026 at 8:45 AM observed R36 lying in bed. No splints in place. On 6/23/2026 at 10:09 AM observed R36 lying in bed. No splints in place. On 6/29/2026 at 9:45 AM observed R36 lying in bed. No splints in place. 4.R8's Facesheet with a print date of 6/25/26 documented she was admitted on [DATE] with diagnosis of, in part, chronic obstructive respiratory disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder. R8's Minimum Data Set (MDS) dated [DATE] documented R8 was cognitively intact, has upper extremity impairment on one side, lower extremity impairment on both sides. R8's Occupational Therapy Evaluation and Plan of Treatment certification period dated 5/14/26-6/12/26 documented R8 was to wear resting hand splint to RUE for 4-8 hours a day, with frequent skin checks in order to decrease risk of further contracture. R8's Occupational Therapy Treatment Encounter Note dated 5/15/26 documented she was referred to services due to right upper extremity contractures, decreased overall strength, and addressing wheelchair positioning to promote out of bed activity. The note continued to document R8's RUE (right upper extremity) ROM (range of motion) is assessed with noted decreased range to right shoulder, elbow, wrist, and digits. R8 will benefit from use of resting hand splint. On 6/24/26 at 8:47 AM, R8 stated her food is cold again as she ate her breakfast. R8 stated she hasn't been cleaned up yet today or been dressed in her clothes. R8 was in bed with a hospital gown on. R8 stated therapy is the only one that really applies her splint, but it does help to have it on. R8's splint was at the bottom of her bed. On 6/24/26 at 9:46 AM, V42 (LPN) and V14 (CNA) came to assist R8 with getting ready for therapy. V14 stated she doesn't know if R8 uses the splint, she is usually on memory care, and this is the first she is seeing that. V15 took R8's right hand splint and grabbed her contracted fingers then placed them in the splint as R8 cried in pain. V15 stated I know, I know, I'm sorry to R8 as she continued to apply the splint and secured it completely. On 6/24/26 at 10:23 AM, V35 (Therapy Manager) stated only we are supposed to apply R8's splint right now and it should never cause her to be in pain. V35 stated we do a slow stretch first before applying it to her right-hand contracture. V35 stated we apply it sometime around lunch every day and then she can remove it herself around 8:00 PM, so she has it on about 8 hours a day. V35 stated she will have to educate the nursing staff about applying splints. On 6/24/26 at 1:11 PM, R8 stated CNAs are not supposed to put my splint on V35 told her. R8 stated when therapy applies her splint, they go slow and stretch her hand out first and if needed they give her rest breaks because of the discomfort. R8 stated when V15 applied her splint, she went too fast and it was very painful.

Based on interview and record review, the facility failed to assure each resident is assessed using the Minimum Data Set (MDS) Assessment tool no less than once every three months for 6 of 21 residents (R28, R42, R45, R49, R72, R97) reviewed for resident assessments in the sample of 59. The findings include: 1. R42's admission Record, dated 6/24/26, documents R42 was admitted to the facility on [DATE]. R42's Minimum Data Set (MDS) with a target date of 5/24/26 (Quarterly assessment) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. R42's MDS with a target date of 5/26/26 (Discharge Return Anticipated) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. R42's MDS with a target date of 5/28/26 (Entry) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. R42's MDS with a target date of 6/2/26 (Quarterly) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. 2. R72's admission Record, dated 6/24/26, documents R72 was admitted to the facility on [DATE]. R72's MDS with a target date of 5/23/26 (Quarterly) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. 3. R28's admission Record, dated 06/30/26, documents she was admitted to the facility on [DATE]. R28's MDS with a target date of 05/22/26 (Quarterly Assessment) was submitted on 6/24/26. Assessment completed late: is more than 14 days after assessment reference date. 4. R45's admission Record, dated 06/30/2026, documents he was admitted to the facility on [DATE]. R45's MDS with a target date of 05/20/26 (Quarterly Assessment) was submitted on 06/24/26. Assessment completed late: is more than 14 days after assessment reference date. 5. R49's admission Record, dated 06/30/2026, documents she was admitted to the facility on [DATE]. R49's MDS with a target date of 05/22/26 (Quarterly Assessment) was submitted on 06/24/26. Assessment completed late: is more than 14 days after assessment reference date. 6. R97's admission Record, dated 06/30/2026, documents she was admitted to the facility on [DATE]. R97's MDS with a target date of 05/25/26 (Quarterly Assessment) was submitted on 06/24/26. Assessment completed late: is more than 14 days after assessment reference date. On 6/30/26 at 9:30 AM, V2, Director of Nursing (DON), stated I would expect the resident's MDS to be completed and submitted on time based on previous date, upon any change in condition, or upon admission or discharge. Our Corporate level staff was supposed to be keeping up with these while our MDS Nurse, who usually does them, was out on leave. The facility's MDS Completion and Submission Policy, dated 6/25/26, documents in part This policy is to ensure completing and submitting all MDS assessments are in accordance with the requirements set in the Resident Assessment Instrument (RAI) User's Manual, as published and maintained by the Centers for Medicare & Medicaid Services (CMS). It is the policy of this facility that all MDS assessments will be completed and electronically submitted in accordance with the RAI Manual currently in effect. Completion Timeframes: MDS items are completed within the timeframes specified in the RAI Manual, including the completion window following the ARD and transmission deadlines. Electronic Submission: Completed assessments are electronically submitted through (electronic medical record system)/Simple within the timeframes required by the most current RAI Manual.

Based on interview, observation, and record review, the facility failed to maintain a resident's dignity while dining for 4 of 21 residents (R59, R98, R100, R107) reviewed for resident dignity in the sample of 59. The findings include:1. R98's admission Record, dated 6/24/26, documents R98 was admitted to the facility on [DATE] with diagnosis of Dementia, Major Depressive Disorder, Anxiety Disorder, Encephalopathy, Delirium, Hypertension (HTN), and Chronic Obstructive Pulmonary Disease (COPD). R98's Minimum Data Set (MDS), dated [DATE], documents R98 has a severe cognitive impairment and requires partial/moderate assistance for eating. On 6/24/26 at 8:00 AM, during a lunch observation in the Transition Care Unit (TCU)/Small Dining Room, V33, Certified Nursing Assistant (CNA), was seen feeding R98 breakfast while standing next to him. 2. R107's admission Record, dated 6/24/26, documents R107 was admitted to the facility on [DATE] with diagnosis of Epilepsy, Autistic Disorder, Subarachnoid Hemorrhage, Hyperhidrosis, Visual loss, Hearing loss, Anemia, and PIKA in adults. R107's MDS, dated [DATE], documents R107 has a severe cognitive impairment and requires supervision/touching assistance for eating. On 6/22/26 at 12:05 PM, during a lunch observation in the TCU/Small Dining Room, V23, CNA, was seen feeding R107 and R98. V23 was seen standing between the two residents, feeding each one with a fork full of food, one after another, with no hand hygiene seen done. On 6/29/26 at 9:10 AM, V50, CNA, stated If I am assisting a resident in feeding, it really depends on what the resident needs, but I will sit next to them and talk to them and assist as needed. We should never stand up and feed the resident. On 6/29/26 at 9:17 AM, V51, CNA, stated If I am feeding a resident, I will sit with them and will use gloves and/or do hand hygiene. We are never supposed to stand next to the resident and feed them because that will make them anxious or nervous. 3. R59's admission Record, dated 06/29/2026, documents R59 was admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's disease with late onset, dementia, moderate, with agitation, and chronic kidney disease. R59's MDS, dated [DATE], documents R59 is severely cognitively impaired and requires supervision or touching assistance with eating. On 06/22/26 at 12:03 PM, during lunch observation in the dining area on the locked dementia unit R59 was seen sitting in a recliner in the dining room with his feet up and his lunch tray sitting on his lap and not eating at a table in a regular chair. R59 was having trouble trying to keep his lunch tray on his lap while eating his meal. 4. R100's admission Record, dated 06/29/2026, documents R100 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia, severe, with agitation, paroxysmal atrial fibrillation, type II diabetes mellitus without complications, and chronic systolic (congestive) heart failure. R100's MDS, dated [DATE], documents R100 is severely cognitively impaired and requires supervision or touching assistance with eating. On 06/22/25 at 12:10 PM, R100 was seen being placed in a recliner in the dining area to eat his afternoon meal instead of being placed at a regular table in a dining room chair. The facility's Resident Rights policy, revised date of 06/01/25, documents Purpose: To promote the exercise of right 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.

Based on observation, interview and record review the facility failed to maintain a comfortable and good repair environment for 1 of 3 (R3) residents reviewed for bed mobility in a sample of 59.Findings include:1. On 6/22/2026 at 2:19 pm observed R3's mattress sunken in the middle. Observed a hole in the mattress. Observed V6, Licensed Practical Nurse, and V22, Certified Nurse Assistant, transfer R2 into bed.On 6/23/2026 at 3:40 PM V18, R3's family, stated that R3 has a hole in her mattress and she has notified the facility repeatedly. V18 stated that this is ridiculous. V18 would not live like that. When the mattress is worn or has a hole you replace it. On 6/29/2026 at 9:35 AM a mattress observed sunken in the middle with a hole in mattress.On 6/29/2026 at V16, Certified Nurse Assistant, stated that she doesn't usually work the hall. V16 verified that R3's mattress was sunken in the middle with a hole in the mattress. V16 stated that she is not sure how long the hole has been there. V16 stated that laying the sunken mattress and the hole would be uncomfortable.The facility's Resident Rights policy, dated 6/1/2025, documents that Purpose: To promote the exercise of 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. It also documents that Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights. Facility practices designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion.

Based on interviews, observations and record reviews, the facility failed to provide pressure reducing devices for 1 of 3 residents (R4); reviewed for pressure ulcers in a sample of 59.Findings include:R4's Facesheet with a print date of 6/25/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, osteomyelitis, pressure ulcer of heel, and sequelae of cerebrovascular disease.R4's Minimum Data Set (MDS) dated [DATE] documented she was dependent on staff for putting on and taking off of footwear, and supervision or touching assistance for rolling left and right in bed.R4's Care Plan dated 11/21/25 documented she was at risk for impairment to skin integrity related to impaired mobility, incontinence of bowel and wound to right heel with interventions of, in part, to have pressure reducing devices in place including heel boots as tolerated.on 6/23/26 at 9:28 AM, V25 (wound nurse) stated R4 has a stage 3 pressure ulcer on her right heel she was admitted with. V25 stated that R4 is to have a boot on her right foot while in bed and up in the wheelchair. On 6/24/26 at 8:47 AM, R4 was in her wheelchair with no boot on her right foot.On 6/24/26 at 9:30 AM, R4 was in her bed; one boot in between her mattress and the frame, the other boot on the wheelchair in the hallway. On 6/24/26 at 10:10 AM, V42 (licensed practical nurse/LPN) stated R4 did not have any boots on her feet. R4's feet only had socks on while she was lying in bed. V42 stated to V15 does she need boots? V15 (certified nursing assistant/CNA) stated she thinks R4's boot is in between the mattress she probably kicked it off. V15 stated she should have two boots, one on each foot. V42 stated she could not find the other boot, is it on her wheelchair in the hallway? V42 found R4's pressure reducing boots in between the mattress and on her wheelchair in the hallway before applying them on her. On 6/25/26 at 11:26 AM, V28 (LPN) stated pressure reducing boots are to be worn especially in bed and in wheelchairs or according to orders. V28 stated they are important to wear to prevent pressure wounds.The facility's Wound Management policy last reviewed 9/5/25 documented an assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to: Mechanical offloading and pressure reducing devices.

Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident abuse for 3 of 3 residents (R2, R7, and R9) in a sample of 24. This failure resulted in R3 physically assaulting R7 and R7 being sent out to the hospital and receiving staples for a head laceration, R9 being slapped on the right side of his face and a red area appearing, and R2 being struck in the face with a cane and sustaining a laceration to her right jawline. Findings Include: R3's Local Hospital Referral, admission date of 09/30/25, documented the following: History of Present Illness (HPI)/Subjective.Patient (Pt) is a [AGE] year-old African American male with past medical history of dementia and Traumatic brain injury. Patient currently lives with wife at home. Per wife patient gets more confused as the day goes on. He does become physically aggressive at night often leaving bruises on her. Patient also tries to escape the residence. Patient is alert to self only. It also documented on 9/29/25: last night had aggressive behavior to the nurse. It further documented Present Illness and Reason for admission: [AGE] year-old black male admitted [DATE] for wellness check per wife's request, who reports R3 becomes more confused, aggressive and wanders at night. History (Hx) of agitation, aggression, code green 09/28/25 at which time a Registered Nurse (RN) was knocked to the ground. Pt lives with wife at home. Per documentation from wife, pt becomes violent and more confused as the day progresses, sundowners. By the evening pt. will hit and attempt to leave/elope from the home. Wife currently is unable to safely care for pt and wants placement. R3's Face Sheet, admission date of 10/10/25, documented he has diagnoses (dx) of but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, Type II Diabetes Mellitus with hyperglycemia, Essential (Primary) Hypertension, and Atrial Fibrillation. R3's Minimum Data Set (MDS), dated [DATE], documented R3 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 00 out of 15, had Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days, put R3 at significant risk for physical illness or injury, and did not put others at significant risk of physical injury. R3's Care Plan, admission date of 10/10/25, documented on 10/10/25 R3 had a history (hx) of physical aggression towards staff related to (r/t) diagnosis (dx) of dementia. Goal: R3 will have no physical aggression through next review. Interventions include but are not limited to approach R3 calmly and respectfully, behavior tracking in place, provide choices, when possible, to give R3 a sense of control, provide positive reinforcement for calm or cooperative behaviors, report allegations of abuse neglect to Administrator immediately (initiated on 11/25/25), utilize clear, simple communication giving directions or explanations. Avoid arguing or reasoning when R3 is upset. R3 is at risk for abuse/neglect related to impaired cognitive skills, needs assistance with activities of daily living (ADLs), impaired cognitive skill, dx of dementia. Goal: R3 will have no psych decline through next review. R3's Progress Note, dated 10/26/25 at 8:16 PM, documented R3 was observed in another resident's room (R7) assaulting the other resident with his (R3) walker at 6:03 PM by the certified nursing assistant (CNA). 1. R7's Face Sheet, admission date of 01/18/21, documented R7 has diagnoses of but not limited to Alzheimer's disease with late onset, unspecified dementia, moderate with agitation, and dementia, with behavioral disturbance. R7's MDS, dated [DATE], documented R7 is severely cognitively impaired, was resistive to care at times, and was dependent on staff for most of his ADLs. R7's Care Plan, admission date of 01/18/21, documented R7 is at risk for abuse/neglect r/t needs assistance with ADLs, impaired cognitive skills, dx of dementia, interventions include but not limited to report allegations of abuse/neglect immediately. R7's Progress Notes, dated 10/26/2025 at 8:08 PM, documented resident was observed at 8:03 PM by the nurse in room with a head injury. The CNA stated she heard a resident screaming for help and she observed another resident hitting R7 with a walker. 911 was called and R7 was transported to the Emergency Department (ED) by EMS (Emergency Medical Services). R7's ED report, dated 10/26/25, documented History of Present Illness (HPI) this is a [AGE] year-old male with history of dementia who presents to the ED for physical assault and head laceration. Per EMS patient apparently got into an altercation with a fellow resident and was hit in the head with a cane and sustained a laceration. Patient is otherwise not able to participate in history taking due to his dementia. It further documented, he had a 2-centimeter (cm) laceration to the scalp and was repaired with staples. 2. R9's Face Sheet, print date of 01/08/26, documented R9 has diagnoses of but not limited to Dementia without behavioral disturbances, anxiety disorder, and psychosis not due to a substance or known physiological condition. R9's MDS, dated [DATE], documented R9 is severely cognitively impaired, and he requires assistance with his ADLs. R9's Care Plan, admission date of 08/08/25, and documented R9 is at risk for abuse/neglect r/t needs assistances with ADLs, impaired cognitive skills, dx of dementia. Interventions include but not limited to monitor R9 closely for any signs of abuse, neglect, or peer to peer altercations; report and document all incidents per facility policy and report allegations of abuse/neglect to administrator immediately. R9's Progress Notes, dated 11/11/25 at 8:23 AM, documented Resident was in his bedroom room in bed resting when R3 entered the restroom belonging to R9 and another resident. When R3 was done in the restroom he exited and entered R9's room. R9 stated that he approached R3 and told him that he was in the wrong room when R3 then stood from his chair and struck R9 across the face. R9 let out a scream that was heard by CNAs who were in the dining area preparing the residents for breakfast. Once R9 approached the nurse's station I could see that R9 had redness to the right side of his face around his eye. R9 stated that R3 had struck him with an open hand, a smack to the face. R9's IDPH Final Report, dated 11/11/25, documented the following: R9 is a [AGE] year-old male that includes a Dx of: Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, and Anxiety. R9 has a Brief Interview for Mental Status (BIMS) score of 0. R9 uses a wheelchair for locomotion. R3 is a [AGE] year-old male with a DX that includes Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance and Dementia in other Diseases. R3 has a BIMS score of 0 and uses a wheelchair at times for locomotion. Both residents reside on the memory unit. Staff overheard R9 yelling in his room. Upon entering R9's room he stated that R3 smacked him in the face stating, you are in the wrong room. R3 had already exited the room. Staff continued to keep them separated. A skin assessment was performed on R9 that revealed a small red area to the right eye. All pertinent parties were notified. IDPH was notified. Care plans of both residents were assessed. Both residents were separated for 48- hour observation. In conclusion the physical altercation between R9 and R3 did occur. Trauma assessments were completed on both residents and both residents stated that they felt safe in the facility. R3 took a wrong turn when exiting the bathroom and thought that R9 was in his room, which he was not. R3 was moved to the top of the hall into a private room with a bathroom to aide in his room confusion. 3. R2's Face Sheet, dated 1/15/25, documented R2 has diagnoses of but not limited to Restlessness and agitation, anxiety disorder, paroxysmal atrial fibrillation, and dementia, moderate, with agitation. R2's MDS, dated [DATE], documented R2 was severely cognitively impaired, had no behaviors documented, and required assistance with her ADLs. R2's Care Plan, admission date of 07/01/24, documented R2 is at increased risk for abuse and neglect r/t dementia with other behavioral disturbances and interventions include but not limited to Keep R2 safe at all times and report suspects abuse/neglect immediately to the facility administrator. R2's Progress Notes, dated 11/25/2025 at 1:54 PM, documented Resident was in her room sleeping when another resident who was in the wrong room stood over her and struck her in the face with a cane causing a laceration to the right side of her jawline. Resident is now in her room a little frantic but resting quietly. Resident stated that she is in pain at a rate of 8 on a scale of 1 to 10. Resident was given two 500mg (milligram) Tylenol tabs tablets (tabs). R2's IDPH Final Report, Incident date of 11/25/25 at 12:51 PM, documented R2 is a [AGE] year-old female resident with a diagnosis of but not limited to Restlessness and agitation, anxiety disorder, paroxysmal atrial fibrillation. BIMS of 0. R3 is a [AGE] year-old male with diagnosis of but not limited to Unspecified Dementia, unspecified severity, with other behavioral disturbance. Hyperlipidemia and Hypertension. BIMS of 0. On 11/25/25, the facility ED was notified that R2 was asleep in her bed located in the memory unit when the LPN heard yelling. She ran to the sound and saw R3 standing over R2 holding a cane. She immediately removed the cane and removed R3 from the room. Upon assisting with getting R2 to a sitting position, she noticed blood coming from R2's jawline. A skin assessment was completed at this time. 1.) Residents were immediately separated.2.) R3 was sent to the local hospital. R3 was admitted with the DX of MDD (Major Depressive Disorder) with psychotic features.3.) Interview with residents and staff were completed.4.) Notified family and MD (Medical Doctor).5.) Care plans updated for R2 and R3. The son and his wife were contacted on 11/25/25 to speak about future living arrangements for R3. They were going to discuss him possibly moving in with them in [NAME] Wisconsin. Follow up calls were made to the family with no further contact. Therefore, an immediate discharge was issued. Trauma assessments were completed on R2 with no further issues noted. On 12/03/25, V36, Family Nurse Practitioner (FNP) wrote a letter regarding R3 and it documented the following: To whom it may concern, R3, DOB (date of birth ) 11-28-46, poses an imminent risk of harm to the patients and staff at the facility. He has been trialed on multiple medications, but unfortunately aggressive episodes are unprovoked and unpredictable making the facility unable to meet his needs at this time due to harming others. Thank you for your time, V36, FNP. On 01/05/26 at 11:35 AM, V5, Resident Aide (RA) said R3 could get agitated quick, and he didn't really like to be redirected. She said you would never know when he was going to become aggressive. On 01/05/26 at 11:40 AM, V6, Licensed Practical Nurse (LPN) said she was at the nurse's station and heard a scream, she ran down the hall to where she heard the scream and seen R3 standing over R2 getting ready to hit R2 again with a cane. V6 said she grabbed the cane before R3 could strike R2 again. V6 said R3 thought R2 was in his room and R3 becomes aggressive when he thinks people are in his room/personal space. On 01/06/26 at 11:10 AM, V15, Social Service Director (SSD) said she wasn't aware R3 was aggressive when they accepted him into the facility. She said with R3 the hospital would have faxed over a referral and then the clinical team would have reviewed it. The clinical team consist of the nurse managers (V2, Director of Nursing) as one of them. She said she doesn't believe she was in on R3's referral and she normally isn't involved. On 01/13/26 at 1:15 PM, V2, Director of Nursing (DON) said, when it comes to admitting R3 to the facility she and V15, SSD both went to the hospital and seen R3 for themselves. She said he was calm and cooperative when they went up to see him. She said she talked with R3's sitter and the nurse who was working and asked them if he was having any behaviors and they both told her he had been nothing but cooperative and the only incident he had was the one when he first came into the emergency room (ER). On 01/13/26 at 1:05 PM, V1, Administrator said on the day of R3's incident with R2 the nurse who was working on the memory care unit came running down to her office frantic with a cane in her hand and stated R3 hit someone with a cane. V1 said the nurse explained to her (V1) R3 went into R2's room and struck R2 with a cane. V1 said V6 stated to her she heard all the commotion, so she ran down to R2's room and when she got there R3 had a cane in his hand, and it was raised to strike R2. V1 said they assisted R2 in sitting up and that's when they saw R2 had blood on her jawline, and they realized she had been hit with the cane. V1 said the staff escorted R3 out of R2's room. V1 said they tried everything regarding R3. She said they thought he was getting confused because of the jack/[NAME] bathrooms so they moved him to a room that had a private bathroom but that didn't work. She said R3 was very protective of what he thought was his bed and if he seen someone sitting on it or lying down on it, he would have an issue with them. V1 said they never knew when R3 was going to go off and she said all the residents were at risk with him here. On 01/14/26 at 10:45 AM, V2, DON said they implemented a lot of different things to try and rectify the situation with R3. They got him psych visits; they did multiple room changes. The last move they did was to put him in a room with a private bathroom thinking he was getting confused and entering the wrong room when coming out of the bathroom. She said that was working well. On the day of the incident between R2 and R3, R3 was in the dining room eating and when he was finished, he got up and was going to his room. He passed up his room and went into R2's room by accident and he thought she was in his bed. V2 said there wasn't anything specific that would trigger R3. The Facility's Abuse Prevention and Prohibition Program, Review date of 12/02/25, documented Purpose To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. II. The facility is committed to protecting residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. It further documents Procedure II. Screening B. The facility screens for potentially abusive residents during the pre-admission process. It also documented IV. Prevention E. The facility maintains adequate staffing on al shifts to ensure that the needs of each resident are met. It also documented G. The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse.

Based on interview and record review the Facility failed to ensure sexual abuse did not occur for 1 of 4 residents (R3) reviewed for abuse and neglect of a sexual nature in the sample of 6. This failure resulted in R2 touching R3 inappropriately when R3 could not deny the advances or give her approval or consent. R3 was incapable of declining to participate in the sexual act and lacks the ability to understand the nature of the sexual act. Findings include: 1-R2's Physician Order Sheet for December 2025 documents a diagnosis of dementia, COPD (Chronic Obstructive Pulmonary Disease), major depression disorder, and muscle weakness, abnormalities of gait and mobility. R2's Minimum Data Set (MDS) dated [DATE] document R2 was moderately impaired for cognition for activities of daily living. Resident does not use a wheelchair or scooter. Sit to stand supervision or touching assistance and walk 10 feet and 50 feet with two turns. R2's Care Plan with a focus date of 11/22/2025 (R2) has had sexual behavior noted related to confusion. Date initiated 11/22/2025. Goal: Resident will not have sexual behaviors and act appropriately with other residents. Date initiated 11/22/2025. Intervention dated 11/22/2025, Place on 1:1 monitoring, behavior monitoring for increased sexual desires will be monitored. R2's Care Plan date initiated of 10/27/2025 also documents (R2) engages in self-stimulation related to dementia, occasionally performing the behaviors in her room without closing the door. On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:49 AM, V2, Director of Nursing stated they did an internal investigation and felt like (V4) jumped the gun because (R2) had her pants down but they were able to determine nothing occurred. On 12/5/2025 at 12:58 AM R2 stated she use to be a CNA (Certified Nursing Assistant) and has never tried to provide care to any other residents including roommate. She states the AC was on and when she went over to turn it down her roommate grabbed her and her pants fell down and then the nurse walked in on her but she was not touching her roommate. They were in bed together. They separated them after that. She also says her roommate was not wet and/or needing changed and/or had poop. R2's Nurse's Notes dated 11/22/2025 at 7:00 PM, SSD (Social Service Director) met with (R2) who is resting in bed. Trauma assessment complete. (R2) denies trauma. SSD asked (R2) if she feels safe here. She responded yes. (R2) asked SSD why she was asking this question. SSD stated to ensure she feels safe. SSD asked why she was on her roommate's side of the room. (R2) responded that she was just trying to help her. SSD asked why (R2) pants were down. (R2) responded that they always slide down and was attempting to pull them up. R2's Progress notes dated 11/24/2025 at 9:21 PM, Resident continues to have a 1:1 related to resident to residents. Resident currently in bed resting with call light in reach. No s/s (signs or symptoms) of acute distress noted at present moment. R2's Initial Report 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Investigation of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. R2's Final Report date of 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Education of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. Investigation: (V4, LPN) entered (R2) and (R3) to observe (R2) on her knees next to the bed with her pants down. (R2) hand was on the bed with her back to (R2) laying on her side. (V4) noted that the room was very cold and that (R2) had BM (bowel movement) on her hand and (R3) had BM on her bed. (V4) did not see (R2) acting inappropriately with (R3), nor did she have history of being inappropriate with resident. (R2) was a long time CNA (certified nursing assistant) of (Facility) prior to coming to live at the facility. (R2) was interviewed, she was noted to have some confusion during questioning but was able to answer some questions sensical. She stated that she was cold and went to turn off the air. The air was noted to be on when (V4) was in the room. When asked why her pants were down she stated, they had fallen down, they were not fastened. (R2) was noted to have BM on her hand. She did not know where that had come from however her hand was located on (R3's) bed that did have BM on it. She was using the bed to help her get off her knees. When asked if she had touched (R3) she said no. I am just trying to help her. (R3) was unable to be interviewed. She was noted to be sleeping at the time of concern. (R3's) skin assessment was completed WNL (within normal limits). Pain assessment completed; no pain noted. (R3) did not have an increase or behavioral changes after time of concern. Other residents were interviewed, when asked if another resident ever touched them inappropriately, all answered no. When asked if they felt safe in the facility, all stated they did. When asked if residents know who to report concerns to, they stated they did, if they did not residents were educated. Conclusion: Our investigation concluded that (R2) did not have any inappropriate contact with (R3). (R2) was trying to turn off the air conditioning and got tangled up in her pants that had fallen down. She went to use (R3's) bed to get up where she had placed her hand on (R3's) soiled bedding. When our nurse entered the room, we do not believe that anything inappropriate occurred, the police were called and agreed that there was no cause for concern. V5, Psyche Nurse Practitioner conducted a [NAME] health visit with both residents to ensure residents were behaving at baseline. (V5) stated she had known (R2) for a long time and has not had any behaviors involving other residents. Final Interventions: (R2) room moved. (R2) placed on 15-minute checks to monitor for increased/changes in behaviors. Skin, pain, trauma assessment completed on (R3). (R2) was interviewed. (R2) was placed on 1:1: monitoring for a change in behaviors. (R2) clothing noted to fit well, Reviewed ability to fasten her clothing properly. Psych MP completed [NAME] health visits on both, the same night as the concern was noted. SSD (Social Service Director) to follow up. Care Plans updated. (This report does not mention R2 touched R3's private parts). 2-R3's POS for December 2025 documents a diagnosis of Alzheimer disease with late onset, Dementia in other diseases classified elsewhere moderate with other behavioral disturbances, Delirium Due to known physiological condition, Patient's noncompliant with medical treatment and regimen. R3's MDS dated [DATE] document R3 was severely impaired for cognition for activities of daily living. She has no impairments on the upper and or lower extremities and uses a wheelchair and is dependent on staff, helper does all of the effort. Resident does none of the effort to complete the activity. R3's Care Plan: (R3) is at risk for abuse and/or neglect r/t impaired cognitive skills, needs assistance with ADL's (activities of daily living) and dx (diagnosis of) of dementia. Date Initiated: 11/01/2024 R3's Nurses Notes does not document anything related to the incident with her roommate (R2) on 11/22/2025. R3's Social Service Notes dated 11/22/2025 at 5:56 PM, documents F/U (follow up) SSD (Social Service Director) met with (R3) who is in dining room for dinner. SSD asked (R3) how she is feeling, (R3) stated ok. SSD attempted to complete trauma assessment. (R3) was unable to participate meaningfully in the assessment related to dx of dementia, Conversation was characterized by rambling speech and an illogical flow of thoughts, preventing completion of evaluation. Will continue to monitor for change in mood, behavior. Statement from V4, Licensed Practical Nurse (LPN) documents, I went to see if either resident was in their room because I needed to stick their fingers for blood sugars. When I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I remained in the room, completed body assessment and called for CNA assistance, as staff remained with (R2) and other staff assisted (R3) to the bathroom and provided care then assisted her to the nurse's station area to remain 1:1 then assisted to the dining room to prepare for dinner. Staff remained 1:1 with (R2) in her room and I notified management. Body assessment with no injuries were done. (R3) cannot say what happened since she is non-sensible. (R2) just said she was trying to help her. I spoke to the doctor, the families and then the PD as well. No concerns were made by any parties. Management arrived and took over and I went back to work on the rest of my med pass and the other stuff for everyone on my unit. On 12/5/2025 at 1:22 PM, V6, Licensed Practical Nurse (LPN), stated, I have worked here for five years. I was not on here when something went down between (R2) and (R3). I know they moved (R3) to the dementia unit and (R2) was put on 15 minutes checks for something inappropriate but I could not tell you what. That was my weekend off. I only know she was on 15-minute checks when I came back because of inappropriate behavior. (R2) can walk and move around if she wants to. On 12/12/2025 at 2:17 PM, V9, LPN stated, (R3) is unable to talk and/or tell you what is going on with her. I was working the day she was moved over here. I was told her and her roommate, (R2), that there was an inappropriate incident between them and they separated them and moved (R3) over to the memory care unit. I was told the nurse found (R2) on (R3's) side of the room and the nurse walked in on them. On 12/12/2025 at 3:24 PM, V11, Registered Nurse (RN) stated, (R3) use to be on this side of the building (100 hall). I was not working when they moved (R3). I was told they moved her because a nurse (V4) walked in when (R2) was touching (R3's) private parts. They moved (R3) over to the dementia unit after that. R2's Police Report dated 11/22/2025 at 5:22 PM, (V4) while conducting rounds at (R2's) room two residents with severe dementia performing sex acts. (V4) observed (R2) digitally manipulating (R3's) vagina and anus. (V4) immediate contacted her supervisors and the police. Residents were separated. On Saturday, 11/22/2025 at approximately 4:28 PM, I, (V8), Local Police Officer responded to (Facility) in reference to two residents with cognitive disabilities performing sexual acts on each other. Upon arrival, I made contact with the caller, (V4). She stated she is a nurse employed by (Facility). (V4) stated while she was conducting her rounds on (R2 and R3's) room, she observed the two patients engaged in sexual activities. (V4) stated (R2) was knelt down near the bed of her roommate (R3) with her pants and underwear removed. (V4) stated (R2's) finger was inserted into (R3's) anus with fecal matter on the bed. (V4) stated medical staff separated (R2) and (R3), advising will no longer reside in the same room. (V4) stated (R3) was recently placed in (R2's) room on 11/3/2025. (V4) stated (R3) suffered from severe dementia and was unable to exit her bed by herself. (V4) stated (R3) was not communicative and could not provide a statement. (V4) stated (R2) was also diagnosed with a lesser severity of dementia, but also had severe cognitive decline. (V4) described (R2's) current limited mental/physical capabilities as able to use the restroom by herself. (V4) stated she contacted her immediate supervisor to conduct an internal investigation of the incident. (V4) also stated she would be contacting the Power of Attorney for both subjects to make them aware of the investigation. On 12/15/2025 at 10:24 AM, V12, Certified Nursing Assistant (CNA) stated I know (R3) was moved off the 100 hall because they said she was assaulted by (R2). They then put (R2) on one on ones and moved (R3) to a different hall. I am not sure what happened and/or the details. On 12/15/2025 at 11:38 PM, V4, Licensed Practical Nurse (LPN) stated, I told the police officer when I went to do accu checks (R2) was over by (R3's) bed and was on the floor. I gave a statement to the facility and to the police. I did see (R2) when I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I called (V1) immediate after it happened. They said nothing like this had have happened before. The CNAs then got (R3) cleaned up. (R3) cannot talk or tell you anything. When I asked (R2) what she was doing she did not respond to me at all. I don't know (R2's) behaviors but she can get up on her own and she does have some confusion but at that time she did not respond and just said she was cold. I asked her what she was doing, and she never said anything in that moment and would not respond to me. On 12/15/2025 at 1:31 PM, V14, Family of R2 stated I originally got a call from the facility, and they told me they caught (R2) masturbating her roommate (R3). Then they called me back later and told me they were not sure that was what happened because (R2) use to be a CNA in the facility and they thought maybe she was just trying to help (R3). Honestly, I am not sure what happened because I was not in the room. On 12/15/2025 at 1:49 PM, V8, Local Police Officer stated he has been called to the facility on [DATE] for an allegation of sexual assault between two residents and everything was in the report. The nurse had reporting while conducing rounds two residents both with severe dementia performing sexual acts. On 12/15/2025 at 2:17 PM, V15, Family of R3 stated, The Facility called me and told me they found another resident in bed with (R3). (R3) can't talk or tell you anything so I was not sure what happened. I was never told (R3) was touched inappropriately or anything related to a sexual nature. On 12/15/2025 at 3:03 PM, V16, Medical Director stated he had just started at the facility on 11/21/2025 and he got a call from the facility the next day (11/22/2025) and was told another resident (R2) had sexually touched another resident (R3). In this case it is difficult because both residents have dementia. I made sure both residents were separated and (R3) was moved to the locked dementia unit and (R2) was placed on one on ones. I did all the appropriate measures one can do in a situation like this. At no time is it acceptable and it is completely forbidden for another resident to touch another resident in a sexual nature without consent. The Facility Abuse Policy with a reviewed date of 12/2/2025 documents, Purpose: To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems.

Based on observation, interview, and record review the facility failed to operationalize their abuse policy and procedures for 2 of 4 reviewed (R2 and R3) for policies in the sample of 6. On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant (PNC) for F600 abuse even though through their investigation they had no findings. V1 stated they did not believe the abuse occurred because (R2) use to be a certified nursing assistant, at this building. They did a PNC ready just in case. On 12/5/2025 at 8:49 AM, V2, Director of Nursing stated they did an internal investigation and felt like (V4) jumped the gun because (R2) had her pants down but they were able to determine nothing occurred. R2's Initial Report 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Investigation of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. R2's Final Report date of 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Education of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. Investigation: (V4, LPN) entered (R2) and (R3) to observe (R2) on her knees next to the bed with her pants down. (R2) hand was on the bed with her back to (R3) laying on her side. (V4) noted that the room was very cold and that (R2) had BM (bowel movement) on her hand and (R3) had BM on her bed. (V4) did not see (R2) acting inappropriately with (R3), nor did she have history of being inappropriate with resident. (R2) was a long time CNA (certified nursing assistant) of (Facility) prior to coming to live at the facility. (R2) was interviewed, she was noted to have some confusion during questioning but was able to answer some questions sensical. She stated that she was cold and went to turn off the air. The air was noted to be on when (V4) was in the room. When asked why her pants were down, she stated, they had fallen down, they were not fastened. (R2) was noted to have BM on her hand. She did not know where that had come from however her hand was located on (R3's) bed that did have BM on it. She was using the bed to help her get off her knees. When asked if she had touched (R3) she said no. I am just trying to help her. (R3) was unable to be interviewed. She was noted to be sleeping at the time of concern. (R3's) skin assessment was completed WNL (within normal limits). Pain assessment completed; no pain noted. (R3) did not have an increase or behavioral changes after time of concern. Other residents were interviewed, when asked if another resident ever touched them inappropriately, all answered no. When asked if they felt safe in the facility, all stated they did. When asked of residents know who to report concerns to, they stated they did, if they did not residents were education. Conclusion: Our investigation concluded that (R2) did not have any inappropriate contact with (R3). (R2) was trying to turn off the air conditioning and got tangled up in her pants that had fallen down. She went to use (R3's) bed to get up where she had placed her hand on (R3's) soiled bedding. When our nurse entered the room, we do not believe that anything inappropriate occurred, the police were called and agreed that there was no cause for concern. V5, Psyche Nurse Practitioner conducted a [NAME] health visit with both residents to ensure residents were behaving at baseline. (V5) stated she had known (R2) for a long time and has not had any behaviors involving other residents. Final Interventions: (R1) room moved. (R1) placed on 15-minute checks to monitor for increased/changes in behaviors. Skin, pain, trauma assessment completed on (R3). (R2) was interviewed. (R2) was placed on 1:1: monitoring for a change in behaviors. (R2) clothing noted to fit well, Reviewed ability to fasten her clothing properly. Psych MP completed [NAME] health visits on both, the same night as the concern was noted. SSD (Social Service Director) to follow up. Care Plans updated. (This report does not mention R2 touched R3's private parts or address R2's Police report and or any statement by the eyewitness (V4). R3's Nurses Notes do not document anything related to the incident with her roommate (R2) on 11/22/2025. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant for F600 abuse even though through their investigation they had no findings. (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant for F600 abuse even though through their investigation they had no findings. Statement from V4, Licensed Practical Nurse (LPN) documents, I went to see if either resident was in their room because I needed to stick their fingers for blood sugars. When I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I remained in the room, completed body assessment and called for CNA assistance, as staff remained with (R2) and other staff assisted (R3) to the bathroom and provided care then assisted her to the nurse's station area to remain 1:1 then assisted to the dining room to prepare for dinner. Staff remained 1:1 with (R2) in her room and I notified management. Body assessment with no injuries were done. (R3) cannot say what happened since she is non-sensible. (R2) just said she was trying to help her. I spoke to the doctor, the families and then the PD as well. No concerns were made by any parties. Management arrived and took over and I went back to work on the rest of my med pass and the other stuff for everyone on my unit. R2's Police Report dated 11/22/2025 at 5:22 PM, (V4) while conducting rounds at (R2's) room two residents with severe dementia performing sex acts. (V4) observed (R2) digitally manipulating (R3's) vagina and anus. (V4) immediate contacted her supervisors and the police. Residents were separated. On Saturday, 11/22/2025 at approximately 4:28 PM, I, (V8), Local Police Officer responded to (Facility) in reference to two residents with cognitive disabilities performing sexual acts on each other. Upon arrival, I made contact with the caller (V4). She stated she is a nurse employed by (Facility). (V4) stated while she was conducting her rounds on (R2 and R3's) room, she observed the two patients engaged in sexual activities. (V4) stated (R2) was knelt down near the bed of her roommate (R3) with her pants and underwear removed. (V4) stated (R2's) finger were inserted into (R3's) anus with fecal matter on the bed. (V4) stated medical staff separated (R2) and (R3), advising will no longer reside in the same room. (V4) stated (R3) was recently placed in (R2's) room on 11/3/2025. (V4) stated (R3) suffered from severe dementia and was unable to exit her bed by herself. (V4) stated (R3) was not communicative and could not provide a statement. (V4) stated (R2) was also diagnosed with a lesser severity of dementia, but also had severe cognitive decline. (V4) described (R2's) current limited mental/physical capabilities as able to use the restroom by herself. (V4) stated she contacted her immediate supervisor to conduct an internal investigation of the incident. (V4) also stated she would be contacting the Power of Attorney for both subjects to make them aware of the investigation. On 12/15/2025 at 11:38 PM, V4, Licensed Practical Nurse (LPN) stated, I told the police officer when I went to do (blood sugar) checks (R2) was over by (R3's) bed and was on the floor. I gave a statement to the facility and to the police. I did see (R2) when I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I called (V1) immediate after it happened. They said nothing like this had have happened before. The CNAs then got (R3) cleaned up. (R3) cannot talk or tell you anything. When I asked (R2) what she was doing she did not respond to me at all. I don't know (R2's) behaviors but she can get up on her own and she does have some confusion but at that time she did not respond and just said she was cold. I asked her what she was doing, and she never said anything in that moment and would not respond to me. On 12/15/2025 at 1:49 PM, V8, Local Police Officer stated he has been called to the facility on [DATE] for an allegation of sexual assault between two residents and everything was in the report. The nurse had reporting while conducing rounds two residents both with severe dementia performing sexual acts. On 12/15/2025 at 2:17 PM, V15, Family of R3 stated, The Facility called me and told me they found another resident in bed with (R3). (R3) can't talk or tell you anything so I was not sure what happened. I was never told (R3) was touched inappropriately or anything related to a sexual nature. On 12/15/2025 at 3:03 PM, V16, Medical Director stated he had just started at the facility on 11/21/2025 and he got a call from the facility the next day (11/22/2025) and was told another resident (R2) had sexually touched another resident (R3). In this case it is difficult because both residents have dementia. I made sure both residents were separated and (R3) was moved to the locked dementia unit and (R2) was placed on one on ones. I did all the appropriate measure one can do in a situation like this. At no time is it acceptable and it is completely forbidden for another resident to touch another resident in a sexual nature without consent. (R2) clearly has some behaviors disorders which is more than likely tied to her dementia diagnosis and does not have control of her thinking and or actions. Unfortunately, there is no treatment for this disease. It was very unfortunate. On 12/15/2025 at 1:39PM, a binder containing in-services was provided by the Facility in servicing all staff on abuse after R2's incident on 11/22/2025. The Facility Abuse Policy with a reviewed date of 12/2/2025 documents, If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team ( the Investigator) to investigate the alleged incident. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident. The Facility ensures protection of residents during abuse investigations. The Investigator may take some or all of the following steps: Reviews all relevant documentation; Reviews the resident's medical record to determine events preceding the alleged incident; Interviews the person(s) making the incident report; Interviews any witnesses to the alleged incident; Interviews the resident (as medically appropriate); Interviews the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interviews Facility Staff members who have had contact with the resident during the period of the alleged incident; Interviews the resident's roommate, family members, and visitors.

Based on interview and record review the Facility failed to ensure all alleged violations are thoroughly investigated for 2 of 4 residents (R2 and R3) reviewed for abuse investigations in the sample of 6. Findings include: On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant (PNC) for F600 abuse even though through their investigation V1 stated she had no findings. V1 stated they did not believe the abuse occurred because (R2) use to be a certified nursing assistant, at this building. They did a PNC ready just in case. On 12/5/2025 at 8:49 AM, V2, Director of Nursing stated they did an internal investigation and felt like (V4) jumped the gun because (R2) had her pants down but they were able to determine nothing occurred. R2's Initial Report 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Investigation of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. R2's Final Report date of 11/22/2025, Initial Allegations: At approximately 3:30 PM, a nurse reported an allegation of abuse. Investigation initiated. Initial interventions: 1) Residents separated and placed on 1:1 monitoring. 2) Interviews with residents and staff initiated. 3) Education of abuse and neglect initiated. 4) Notified: Police, Family and MD. 5) Assessment initiated. 6) IDPH initial report sent. Investigation: (V4, LPN) entered (R2) and (R3) to observe (R2) on her knees next to the bed with her pants down. (R2) hand was on the bed with her back to (R2) laying on her side. (V4) noted that the room was very cold and that (R2) had BM (bowel movement) on her hand and (R3) had BM on her bed. (V4) did not see (R2) acting inappropriately with (R3), nor did she have history of being inappropriate with resident. (R2) was a long time CNA (certified nursing assistant) of (Facility) prior to coming to live at the facility. (R2) was interviewed, she was noted to have some confusion during questioning but was able to answer some questions sensical. She stated that she was cold and went to turn off the air. The air was noted to be on when (V4) was in the room. When asked why her pants were down, she stated, they had fallen down, they were not fastened. (R2) was noted to have BM on her hand. She did not know where that had come from however her hand was located on (R3's) bed that did have BM on it. She was using the bed to help her get off her knees. When asked if she had touched (R3) she said no. I am just trying to help her. (R3) was unable to be interviewed. She was noted to be sleeping at the time of concern. (R3's) skin assessment was completed WNL (within normal limits). Pain assessment completed; no pain noted. (R3) did not have an increase or behavioral changes after time of concern. Other residents were interviewed, when asked if another resident ever touched them inappropriately, all answered no. When asked if they felt safe in the facility, all stated they did. When asked of residents know who to report concerns to, they stated they did, if they did not residents were education. Conclusion: Our investigation concluded that (R2) did not have any inappropriate contact with (R3). (R2) was trying to turn off the air conditioning and got tangled up in her pants that had fallen down. She went to use (R3's) bed to get up where she had placed her hand on (R3's) soiled bedding. When our nurse entered the room, we do not believe that anything inappropriate occurred, the police were called and agreed that there was no cause for concern. V5, Psyche Nurse Practitioner conducted a [NAME] health visit with both residents to ensure residents were behaving at baseline. (V5) stated she had known (R2) for a long time and has not had any behaviors involving other residents. Final Interventions: (R1) room moved. (R1) placed on 15-minute checks to monitor for increased/changes in behaviors. Skin, pain, trauma assessment completed on (R3). (R2) was interviewed. (R2) was placed on 1:1: monitoring for a change in behaviors. (R2) clothing noted to fit well, Reviewed ability to fasten her clothing properly. Psych MP completed [NAME] health visits on both, the same night as the concern was noted. SSD (Social Service Director) to follow up. Care Plans updated. (This report does not mention R2 touched R3's private parts or address R2's Police report and or any statement by the eyewitness (V4). R3's Nurses Notes do not document anything related to the incident with her roommate (R2) on 11/22/2025. Statement from V4, Licensed Practical Nurse (LPN) documents, I went to see if either resident was in their room because I needed to stick their fingers for blood sugars. When I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I remained in the room, completed body assessment and called for CNA assistance, as staff remained with (R2) and other staff assisted (R3) to the bathroom and provided care then assisted her to the nurse's station area to remain 1:1 then assisted to the dining room to prepare for dinner. Staff remained 1:1 with (R2) in her room and I notified management. Body assessment with no injuries were done. (R3) cannot say what happened since she is non-sensible. (R2) just said she was trying to help her. I spoke to the doctor, the families and then the PD as well. No concerns were made by any parties. Management arrived and took over and I went back to work on the rest of my med pass and the other stuff for everyone on my unit. On 12/5/2025 at 1:22 PM, V6, Licensed Practical Nurse (LPN), stated, I have worked here for five years. I was not on here when something went down between (R2) and (R3). I know they moved (R3) to the dementia unit and (R2) was put on 15 minutes checks for something inappropriate but I could not tell you what. That was my weekend off. I only know she was on 15-minute checks when I came back because of inappropriate behavior. (R2) can walk and move around if she wants to. On 12/12/2025 at 2:17 PM, V9, LPN stated, (R3) is unable to talk and or tell you what is going on with her. I was working the day she was moved over here. I was told her and her roommate (R2) that there was an inappropriate incident between them, and they separated them and moved (R3) over to the memory care unit. I was told the nurse found (R2) on (R3's) side of the room and the nurse walked in on them. On 12/12/2025 at 3:24 PM, V11, Registered Nurse (RN) stated, (R3) use to be on this side of the building (100 hall). I was not working when they moved (R3). I was told they moved her because a nurse (V4) walked in when (R2) was touching (R3's) private parts. They moved (R3) over to the dementia unit after that. R2's Police Report dated 11/22/2025 at 5:22 PM, (V4) while conducting rounds at (R2's) room two residents with severe dementia performing sex acts. (V4) observed (R2) digitally manipulating (R3's) vagina and anus. (V4) immediate contacted her supervisors and the police. Residents were separated. On Saturday, 11/22/2025 at approximately 4:28 PM, I, (V8), Local Police Officer responded to (Facility) in reference to two residents with cognitive disabilities performing sexual acts on each other. Upon arrival, I made contact with the caller (V4). She stated she is a nurse employed by (Facility). (V4) stated while she was conducting her rounds on (R2 and R3's) room, she observed the two patients engaged in sexual activities. (V4) stated (R2) was knelt down near the bed of her roommate (R3) with her pants and underwear removed. (V4) stated (R2's) finger were inserted into (R3's) anus with fecal matter on the bed. (V4) stated medical staff separated (R2) and (R3), advising will no longer reside in the same room. (V4) stated (R3) was recently placed in (R2's) room on 11/3/2025. (V4) stated (R3) suffered from severe dementia and was unable to exit her bed by herself. (V4) stated (R3) was not communicative and could not provide a statement. (V4) stated (R2) was also diagnosed with a lesser severity of dementia, but also had severe cognitive decline. (V4) described (R2's) current limited mental/physical capabilities as able to use the restroom by herself. (V4) stated she contacted her immediate supervisor to conduct an internal investigation of the incident. (V4) also stated she would be contacting the Power of Attorney for both subjects to make them aware of the investigation. On 12/15/2025 at 10:24 AM, V12, Certified Nursing Assistant (CNA) stated I know (R3) was moved off the 100 hall because they said she was assaulted by (R2). They then put (R2) on one on ones and moved (R3) to a different hall. I am not sure what happened and or the details. On 12/15/2025 at 11:38 PM, V4, Licensed Practical Nurse (LPN) stated, I told the police officer when I went to do (blood sugar) checks (R2) was over by (R3's) bed and was on the floor. I gave a statement to the facility and to the police. I did see (R2) when I entered the room. (R2) was on her knees next to (R3's) bed on the floor mat resting her knees. (R3) was in bed, lying on her left side face towards the wall. (R2) had her left hand in (R3's) buttocks region and was lifting her buttocks at which point she placed her middle finger near (R3's) rectum and I asked her to stop immediately at which time (R2) stopped and stood up, fixing her pants from their lowered position and sent over to her bed. I called (V1) immediate after it happened. They said nothing like this had have happened before. The CNAs then got (R3) cleaned up. (R3) cannot talk or tell you anything. When I asked (R2) what she was doing she did not respond to me at all. I don't know (R2's) behaviors but she can get up on her own and she does have some confusion but at that time she did not respond and just said she was cold. I asked her what she was doing, and she never said anything in that moment and would not respond to me. On 12/15/2025 at 1:31 PM, V14, Family of R2 stated I originally got a call from the facility, and they told me they caught (R2) masturbating her roommate. Then they called me back later and told me they were not sure that was what happened because (R2) use to be a CNA in the facility and they thought maybe she was just trying to help (R3). Honestly, I am not sure what happened because I was not in the room. On 12/15/2025 at 1:49 PM, V8, Local Police Officer stated he has been called to the facility on [DATE] for an allegation of sexual assault between two residents and everything was in the report. The nurse had reporting while conducing rounds two residents both with severe dementia performing sexual acts. On 12/15/2025 at 2:17 PM, V15, Family of R3 stated, The Facility called me and told me they found another resident in bed with (R3). (R3) can't talk or tell you anything so I was not sure what happened. I was never told (R3) was touched inappropriately or anything related to a sexual nature. On 12/15/2025 at 3:03 PM, V16, Medical Director stated he had just started at the facility on 11/21/2025 and he got a call from the facility the next day (11/22/2025) and was told another resident (R2) had sexually touched another resident (R3). In this case it is difficult because both residents have dementia. I made sure both residents were separated and (R3) was moved to the locked dementia unit and (R2) was placed on one on ones. I did all the appropriate measure one can do in a situation like this. At no time is it acceptable and it is completely forbidden for another resident to touch another resident in a sexual nature without consent. (R2) clearly has some behaviors disorders which is more than likely tied to her dementia diagnosis and does not have control of her thinking and or actions. Unfortunately, there is no treatment for this disease. It was very unfortunate. On 12/15/2025 at 1:33 PM, V1 stated they had provided all of their investigations and interviews for (R2). No documentation was provided addressing any steps the facility would take for the alleged violation. On 12/15/2025 at 1:39PM, a binder containing in-services was provided by the Facility in servicing all staff on abuse after R2's incident on 11/22/2025. The Facility Abuse Policy with a reviewed date of 12/2/2025 documents, If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team ( the Investigator) to investigate the alleged incident. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident. The Facility ensures protection of residents during abuse investigations. The Investigator may take some or all of the following steps: Reviews all relevant documentation; Reviews the resident's medical record to determine events preceding the alleged incident; Interviews the person(s) making the incident report; Interviews any witnesses to the alleged incident; Interviews the resident (as medically appropriate); Interviews the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interviews Facility Staff members who have had contact with the resident during the period of the alleged incident; Interviews the resident's roommate, family members, and visitors.

Based on interview and record review the facility failed to label medication per current standards of practice. This has the potential to affect all 99 residents residing in the facility.Findings include:R3's admission Record, dated [DATE], documents admission date [DATE] with Dementia, Chronic kidney Disease, hypertension, and Anxiety listed as diagnosis.R3's Care Plan, dated [DATE], documents that (R3) has potential for acute pain r/t (related to) dx (diagnosis) Dementia, Chronic Kidney Disease, GERD.R3's Physician Order, dated [DATE], documents Morphine Sulfate Oral Solution 20 MG/5ML (milligram/milliliter) Give 0.25 ml by mouth every 4 hours as needed for pain.R3's Controlled Drug Record documents 30ml bottle of Morphine Sulfate 100mg/5ml. It documents R3's name with a hand drawn line thru it and R5's name handwritten above it. It also documents on 9/16 at 9:20 0.25 ml given and at 5:45 0.25 ml given. A handwritten line is drawn across the Controlled Drug Record. It continues starting 29.50ml in bottle and V5's initials. It then documents 0.5ml doses administered 9/20 at 8pm, 9/21 at 10 AM, 9/21 2PM, 9/21 4 PM, 9/21 8PM, 9/22 2AM.The facility's initial letter, dated [DATE], documents that the facility's medication tampering suspected by hospice nurse. Please find this as the initial reporting of Suspected medication tampering by hospice nurse during care provided to mutual resident of the facility. It appears that the nurse changed the label and repurposed a bottle of liquid medications from a deceased resident to a current resident. No harm occurred and the hospice company was notified, and an investigation initiated. A full report will follow upon completion of all investigation steps.The facility's final letter, dated [DATE], documents Re: Medication tampering suspected by hospice RN. On [DATE] during narcotic destruction it was noted that a medication label had been altered by the Vitas Hospice nurse at the time of admitting a new patient onto their services. All notifications were made, and initial reporting completed. Vitas hospice conducted an investigation into the nurse responsible for the label alteration from the original resident (also a Vitas Hospice patient) to the newly admitted Vitas patient. The nurse in question admitted changing the label so as not to delay getting the medication started for the patient who was in active decline. Despite her feeling she was doing what was best for the resident at the time, the nurse was educated and ultimately terminated from her position due to her actions. The facility DNS has educated all hospice providers on the incident and outcome to ensure no future instance occur. No medication dose discrepancies were noted as all medication was provided to residents under the care of Vitas Hospice.On [DATE] at 1:32 PM V2, Director of Nursing, stated that she has a strict policy as the floor nurses are not to destroy narcotics. V2 stated that the medication is counted on the floor and given to her for destruction. V2 stated that because of using agency staff and past experiences she put this in place to prevent diversion. V2 stated that R3 passed away on a Wednesday or Thursday. V2 stated that when she went to destroy the medication, she noted that the Controlled Drug Record was altered with R3's name marked out and R5's name handwritten on the record. V2 stated that she checked the medication and noted that the medication and noted that the original box was altered in the same way. V2 stated that she then checked with her staff and was informed by V6, ???, that when R5 was admitted he was experiencing pain. It was noted that the morphine was in the cart and V5, Hospice RN, changed the name on the record and the box. V2 stated that she notified hospice of what she was made aware. V2 stated that her staff did administer R3's medication to R5. V2 stated this is not the normal practice of the facility and she expects her staff to use medication that is prescribed for the resident and not change the label and use for another resident.On [DATE] at 3:07 PM V5 stated that she came to the facility because R5 was being admitted to hospice. V5 stated that R5 was in a lot of pain and family was requesting pain relief. V5 stated that she was informed by V6 that R3's Morphine was in the cart. V5 stated that she initialed that R3 had 29.5 mls of Morphine. V5 stated that she did not alter the record or the container and did not administer the medication. V5 stated that V6 altered the document and the bottle. V5 stated that she did place orders for R5's medication but did not order the morphine because she was informed that that they would use R3's medication.On [DATE] at Approximately 10:00 AM V2 provided Midnight Census report, dated [DATE], that documents 99 occupied resident beds in the facility.On [DATE] at 2:12 PM V10, Pharmacist, stated that the medications are labeled, with a specific resident's name and sent from the pharmacy with that label. V10 stated that once the medication leaves the pharmacy the label remains the same and is not to be changed in the facility. If the medication is expired or the person dies the medication is to be destroyed. V10 stated that each medication is specific to a particular resident and not to be shared or used for another.The facility's Medication Storage policy, dated 1/15, documents that POLICY: All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy.The facility's Medication Administration General Guidelines, dated 1/15, documents that POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices. Procedure; 18. Prior to administration, the medication and dosage schedule on the resident's MAR I TAR is compared with the medication label. Information on the medication should be checked against the MAR / TAR at least three times during the med preparation and administration process. If the label and MAR I TAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule prior to administering. If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal.

Based on interview, observation, and record review the facility failed to ensure safety as indicated per plan of care for 4 of 4 (R11, R17, R53, R72) residents reviewed for accidents and hazards in the sample of 79. This failure resulted in R72 suffering multiple falls and receiving a skin tear to her right knee. Findings include: 1. R72's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, neoplasm of brain, dementia, and neoplasm of lung. R72's MDS dated [DATE] documented she is moderately cognitively impaired and required supervision or touching assistance for all transfers, walking, and going from a sitting to a standing position. R72's Care Plan dated 1/7/25 documented she has high risk for falls related to confusion, gait/balance problems, psychoactive drug use, mood adjustment disorder and anxiety. Fall risk interventions put in place included: for 2/25 0900: provide sign on walker to remind resident to use walker when ambulating added on 3/4/25, for 2/25 1200: place in-room signage to remind resident to request help from staff when feeling tired/weak added on 3/4/25, anticipate and meet R72's needs added on 1/7/25, ensure that she is wearing appropriate footwear i.e. shoes/non-skid socks) when ambulating with wheeled walker added on 11/19/24, evaluate the effectiveness and side effects of psychoactive drugs for possible decrease in dosage/elimination of drug on 11/19/24, follow facility fall protocol added on 11/19/24, hospice to provide Bolstered mattress for increased safety and to avoid rolling out of bed when resting added on 4/15/25, increase safety observations: staff to check room during routine rounding and PRN for environment safety, ensure no clothing are left on the floor added on 3/4/25, observe for removal of shoes when sitting in chair, re-direct resident to ensure shoes remain in place when OOB (out of bed) added on 4/15/25, Pt (physical therapy) evaluate and treat as ordered or PRN (as needed) added on 11/19/24, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible, educate resident/family/caregivers/IDT (interdisciplinary team) as to causes added on 11/19/24, and R72 needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach added on 1/7/25. R72's fall care plan had interventions added on the following dates: 11/19/24, 1/7/25, 2/25/25, 3/4/25, and 4/15/25. R72's Morse Fall Risk assessment dated [DATE] documented she is a high fall risk and to implement high fall risk interventions. The Facility's Incidents by Type Report from 1/21/25 to 4/21/25 documented R72 had 8 total falls on 2/25/25 (twice), 3/9/25, 4/13/25, 2/23/25, 2/27/25, 3/31/25, and 4/4/25. R72's Progress Notes documented her having a total of 12 falls on the following dates: 1/10/25, 1/16/25, 2/23/25, 2/25/25 (twice), 3/10/25, 3/12/25, 3/17/25, 4/4/25, 4/13/25, 4/19/25, and 4/23/25. R72's Progress Note dated 4/19/25 at 2:59 PM, documented R72 obtained a skin tear to her right knee after being found laying on the floor next to her bed on the left side of her face. R72's Progress Note dated 4/19/25 at 6:27 PM, documented she returned from the hospital with diagnosis of pneumonia and a urinary tract infection. On 4/21/25 at 8:59 AM, on 4/22/25 at 9:23 AM, 11:39 AM and at 2:55 PM R72 was observed not wearing non-slip socks or shoes. On 4/21/25 at 8:59 AM, R72 had a bruised left eye with bloody sclera. R72 does not remember what from; she did not have non-slip sock on and was sitting in her wheelchair. On 4/22/25 at 9:04 AM R72's door was closed, this surveyor knocked, and walked in. R72 was lying in bed awake, call light on floor, fall mat on left side, no mat on right side, bed in low position, and no footwear on and her bed did not have a bolster mattress in place. On 4/22/25 at 9:23 AM, R72 was in wheelchair at dining area in front of nurse's station with a snack after her morning medications; R72 was not wearing non-slip socks or shoes. On 4/22/25 at 2:55 PM, V23, R72's daughter, stated her mother came here with lung cancer and it has since metastasized to her brain. Since the metastasis, V23 stated she thinks R72 has had increased falls. V23 stated her mother doesn't have non-slip socks on and she is supposed to. V23 stated she requested the facility try to utilize an alarm system for R72 but was told they couldn't. V23 stated she does not feel like R72 has enough supervision to prevent falls and would like to know if the bolster mattress will be put in place soon. V23 stated she does like the fall mats in place. On 4/23/25 at 10:26 AM, V24, CNA, stated fall interventions for R72 include floor mats, frequent checks, and assistance to the bathroom, as well as offering the restroom often. On 4/23/25 at 10:28 AM V25, CNA, stated fall interventions for R72 include floor mats by bed, providing assistance. On 4/23/25 at 10:29 AM V5, LPN, stated fall interventions for R72 include having the bed in low position, use of fall mats, observation, keep closer to nurse's station, non-slip socks, and fall interventions for R10 include bed in low position, reminders for safety, offering help fast. V5 stated she is new to the facility and since working here for about 2 weeks she has not seen any concerns between R88 and R90. V5 stated interventions for wandering include offering lots of activities, keeping the residents busy, toileting them and providing naps with frequent assistance of needs. On 4/23/25 at 2:24 PM, V2 DON (director of nursing) stated there was no fall for R72 on 4/19/25 after a fall investigation was requested for that date and would have to check back after this surveyor mentioned there was one documented in the progress notes. On 4/23/2025 at approximately 2:40 PM V2, Director of Nursing, stated that initially she did not remember what fall that occurred on 4/19/2025 until she read the note in the computer. V2 stated that R72 was sent to the hospital for a change in condition. V2 stated that she remembered at that time R72 was on the floor. V2 stated that they thought R72 had a stroke. V2 stated that the hospital determined that R72 did not have a stroke and was diagnosed with pneumonia. 2.R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of dementia with severe agitation and psychotic disturbance, and schizoaffective disorder. R53's MDS dated [DATE] documented he was severely cognitively impaired and exhibits wandering behavior daily. R53's Care Plan dated 1/13/2025, documented he is an elopement risk due to the following behaviors: exit seeking, confusion, wandering aimlessly and he resides on a secured unit. Interventions for this care plan included encourage R53 to verbalize through one-to-one interaction added on 1/8/2025, place R53 in area where observation is possible added on 1/8/2025, and provide diversional activities for resident when anxious, offer resident a snack added on 12/4/2024. On 4/21/25 at 9:30 AM, R69 stated R53 wanders into his room and takes things so they keep his door closed, he needs to be watched. On 4/22/25 at 9:00 AM, R53 was observed walking up and down the hallway. At 9:07 AM, R53 walked into R90's room then came back out and walked into R80 and R33's room, closed the door and came back out within a couple minutes. This surveyor observed no staff intervene while R53 walked into other resident's room. 44967 3. R17's Admission Record, dated 4/24/25, documents R17 was admitted to the facility on [DATE], with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Anxiety Disorder, HTN, Encephalopathy, Spinal Stenosis, Thoracolumbar and Lumbar Region, Low Back Pain, Radiculopathy Lumbar Region. R17's Care Plan, dated 1/13/25, documents R17 has potential for acute risk for falls related to Confusion, Deconditioning, Psychoactive drug use. Interventions: Anticipate and meet R17's needs, educate R17/family/caregivers about safety reminders and what to do if a fall occurs, encourage R17 to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that R17is wearing appropriate footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating or mobilizing in wheelchair, follow facility fall protocol, PT (physical therapy) evaluate and treat as ordered or PRN (as needed), review information on past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible, educate R17/family/caregivers/IDT (interdisciplinary team) as to causes. R17's MDS, 3/19/25, documents R17 has a moderate cognitive impairment and requires supervision/touching assistance for toileting, and supervision/touching assistance for sit-to-stand and toilet transfers. R17's Fall Risk Assessment, dated 3/20/25, documents R17 is a High Fall Risk. R17's EZ Move Assessment, dated 3/21/25, documents in part Device Required: Gait Belt. On 4/21/25 at 9:02 AM, R17 put her call light on with V12, CNA, entering to assist. R17 stated she needed to use the restroom and V12 assisted R17 to side of her bed, R17 stood and pivoted into her wheelchair with V12 holding onto R17 by under her arm and down into the wheelchair, then pushed R17 into restroom. R17 stood and pivoted to the toilet again with V12 holding onto under R17's arm. V12 had a gait belt around her waist, and it dropped to the floor with V12 picking it back up and putting it around her waist again, but never used it on assisting R17 in her transfers. 4. R11's Admission Record, dated 4/23/25, documents R11 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Psychosis, Generalized Osteoarthritis, and Vertigo. R11's Care Plan, dated 1/20/25, documents R11 is at moderate risk for falls related to gait/balance problems, incontinence, psychoactive drug use, behaviors. Interventions: Follow facility fall protocol. R11's MDS, dated [DATE], documents R11 has a severe cognitive impairment and requires partial/moderate assistance for sit-to-stand and bed to chair transfers. R11's EZ Move Assessment, dated 1/24/25, documents in part Lifting/Mobility Required: one-person, Device Required: Gait Belt. R11's Fall Risk Assessment, dated 1/24/25, documents R11 is a High Fall Risk. The Facility's Fall Log, documents R11 had a fall on 3/21/25, and 3/26/25. On 4/23/25 at 8:55 AM, R11 was seen in bed with V20, CNA, assisting to get her out of bed. V20 had R11 sit up on side of bed, held R11 under her right arm, while R11 stood up and pivoted to her wheelchair. V20 had a gait belt wrapped around herself and did not use on R11. On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am assisting a resident with a transfer, I always carry a gait belt around my waist and will use it while assisting the resident. On 4/28/25 10:35 AM, V25, CNA, stated that she uses a gait belt on residents during transfers. On 4/28/25 10:40 AM, V12, CNA, stated that she uses her gait belt when transferring residents. On 4/28/25 at 11:00 AM, V2, DON, stated I would expect all staff to maintain resident safety and perform safe resident transfers by using the gait belt for high fall risk residents. The Facility's Transfer Belts/Gait Belts Policy, dated 4/2014, documents in part To promote safety in transferring residents, a gait belt is utilized when deemed appropriate. The Facility's Fall Prevention Strategies and Interventions undated in part Transfer Assistive Devices: Ensure staff uses gait belt, transfer resident with gait belt. The Facility's Elopement Guidelines, dated 8/2017, documents in part The Elopement Risk Evaluation is to be done upon admission and quarterly and as needed with exit seeking behaviors. At the beginning and end of each shift the charge nurse is to make visual rounds on each high risk resident to ensure that they can be located in the facility. When exit seeking activity occurs consider 1:1 supervision or 15-minute checks.

Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 residents (R18) reviewed for wound care in the sample of 79. This resulted in R18 experiencing severe excoriation, including skin breakdown and pain. The Findings Include: R18's Admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment. R18's Minimum Data Set (MDS), dated [DATE], documents R18 has a severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder. R18's Physician Order, dated 2/10/25, documents Skin assessment weekly every Tuesday day shift. Every day shift every Tuesday for weekly skin check. Please complete skin checks in (computer system). R18's Physician Order, dated 4/22/25, documents Cleanse bilateral buttocks with NS (normal saline) or WC (wound cleaner), apply barrier cream daily and PRN (as needed). Every Day shift for incontinence dermatitis. R18's Physician Order, dated 7/19/24, documents Cleanse peri area with mild soap and water or facility wipes, pat dry, apply Calazinc cream to buttocks, peri area, and inner thighs PRN. R18's Weekly Skin Assessment, dated 4/15/25, documents Incontinence Dermatitis to left buttock, right thigh, and left thigh. R18's Weekly Wound Assessment, dated 3/11/25, documents R18 had a Pressure Ulcer to left buttock that was healed. There is no further wound notes completed. R18's (Wound Management Specialist) Note, dated 3/18/25, documents in part Visit Date: 3/18/25, DC (discontinue) (Wound Management Specialist) services, Nursing to continue to monitor and notify me of changes. On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), in to do peri-care on R18, and during incontinent care, R18 was rolled to her right side, and her buttocks appeared very reddened with open sores that appear like skin tears with slight bleeding from areas. V12 continued to wipe R18, causing even more bleeding. A clean brief was applied with no moisture barrier cream applied to R18 and no drying seen done. On 4/22/25 at 10:18 AM, V12, CNA, stated (R18) did not have these sores on her bottom the last time I was working here. It looks like it is from sitting in wetness, especially when sitting her in her wheelchair. On 4/23/25 at 9:10 AM, V19, Wound Nurse, stated (R18) did have sores on her buttock before and the (Wound Management Specialist) was working with her, but that was all healed. The CNAs are supposed to be putting moisture barrier on her with each incontinence care. When told that R18's buttocks were excoriated and bleeding, V19 stated No one has told me about that, I was not aware of it. I will check her out this morning and probably have (Wound Management Specialist) look at her again. On 4/23/25 at 9:48 AM, V15, CNA, stated If I'm doing incontinent care and the resident has redness or open sores, I would use a barrier cream and will tell the nurse about it. On 4/23/25 10:50 AM, V19 gathered supplies to assess R18's wounds with V22, CNA, assisting. V19 opened R18's legs to expose her inner thighs and perineum area which were very bright red and excoriated. V22 turned R18 to her right side exposing her buttocks which showed three open wounds to her back side with the entire buttocks, anal area, gluteal creases all red and excoriated. V19 stated I was not aware of any of these wounds. R18 has been red for quite a while, and we were supposed to be using moisture barrier cream for it because she is a heavy wetter and is always saturated. I will have to call the physician now and get some orders for wound treatment. This looks very painful, and she should be in pain the way it looks. V19 measured R18's wounds which was the right buttock 2 CM (centimeters) X 5 CM X 1.0 CM, the left inner thigh 1.0 CM X 4.3 CM, and the right gluteal fold 0.4 CM X 3.7 CM. On 4/23/25 at 10:55 AM, V22 stated I just did peri-care on (R18), and she was yelling that it hurt every time I would wipe her. She was definitely in pain. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the CNAs to report any resident's change in skin condition to the nurse and I would expect the nurses to perform skin and wound assessments and provide appropriate treatments as ordered by the physician. On 4/23/25 at 11:30 AM, V19 stated I just spoke with the physician and (R18) will be followed up with (Wound Management Specialist) again and he gave me orders to take care of her wounds. On 4/23/25 at 11:35 AM, V19 gathered her supplies for wound care. V19 sprayed 4X4 gauze with wound cleaner and right buttock wound wiped, then Collagen and Calcium Alginate and foam dressing applied. R19 started to have a loose bowel movement so the wound care paused for peri-care. On 4/23/25 at 11:53 AM, V19 continued wound care on R18. Previous dressing was replaced due to feces on it. Wound cleanser sprayed on 4X4, wound wiped, then patted dry. Cavalon wiped on left inner thigh and right gluteal fold wounds, allowed to dry, then V19 wiped barrier cream all over R18's buttock/anal area. The previous dressing on R18's right buttock was falling off, V19 removed the old dressing, recleaned site, applied Collagen and Calcium Alginate and foam dressing again. While R18 was turned to her right, a small thin open slit was noticed on R18's gluteal cleft, V19 made aware and wiped barrier cream on it. R18 rolled back to her back side and covered up. There was no cleaning, or wound care provided to R18's front inner thighs or peri-area. R18's New Physician Order, dated 4/23/25, documents Cleanse bilateral buttocks with NS or WC, apply barrier cream Q shift and PRN. Every shift for incontinence dermatitis/excoriation/ MASD (moisture associated skin dermatitis). R18's New Physician Order, dated 4/23/25, documents Cleanse wound to right buttock NS or WC, apply Collagen, Calcium Alginate, and cover with a foam dressing daily and PRN. Every Day shift for open area to right buttock. R18's New Physician Order, dated 4/23/25, documents Cleanse anterior inner things with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to BIL (bilateral) inner thighs. R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to inner thighs. R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs/gluteal folds with NS or WC, pat dry, and apply Cavilon once weekly and PRN. Every day shift every Wed (Wednesday) for excoriation/MASD to BIL thighs. The Facility's Guide for Wound Evaluation, undated, documents in part Procedure: 1. Upon identification of a pressure ulcer/injury (arterial, venous, or neuropathic), regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation Form or in the electronic format. 2. Non-Ulcers are to be documented weekly on a Skin Condition Form or in electronic format. 3. Contact physician, interdisciplinary team, family members, and significant others as indicated. 4. Initiate appropriate treatment per treatment protocol and physician order. 5. Evaluate further interventions that may be indicated to promote healing and prevent infection. 6. Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form / Skin Condition Form as appropriate. 7. The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. 10. The Director of Nursing Services and/or designated Licensed Nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The Facility's Wound Care Treatment Protocol, dated 11/2012, documents in part Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document / Report findings. Provide treatment as per physician's order.

Based on Interview, Observation, and Record Review, the Facility failed to maintain a resident's privacy and dignity for 4 of 6 residents (R18, R38, R56, R63) reviewed for resident privacy and dignity in the sample of 79. This failure resulted in R18 and R63 feeling embarrassed and uncomfortable. A reasonable person would expect to have privacy in their home and would experience anxiety, humiliation, and embarrassment if their privates were exposed. The Findings Include: 1. R18's Admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment. R18's Minimum Data Set (MDS), dated [DATE], documents R18 has severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder. On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), provided incontinence care on R18. The window blinds were left open with R18 lying in the bed by the door with the curtain between the beds not pulled to obstruct the view from the window. There is a patio where residents can sit outside, as well as cars seen parked in a parking lot outside her window. On 4/23/2025 at 9:57 AM R18 stated that she doesn't really pay attention to the CNAs if they pull the curtain or not. R18 stated that she would not feel comfortable if she was exposed to other people. R18 stated that with the staff she must be ok, but with other people she would be embarrassed and would not like it. On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am providing care to a resident in their room, I make sure the blinds are closed, the curtains are pulled, and the door is shut. 2. R63's Admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Overactive Bladder, Chronic Kidney Disease-stage 4, Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs related to impaired mobility. Diagnosis Cerebrovascular Accident (CVA)/hemiplegia. R63 has shortness of breath (SOB) with exertion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, provide setup assist and encouragement for those task that resident can perform independently, observe for signs/symptoms or complaint of shortness of breath, elevate head of bed as needed/requested, administer oxygen as ordered per MD (Medical Doctor). It continues (1/13/25) R63 is at risk for skin issues related to impaired mobility. Interventions: Staff to provide incontinent care after each incontinent episode, weekly skin assessment, staff to assist with turning and repositioning as tolerated, pressure redistribution mattress to bed. R63's MDS, dated [DATE], documents R63 is cognitively intact and is dependent on staff for toileting. On 4/22/25 at 9:25 AM, V12, CNA, was seen providing incontinence care for R63. The window blinds were left open with R63 lying in the bed by the window. There is a patio where residents can sit outside, as well as cars seen parked in the parking lot outside the window. On 4/22/2025 at 1:20 PM, R63 stated that she did not pay attention to the CNA and if she closed the blinds or not. R63 stated that she would expect them to close the blinds, and she assumed that they do. R63 stated that her window is facing the patio and there are people out there at times. R63 stated at night with the light on, and during the day with the sun, you can see directly in her room. R63 stated that she would not want her privates to be exposed to the outside. R63 stated that this would be a problem for her. R63 stated that it would be embarrassing. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect staff to provide privacy for the resident at all times, including closing the blinds and curtains during care. The Facility's Incontinent Care Policy, dated 1/2015, documents in part Procedure: 6. Provide Privacy. 9. Avoid unnecessary exposure of the resident during the procedure. 42108 3. R38's Care Plan, dated 1/23/2025, documents that R38 has an ADL self-care performance deficit r/t Aggressive Behavior, Confusion, Hemiplegia, Impaired balance, Cerebral Infarction, aphasia. It also documents TOILET USE: (R38) requires a 1 person assist toileting. 04/24/25 12:47 PM entered open room door and observed V17, CNA, assisting R38 with toileting. V17 was in bathroom, door open with R38 in a standing position, pants down exposing R38's buttocks and scrotum to R38's roommate. On 4/24/2025 at 1:00 PM R36 stated that he does not like watching his roommate going to the bathroom and does not want to look at his genitals. On 4/24/2025 at 12:45 PM V45, R38's sister in law, stated that R38 would not like to be exposed to others and would want the door closed when going to the bathroom. 50908 4.R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia. R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder. On 4/23/25 at 10:45 AM, V26, CNA, and V24, CNA, left the blinds to R56's room and curtain open while having his peri-region exposed during peri care. V26 stated he forgot to close the blinds. V24 then went over to the blinds and closed them. The Residents' Rights for People in Long-term Care Facilities brochure, undated, documented that residents have the right to privacy, including medical and personal care.

Based on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) residents reviewed for abuse in the sample of 79. This failure resulted in R36 suffering psychosocial harm and feeling scared, unsafe, unable to protect himself and less of a man. This failure also resulted in R90 suffering harm and being hit in the face, stomach and leg by another resident and R88 having a scratch to upper lip. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], moderately cognitively impaired. On 4/21/2025 at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room. On 4/21/2025 at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation. On 4/22/2025 at 11:30 AM R36's medical record reviewed. No documentation of the resident to resident altercation. The facility's Midnight Census report dated 4/24/2025 at 9:54 AM documents that R38 and R36 remain roommates. On 4/23/2025 at 1:30 PM the facility provided documentation of resident to resident abuse reported to IDPH. On 4/22/2025 at 1:10 PM R36 stated that his roommate is still in the room. R36 stated that his roommate is mean. R36 stated that R38 has been mean and hitting him since moving to the room. R36 stated that he is scared and does not feel safe in the room. R36 stated that he feels that he can't protect himself. R36 stated that he feels less of a man because he can't really defend himself. R36 stated that he has notified V31, Social Services Director (SSD), about he and his roommate not getting along and feeling scared. On 4/22/2025 at 1:14 PM V4, Registered Nurse (RN), stated that she was not aware of a resident to resident altercation that occurred between R36 and R38. V4 stated that R38 does have aggressive and combative behaviors. V4 stated that R38 is usually the aggressor. V4 stated that R36 is quiet and doesn't bother anyone. V4 stated that R36 has not had any behaviors of aggression towards staff and or resident. On 4/23/2025 at 11:45 AM V4, RN, stated that she notified V2, DON, of the resident to resident altercation that was reported to her yesterday. On 4/23/2025 at approximately at 12:30 PM V1, Administrator, stated that she was not aware of a resident to resident altercation that occurred between R36 and R38 until today. V1 stated that when the state surveyor reported it; V1 that is the time it was reported to the state. V1 stated that she was not notified by the staff that were present. V1 stated that V29 is not a CNA. V1 stated that V29 is a safety aide and here to help monitor the residents to keep them safe. V1 stated that V29 did not report the abuse. On 4/28/2025 at 11:00 AM V4 stated that R36 is alert and oriented and able to voice needs. V4 stated that he can answer questions appropriately. R38's Care Plan, dated 12/30/2024, documents that R38 BEHAVIOR: (R38) has a hx (history) of physical aggression towards peers. i.e. (for example) on 12/1/24 (R38) grabbed another resident's arm causing him to bleed. 50908 2. R88's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, osteoarthritis, degenerative disease of nervous system, and psychosis not due to a substance or known physiological condition. R88's MDS, dated [DATE], documented he is severely cognitively impaired. R88's Care Plan does not include him to be at risk for abuse. R90's face sheeting documented he was admitted on [DATE] with diagnosis of, in part, osteoarthritis, dementia with moderate agitation, and psychosis. R90's MDS, dated [DATE], documented he is severely cognitively impaired. R90's Care Plan dated 12/12/24 documented he is at risk for abuse and/or neglect related to impaired cognitive skills, diagnosis of Alzheimer's and Dementia. The facility's Initial Event Reporting dated 2/7/25, documented, Please find this as the initial reporting related to an allegation of a resident to resident physical altercation. R90 and R88, two cognitively impaired male residents of the facility locked dementia care unit, were reported to have had an altercation resulting in a small scratch to R88's upper lip. Staff intervened to ensure safety with assessments and notifications completed. R90 was transferred for evaluation related to his behaviors and remains at the ER (emergency room ) at this time. The facility's final report regarding the allegation of resident-resident physical altercation occurring on 2/7/25 documented, On 2/7/25 at approx. (approximately) 1830 (6:30 PM), memory unit staff heard a commotion from the room of R88. Staff responded to the room urgently. As they were approaching R88 was exiting his room reporting R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 hit him three time(sic). R88 reports that R90 hit his face, stomach, and leg. Staff separated resident's immediately. The facility's interview statement with V42, CNA, dated 2/8/25 documented, R88 was wandering said looking for his wife last I saw by shower room. We heard some yelling, rushed to them. R90 said he hit him. We got R88 away and watched him until he went out. He thought they were sleeping with his wife or something. V42 documented that R90 was last seen wandering. The facility's interview statement with V43, LPN, dated 2/8/25, documented, R90 was wandering looking for his wife. When we heard the commotion and got to the room they were just yelling. R88 said R90 hit him. We got them away, did assessments and notified and sent R90 out. R88 was okay. He said he thinks he was looking for his wife and he didn't have her. V43 documented R88 was last seen wondering. The facility's interview statement with R90 dated 2/8/25, documented he had no recollection of the event.

Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from ,d+[DATE] through ,d+[DATE] and subsequently becoming unresponsive on [DATE] at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, and intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to: 1. assess, monitor, and provide timely treatment for a change in R3's condition. 2. Notify the physician of R3's decline in ADLs from ,d+[DATE] through ,d+[DATE] and being unresponsive on [DATE] at 9:00 AM. 3. Obtain medical treatment for R3's change of condition from 9:00 AM to 4:00 PM at the time of ambulance transfer with R3 experiencing cardiac arrest with Cardiac Pulmonary Resuscitation performed, intubation and hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. V2, Director of Nursing, and V3, Regional Clinical Consultant, were notified of the Immediate Jeopardy on [DATE] at 1:17 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on [DATE], but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings include: R3's Care Plan, dated [DATE], documents Advance Directives: R3 is a full code and requests life sustaining measures. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL). R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated [DATE], documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment. R3's Progress Notes, dated [DATE] at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4) for the following: Send resident to ER (emergency room ) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with (local ambulance company). R3's Progress Notes, dated [DATE] at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status. R3's Progress Note, dated [DATE] at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637. R3's Progress Note, dated [DATE] at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics writer will continue to follow up. R3's Progress Note, dated [DATE] at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23. R3's Therapy Communication Form, documents [DATE] report of change of status to NP, blood work ordered [DATE] change diet to puree, [DATE] educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient. R3's Local Fire Department Patient Care Records, dated [DATE], documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated. R3's Local Hospital History and Physical, dated [DATE], documents that This [AGE] year [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. ,d+[DATE] Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: ,d+[DATE] 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: ,d+[DATE] Intubation: A time-out was completed verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated [DATE], documents diagnosis: Cardiac Arrest and Severe Septic Shock. On [DATE] the facility provided a 5 ways Root Cause Analysis Template, dated [DATE], that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse. On [DATE] at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room . V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything. On [DATE] at 1:50 PM V7, Certified Nurse's Assistant, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started [DATE] and this is when he started notifying the nurses and the Director of Nursing. On [DATE] at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift. On [DATE] at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day. On [DATE] at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM. V6 stated that she received shift report and was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes, if not call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911. On [DATE] at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out. On [DATE] at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual. On [DATE] at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increase incontinence. V15 stated that the nurse was notified. On [DATE] at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different. On [DATE] at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and there was no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and no to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and raise the head of the bed. V9 stated that at about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now. On [DATE] at 10:46 AM V10, CNA, stated that she took care of R3 on [DATE]. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know. On [DATE] at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided. On [DATE] at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy, and she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but did not actually see R3 prior to this event. On [DATE] at 1:35 PM V4, Nurse Practitioner, stated that on [DATE] at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send to R3 to the ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before. On [DATE] at approximately 11:15 AM V5 stated that he was notified of R3's change of conditions prior to R3 being unresponsive and thought it was behavioral. V5 stated that R3 would refuse care and have behaviors in dining room. On [DATE] at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub, attempts to arouse R3 had failed; he would have considered that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allowing staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room . V21 stated that he would expect to be notified of the changes of condition prior to the unresponsive episode with assessment including vitals. On [DATE] at approximately 11:30 AM V2 stated that they had a QA meeting on [DATE] concerning the change of condition to try to find out what was the cause of the delay in treatment. V2 stated this was transcribed to the 5 ways Root Cause Analysis Template. V2 stated that their findings were transcribed to the form. V2 stated that the Facility failed to Assess, monitor, and provide timely treatment, Nurse failed to follow up, assess resident and call MD, Nurse thought this was resident behavior and Poor assessment skills by nurse was the root cause of the delay in treatment. On [DATE] at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them. The facility's Notification of a Change in a Status Change in Condition policy, dated ,d+[DATE], documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party. The facility presented an Abatement plan to remove the immediacy on [DATE]. The survey team reviewed the Abatement plan and was unable to accept the plan to remove the immediacy. The Abatement plan was returned to the facility on [DATE] and [DATE] for revisions. The facility presented a revised Abatement plan on [DATE] and the survey team accepted the Abatement plan on [DATE]. On [DATE], during the validation of the abatement plan by the survey team, it was noted that several staff members had not been in serviced prior to working their shift, and vital sign equipment was not operational at the time of observation. On [DATE], at 11:30 AM, V1, V2, and V3 were notified the abatement was not validated as multiple staff persons working had not received the in-service prior to their shift and vital sign equipment was not functioning. All staff who had not previously received in serviced were completed and vital sign equipment was in working order by end of day on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. Emergency QA held [DATE] at 2:45pm with interdisciplinary team which consisted of the Medical Director, [NAME] President/Governing body (V51), Executive Director (V1), Director of Nursing Services (V2), Regional Nurse (V3), Memory Care Manager (V52), Wound Care Nurse ( V35), and Social Service Director (V53), to establish a system that addresses any resident in distress and or unresponsive will be treated timely and without delay. Charge nurse will notify the MD (The resident MD), DNS (V2) and or Administrator (V1) to ensure immediate action is taken to ensure the health and wellbeing of the resident. A Root Cause analysis completed on [DATE] related to staff failure to immediately notify and transfer resident to hospital when change in condition arose. Due to the fact of this occurrence, there was also a failure to report R3's non-responsiveness status and seriousness of R3's current status to the oncoming shift. This will be addressed to ensure compliance. The DNS (V2) and or Designee performed Inservice to Licensed Nurses to ensure that shift to shift report is done. This was performed on [DATE]. 2. Facility immediately suspended on [DATE] V5 (LPN) and V9 Speech Therapist, for not responding or making any effort to assist R3 when unresponsive. This suspension will be on-going until a complete investigation of all actions taken by V5 LPN and V9 Speech Therapist on [DATE] is thoroughly investigated by the Administrator, V1. 3. DNS (V2) and Regional Clinical Operations Nurse (V3) will immediately begin in-servicing All Staff in person or by phone. This in-service to include notification of any change in condition to charge nurse and Director of Nursing. Then licensed nurses will notify physician immediately. If resident is unresponsive or acute distress to call 911 immediately and notify physician, DNS (V2) and or Administrator (V1) and resident's responsible party. This in-service completed [DATE] by 11pm. Staff will not be allowed to work unit until in-service completed. 4. DNS (V2) and or designee will do 100% visual assessment to ensure all current residents are in stable condition and not in acute distress. Completed [DATE] at 3:30pm. 5. DNS (V2) and or designee will do 100% audit of vital sign equipment (Blood pressure cuff, pulse oximetry, and thermometer) to ensure each unit has a working vital sign equipment readily available. These will be accounted for daily and stored in the med cart. Monitoring: -DNS (V2) and Unit Managers (V2, Memory Care, V27 LPN - SDC, V37 LPN - MDS, V36 LPN - Restorative and V35 LPN- Wound Care) will visually monitor every resident daily to ensure residents are not in distress and in stable condition. -DNS and Unit Managers will monitor daily that each unit has vital sign equipment, and it is in working condition. -Policy (Change in Condition) regarding this IJ related to F684 was reviewed at the Emergency QA meeting on [DATE] at 3:30pm. There was no change in the Policy. There were system changes related to assessing, monitoring, and providing timely treatment for R3's change in condition. The discussion will continue to occur monthly, and any trends and concerns will be address immediately to ensure compliance.

Based on interview and record review, the facility neglected to provide necessary medical services including assessing a change in resident's condition and recognizing when a resident needs emergent medical intervention. This failure resulted in the medical neglect of R3, who did not receive needed emergency medical treatment in a timely manner despite, over the course of five and a half hours, R3 exhibiting a significant decline in condition and subsequently becoming unresponsive on [DATE] at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. Findings include: R3's Care Plan, dated [DATE], documents Advance Directives: R3 is a full code and requests life sustaining measures. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL). R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated [DATE], documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment. R3's Progress Notes, dated [DATE] at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4 Nurse Practitioner) for the following: Send resident to ER (emergency room ) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with the ambulance company. R3's Progress Notes, dated [DATE] at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708 EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status. R3's Progress Note, dated [DATE] at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637. R3's Progress Note, dated [DATE] at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics writer will continue to follow up. R3's Progress Note, dated [DATE] at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23. R3's Therapy Communication Form, documents [DATE] report of change of status to NP, blood work ordered [DATE] change diet to puree, [DATE] educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient. R3's Local Fire Department Patient Care Records, dated [DATE], documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated. R3's Local Hospital History and Physical, dated [DATE], documents that This 63 yrs (years) old [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. ,d+[DATE] Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: ,d+[DATE] 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: ,d+[DATE] Intubation: A time-out was completed verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated [DATE], documents diagnosis: Cardiac Arrest and Severe Septic Shock On [DATE] the facility provided a 5 ways Root Cause Analysis Template, dated [DATE], that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse. On [DATE] at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room . V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything. On [DATE] at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went, he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started [DATE] and this is when he started notifying the nurses and the Director of Nursing. On [DATE] at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift. On [DATE] at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day. On [DATE] at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM. V6 stated that she received shift report, was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes and if not, call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911. On [DATE] at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out. She (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out. On [DATE] at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but V17 did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual. On [DATE] at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increased incontinence. V15 stated that the nurse was notified. On [DATE] at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different. On [DATE] at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and there was no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and not to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and to raise the head of the bed. V9 stated that about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now. On [DATE] at 10:46 AM V10, CNA, stated that she took care of R3 on [DATE]. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know. On [DATE] at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided. On [DATE] at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy, she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but had not actually seen R3 prior to this event. On [DATE] at 1:35 PM V4, Nurse Practitioner, stated that on [DATE] at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send to ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before. On [DATE] at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub andd attempts to arouse R3 had failed. He would have consideresd that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allowing staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room . V21 stated that he would expect to be notified of the changes of condition prior to and the unresponsive episode with assessment including vitals. On [DATE] at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them. The facility's Notification of a Change in a Status Change in Condition policy, dated ,d+[DATE], documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party. The facility's Abuse Prevention Policy, revised [DATE], documented Neglect: A failure of the facility, its employees, or service providers to price goods and services necessary to avoid physical harm, mental anguish, emotional distress or pain.

Based on interview and record review the facility failed to notify the physician of R3's change in condition and unresponsive episode for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from ,d+[DATE] through ,d+[DATE] and subsequently becoming unresponsive on [DATE] at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. Findings include: R3's Care Plan, dated [DATE], documents Advance Directives: R3 is a full code and requests life sustaining measures. R3's Minimum Data Set, dated dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL). R3's POLST (Physician Orders for Life-Sustaining Treatment), dated [DATE], documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment. R3's Progress Notes, dated [DATE] at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4, Nurse Practitioner) for the following: Send resident to ER (emergency room ) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with ambulance company. R3's Progress Notes, dated [DATE] at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status. R3's Progress Note, dated [DATE] at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637. R3's Progress Note, dated [DATE] at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics, staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived, resident was still breathing and had a pulse, but it was faint and light, paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher, writer sent resident out to hospital, resident currently being transported to hospital by paramedic,s writer will continue to follow up. R3's Progress Note, dated [DATE] at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23. R3's Therapy Communication Form, documents [DATE] report of change of status to NP, blood work ordered [DATE], change diet to puree, [DATE] educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient. R3's Local Fire Department Patient Care Records, dated [DATE], documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated. R3's Local Hospital History and Physical, dated [DATE], documents that this [AGE] year [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. ,d+[DATE] Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per EMS patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: ,d+[DATE] 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: ,d+[DATE] Intubation: A time-out was completed verifying correct patient, procedure, site, positioning and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated [DATE], documents diagnosis: Cardiac Arrest and Severe Septic Shock On [DATE] the facility provided a 5 ways Root Cause Analysis Template, dated [DATE], that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse. On [DATE] at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room . V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything. On [DATE] at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started [DATE] and this is when he started notifying the nurses and the Director of Nursing. On [DATE] at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift. On [DATE] at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day. On [DATE] at 8:30 AM V6, LPN, stated that she was running late and got there after 2:00 PM. V6 stated that she received shift report and was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes if not call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911. On [DATE] at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out. On [DATE] at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but did not a look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual. On [DATE] at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increase incontinence. V15 stated that the nurse was notified. On [DATE] at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different. On [DATE] at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and not to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and to raise the head of the bed. V9 stated that at about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now. On [DATE] at 10:46 AM V10, CNA, stated that she took care of R3 on [DATE]. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know. On [DATE] at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided. On [DATE] at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but did not actually see R3 prior to this event. On [DATE] at 1:35 PM V4, Nurse Practitioner, stated that on [DATE] at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send R3 to ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before. On [DATE] at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub and attempts to arouse R3 had failed he would consider that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allow staff to care for her for days. V21 stated that these are red flags and would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room . V21 stated that he would expect to be notified of the changes of condition prior to the unresponsive episode with assessment including vitals. On [DATE] at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them. The facility's Notification of a Change in a Status Change in Condition policy, dated ,d+[DATE], documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party.

Based on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 8 residents (R3 and R4) reviewed for abuse in a sample of 22. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so. Findings include: R3's Face Sheet, print date of 10/02/23, documents R3 has diagnoses of cognitive communication deficit, altered mental status, and dementia. R3's Minimum Data Status (MDS), dated [DATE], documents R3 is moderately cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. R3's MDS documents R3 requires extensive assistance of two plus person physical assist with bed mobility, transfer, and toilet use. R4's Face sheet, with a print date of 10/02/23, documents R4 has diagnoses of personal history (Hx.) of traumatic brain injury, and Major depressive disorder. R4's MDS dated [DATE], documents R4 is moderately cognitively impaired with a BIMS of 08 out of 15. On 10/03/23 at 1:10 PM, V12, Housekeeping stated she was the one who found R3 and R4 in R4's room. She said the door was open but the curtain in the room was pulled so you couldn't see who was in the room until you entered. She said she knocked on the door and there was no response, so she entered the room. V12 stated when she went around the curtain, she observed R3 and R4 both had their genitals out and R4 performing oral sex on R3 while masturbating at the same time. V12 stated she asked them what they were doing and then she went directly to the nurse's station and informed the nurse what was happening in the room. V12 stated the nurse and CNA (Certified Nurse's Aide) went directly down to R4's room and removed R3 from R4's room. She said R3 was taken off the hallway for a couple of weeks and when they brought him back, he went into a room with his wife. V12 stated R4 doesn't know what is going on all the time. The Illinois Department of Public Health Final investigation report completed on 9/15/2023, documents At approximately 1340 (1:40PM) on 9/10/2023 the north unit housekeeper knocked on the door to (R4's room). When no response was heard, the housekeeper proceeded to enter the room to complete her daily tasks. Upon entering the room (R3) (R3's room identified) was noted in the room of (R4) where the two were observed to be engaged in sexual activity towards one-another. Both residents were observed with their pants undone and sex organs exposed. (R4) was reportedly leaning forward into (R3's) lap attempting to perform oral sex. Upon observing the situation, the unit nurse was notified, and the residents were separated immediately followed by the completion of full body assessments on both residents with no issues noted. The facility Administrator, Director of Nursing Services, facility MD/Medical Director, and the POAs (Power of Attorneys) for both residents were notified of the occurrence. No concerns were voiced during notifications and agreement with the residents plans of care were expressed. (R3) was placed on 15 min (minute) checks and temporarily re-located to the TCU (Transitional Care Unit) unit in an attempt to ensure closer observation and discourage him from re-entering the room of (R4). A care plan meeting was set with (V13, R4's mother/POA) for 9/14/23 per her earliest convenience. Interviews and investigation were initiated per protocol and an initial report was forwarded to IDPH due to the low BIMS scores for both residents involved. Initial interviews with both residents were completed within 30 min of the event. At the time of the initial interviews, (R3) denied any sexual activity and reported he was in (R4's) room to assist him with his TV (television). (R4) reported no recollection of the event. The facility administrator along with the SSD (social service director) and DNS (director of nursing services) completed follow-up interviews with both residents on Monday 9/11/2023. During the follow-up interviews, (R4) continued to report no memory of the occurrence. (R3), reported that he is 'not gay or bi-sexual' but that he did allow (R4) to unzip his pants and allowed him access to his body. Continued SSD support and follow-up x72 hours remained in place for residents and no long-term negative psych-social issues were observed. The facility SSD completed interviews with multiple staff and residents to determine if there were any past observations of inappropriate sexual behavior with all responses indicating no concern. On 10/03/23 at 12:20 PM, R4 was questioned about the incident that happened between himself and R3 and he stated he doesn't remember any incident between himself and R3. On 10/03/23 at 12:50 PM, R3 was questioned about the incident that occurred between himself and R4. He stated something should be done about R4, he just likes to go up and grab people. He said R4 took his phone so he could call his mom and he was just chasing him down to get his phone back from him. He stated nothing inappropriate happened between R4 and himself. He said he didn't do anything to R4 and R4 didn't do anything to him. On 10/12/23, at 10:09 AM, V13, R4's mother, stated this is very much out of character for R4. She said he would touch female's arms and she would have to remind R4 that he couldn't do that stuff. V13 stated she doesn't feel like R4 is capable of making decisions regarding sexual activity, she said he can barely walk let alone do anything else. She said he likes women and generally doesn't get along with men. She said it was totally shocking that this all happened. She said based on his past he would be more likely to be with a female than a male. On 10/17/23 at 1:10 PM, V30, Medical Doctor when questioned by this surveyor if R3 and R4 who both are moderately cognitively impaired were able to make decisions when it comes to sexual activity and V30 stated no, they don't. He stated if they are impaired, they can't make a rightful decision. This surveyor repeated the question a second time and V30 stated if you are telling me they are cognitively impaired then they can't make a rightful decision. The facility had no documented assessment regarding R3 and R4 decisional capacity to engage in sexual encounters. The facility's abuse prevention policy, not dated, documents Policy: The facility is committed to protecting the residents form abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. It further documents c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. It also documents Protection: 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.

A. Based on interview and record review the Facility failed to provide supervision to prevent elopement for 1 of 1 resident (R65) from eloping in the sample of 51. This failure resulted in R65 being transferred to local hospital and treated for abrasions. B. Based on interview, and record review, the facility failed to implement safe transfer techniques and implement progressive interventions to prevent falls and accidents for 4 of 4 residents (R59, R47, R62) reviewed for supervision to prevent accidents in the sample of 51. Findings include: A. R65's Face Sheet documents R65 was admitted to the facility 7/3/2021 with diagnoses of Dementia, Schizophrenia, Hyperlipidemia, and Major Depressive Disorder. R65's Risk of Elopement Evaluation, dated 12/19/2022, documented R65 is alert and oriented has a history of leaving, increased risk, ambulates independently. R65's Care Plan dated 7/3/2021 documents (R65) has a history of wandering and attempts to leave related to behavioral issues. The Care Plan documents she requires monitoring for safety. Interventions include Frequent monitoring for safety. R65's Nurse's Notes dated 1/13/2023 at 8:36 PM document Resident was last seen in her room at about 4:05 PM, during the evening med pass. Once I made it halfway up the hall, I was approached by a CNA (Certified Nurse's Aide) who was taking a smoke break when she realized that the residents window shade had been kicked out and the resident was missing. Every staff member in the facility was notified and we began the search. DON (Director of Nursing), Admin (Administrator), family and doctor were notified, and patient was found in less than 5 min (minutes) a block over hiding behind a bush near the (local business). Res was aroused and aggressive with staff once she made it into the building and also refused body assessment and vitals. EMS (Emergency Medical Service) was called and when they arrived she allowed them to talk with her and take her vitals. Res is currently at (local hospital) in the behavior department. R65's local hospital emergency department, ED, records, dated 1/13/2023 document R65 presented from the facility to ED complaining that R65 asked staff to open window and they would not. The ED Record documented R65 proceeded to kick out the window and was found walking down the street. The ED Record documented R65 being sent in for psych evaluation. The ED History and Physical documents R65 requested the window open but staff refused. The ED Record documented R65 kicked out window and was found wandering outside the nursing home. ED Record documented exam revealed R65 has an abrasion of 0.75cm on tip of the nose. No fractures to nose or facial bones. R65's discharge instructions document diagnosis of abrasion to nose. R65's Nurse's Note, dated 1/17/23 at 10:06 AM, documented R65 had a Brief Interview of Mental Status (BIMS) score of 13 indicating she was cognitively intact. R65's Nurse's Notes Addendum dated 1/18/2023 at 10:31AM documented a Note Clarification for 1/13/2023 5:50PM. The Note documented CNA came to this nurse to inform me that the window in one of the rooms looked to be kicked out. When she came in to check the room, the window was opened, and the resident assigned to the room was not present. I immediately went to look and (R65) was not in her room. This resident does not come out of room. I alerted all staff per facility policy by calling a Dr. Wander for elopement. Staff began searching the facility. I then notified ED (Executive Director) /DNS (Director of Nursing Service), Nurse Manager, and Hospice. The Note continued 6:01 PM, (R65) was located and returned to the facility by staff. Staff reported that they retrieved her from the business complex about 1 block from the facility. She was in front of the (local business) going behind the shrubbery. It seemed like she was attempting to hide. As (R65) was brought into the facility she was irate and yelling out. When I attempted to ask her why she left, she stated 'I', hungry. I want some real food and I'm not eating that s***.' She then requested heat because she was cold. I attempted to perform a skin and pain evaluation on her, but she refused. She was wearing a long-sleeved fleece sweater, long pants, socks, and rubber soled shoes. She also had a blanket wrapped around her shoulder. The temperature was 28 degrees, she was not appropriately dressed for the weather. On 5/4/2023 at 3:45PM V1, Administrator stated R65 rarely comes out of her room. V1 stated R65 wants to be by herself. V1 stated she is in that room because she wants to be by herself and can't get along with any other roommates. V1 stated She is very picky about food, but never comes out of her room. Activities cannot get her out, nobody can. That's the only private room in the facility. The door next to it is an alarm door. (R65) knew what she was doing, she put on all these clothes. She didn't go out the door, she got dressed and put on the clothes and kicked out the window. V1 stated POA (Power of Attorney) declined R65 going to another facility. V1 stated R65 is not cognitively impaired. R65 very full well knew what she was doing, and she is here because she is schizophrenic. V1 stated R65's safety awareness is poor because she has a mental health condition. V1 stated it was a screen R65 kicked out to get out of window and all windows slide open. On 5/4/23 at 3:31 PM, V2, Director of Nursing, DON, stated on [DATE], it was about 5-6PM, I got a phone call that said they couldn't find (R65). When I interviewed the staff, I was told (V31, Certified Nursing Assistant, CNA), went outside the North (100 hall) door to smoke and noticed there was some damage on the window. I was notified by (V32, Unit Manager), at the time. (V32) said they couldn't find her. (V31) came in to look at the room with the window damage. (V31) realized (R65) was not in the room and informed (R65's) nurse. (V13, Licensed Practical Nurse/LPN) did a 100% head count. We counted all the residents which took about 5 minutes max. I live about 30 minutes away, before I even made it more than a few minutes, they had already retrieved (R65). The reason we know how long it took is because (R43) was on the front porch. (R43) said he saw someone walking. She walked right by. It wasn't totally dark, but it was getting dark. V2 stated when the staff asked R43 if he had seen anyone, he pointed in the direction he thought R65 was going. V2 stated One of the nurses, (V33, LPN), and (V21, CNA), got in the car and drove in that direction. When they got over that way, they saw a small figure going behind a shrub at a business complex. (V21) got out and it was (R65). V2 stated R65 yelled a bit; they got R65 in the car and brought her back. V2 stated R65 had on terrycloth slippers with rubber soles, sweatpants, fleece, and blanket. V2 stated when they got R65 back, she yelled and screamed. R65 said she didn't want the food in the dining room and was going to look for food. R65 didn't go back to her room; we immediately sent her out just to be evaluated. V2 stated R65 had a tiny 0.5-centimeter (cm) abrasion on her nose, and they took her out to the hospital. V2 stated R65 was in room on the dementia unit. V2 stated R65 stood on her bed and kicked the screen out. V2 stated R65 was on the memory unit and was moved off for behaviors but didn't get along with anybody and was still high functioning at that time. V2 stated When I moved her off the hall (memory unit), I put her on the short hall, but she had a roommate, and they didn't get along. Another roommate on north hall, didn't get along. So, I had to get her a private room. V2 stated R65's safety awareness is poor because she has diagnosis of dementia and is also schizophrenic. On 5/3/2023 at 2:00PM V12, LPN, stated (R65) didn't want to be here. She would say we couldn't make her be here. V12 stated R65 spoke this prior to the 1/2023 elopement. On 5/3/2023 at 4:00 PM V13, LPN, stated I was working the day (R65) left the facility. I was passing meds and saw her in her room around 4pm. At closer to 5:00PM (V31, CNA) was out smoking and came in saying that (R65's) window was out. I ran to (R65's) room and saw she was gone. I alerted everyone in the building and called 911. I was running all over searching inside and outside. We found her in about 10 minutes. When (R65) came back, I saw she had an abrasion on her nose. She wouldn't let me touch her. She let EMS take her and I heard her say to EMS she wanted out of here. (R65) has a lot of behaviors. She cusses, kicks, and yells. She is in the same room she was in before. On 5/5/2023 at 8:54 AM V24, Nurse Practitioner (NP) stated she was aware R65 eloped from the facility in January 2023. V24 stated R65 has multiple psychiatric diagnoses including schizophrenia and should not have been outside the facility by herself. V24 stated R65 does not have safety awareness, that is why she is in a nursing home, so they provide oversight. V24 stated R65 didn't have exit seeking behavior but exhibited agitated and aggressive behavior but not exit seeking. V24 expects the facility to provide protective oversight and keep all residents safe, she also expects staff to follow the facility's policies and procedures. Facility elopement policy updated 5/2022 documents The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc. The staff in these programs will be responsible for the locations of their participants. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the Charge Nurse as soon as practical. B. R59's Face Sheet documents an admitted [DATE], with diagnoses of Hemiplegia following cardiac infarction affecting left nondominant side, Seizures, Unspecified Pain, and Major Depressive Disorder. R59's Incident Report, dated 1/2/2023 at 3:10PM documents R59 was in the process of being transferred by 3 staff members with the mechanical lift when one of the straps broke from the mechanical lift pad causing her to fall back into her chair and she then slid to the floor. R59 had no injuries during fall and did not hit her head on the way down. Facility's weight log documents on 1/9/2023 R59's weight was 364.2 pounds. R59's Minimum Data Set, MDS, dated [DATE] documents R59 has no cognitive deficits and is totally dependent on staff for transfers. R59's Care Plan with a signature date of 1/2/2023 documents R59 is at risk for falls related to needs mechanical lift assistance for transfers, is incontinent, seizures, slide when up in wheelchair at times, Cerebral Vascular Accident with hemiplegia affecting left non dominant side and receives psychoactive drugs. Diagnosis of hypertension and is being treated for this. Interventions include dycem in seat of wheelchair, use of reclining high back wheelchair when up, assist as needed to adjust body position when up, administer medications as ordered, keep call light in reach, assist of 2 to 3 staff with mechanical lift transfers. Skin/pain assessments, passive range of motion after issue, reevaluated weight capacity of mechanical lift, new slings ordered/received, increase staff presence during transfers. R59's Nurse's Note, dated 1/2/2023 document R59 was being transferred by 3 CNAs when the mechanical lift pad strap broke while R59 was in the air hovering over her wheelchair. R59 then slid to the floor. The Note documented a full body assessment was completed and R59 did not complain of any pain or had any injuries. The Note documented R59 was then rolled back on to a mechanical pad where she was lowered to her bed and performed a safe transfer. On 5/5/2023 at 9:00 AM V2, DON, stated, The CNAs were getting (R59) up in mechanical lift and one of the straps on the lift pad broke. (R59) landed on the bed or chair. She had no complaints of pain. I ordered more lift pads that are weight appropriate. My understanding is that the lift pad loops were frayed, but the pad was the appropriate weight. Laundry staff is now assessing the pads and loops. The pad that tore with (R59) on it shouldn't have been in circulation. 5/3/2023 at 4:00PM V13, Licensed Practical Nurse, LPN, stated I was working the day (R59) fell from the mechanical lift on 1/2/2023. I was working on the hall and 2 or 3 CNAs were putting (R59) in bed using the mechanical lift. (V12, LPN) came out of (R59's) room and said one of the lift's straps had snapped. (R59) must've been too heavy. (R59) was laying down and myself, (V12), and 3 CNAs transferred (R59) up in a new mechanical lift pad. (R59) had no complaints. The pad we were using was the biggest pad we have. The staff assisting to get her up were V12, V19, CNAs, and V16, CNA. 05/04/23 09:45 AM V16 stated I was in the room with 2 other staff, and we were transferring (R59) from the chair to the bed. During midair one of the strap's loops just broke. There are 4 straps and one of the loops just snapped. (R59)'s head hit another CNA, and then went to the floor gradually. We got other people to assist to get (R59) up off the floor. The nurse assessed (R59) and she didn't have any complaints. We have 2 mechanical lifts. One is a 450# max weight, and the other lift is 600# max. The lift pad we use for (R59) is larger and darker blue. We always use 3 people for transfer (R59). After this incident with (R59) we had a facility wide in-service on transfers. There is now a sheet in housekeeping that they have checked the straps. The pads are washed daily, so housekeeping checks the straps. 05/04/23 10:44 AM V19, CNA, stated I have worked here 3 years. In January I was in (R59)'s room with (V12), (V16) and (V21). (R59) was in her chair and we were putting her in her bed. We had (R59) hooked up to the mechanical lift and when she went up, one of the straps snapped. I stuck my leg out and she landed on my leg. (R59)'s head landed on my leg. We let her lay for a second and got her vitals. We got another lift pad under her. We got her in bed. She wasn't hurt at all. (R59)'s lift pads have numbers on them. They get washed every day. I check the loops. The loops looked warn and frayed, but they looked like they could hold her. We use mechanical lift (Brand name of Full Body Mechanical Lift.) 05/04/23 12:30 PM V25, Laundry, housekeeping, stated We wash the mechanical lift pads every time they are sent to us. I have a chart and inspect the pads monthly. I did not begin inspecting the lift pads until February. Facility policy dated 8/2016 documents The (Brand Name Full Body Mechanical Lift) is to be used for total lifts to obtain a resident's weight from bed to chair, chair to bed, or from the floor (maximum lifting per manufacture's guideline). (Brand Name Full Body Mechanical Lift) capacity is less than 450#. (Brand Name Full Body Mechanical Lift) weight capacity is less than 600#. 43794 R47's Physician Order Sheet (POS) dated 09/10/21 documents weakness, Unsteadiness on feet, other abnormalities of gait and mobility, Alzheimer's disease with early onset. R47's MDS dated [DATE], documents R47 has severely impaired cognition. The MDS also documents that R47 requires extensive assistance of two plus persons for locomotion on unit and locomotion off unit. The MDS documents R47 is not steady, only able to stabilize with staff assistance. R47's Care Plan dated 07/27/22 documents (R47) is at risk for falls related to impaired thought processes. Diagnosis of epilepsy, unspecified dementia without disturbance, Alzheimer's disease, and CVA with left sided weakness, needs assistance with transfer, is impulsive, and is incontinent of bowels and bladder. The Care Plan documents R47 had falls on 11/21/21, 11/29/21, 10/11/22, 10/17/22, 12/09/22, and 01/09/23. R47's Care Plan Interventions dated: 11/21/21 documents bolster mattress to his bed. R47's Care Plan Intervention dated 11/29/21 documents Give frequent reminders to call for assistance with transfers. R47's Care Plan Intervention dated 10/11/22 documents remind to call assist with ADLs, transfers, mobility, toilet before each meal. R47's Care Plan Intervention dated 10/17/22 documents for therapy eval for transfer/gait imbalance. R47's Care Plan Intervention dated 12/09/22 documents to educate R47 on follow up importance of notifying for staff to assist him to bed. Refer to skilled therapy for balance and transfer. R47's Care Plan intervention dated 01/09/23 documents skilled therapy to evaluate for trunk strengthening/balance, abdominal assessment: urinary retention foley inserted. R47's Fall Investigation dated 10/11/22 documents Resident had come back from the dining room before supper and attempted to put himself on the toilet in the North Hall shower room. I was at the nurses' station when I suddenly heard yelling coming from the shower room. When I approached the shower room resident was laying on his side. Resident stated he did not hit his head during the fall, explained to be that he was not hurt when asked and showed no sign of pain during ROM and no signs of physical injuries. Reminded to seek assist with ADLs toileting, and transfers. Toilet before meals. R47's Nursing Note dated 10/12/22 at 8:59 PM documents Late entry 10/11/22 resident attempted to put himself on toilet in the shower room without help during supper time. Res (Resident) was found on the floor in the shower room on the floor laying on his side. When asked did he hurt anything or hit his head resident stated no. There were no physical injuries during head-to-toe assessment. No pain during ROM (range of motion). Resident was warned to not transfer himself to the toilet without staff assistance. Will continue to monitor. R47's Nursing Note dated 10/17/22 at 1:33 PM documents resident was in the shower and was holding rail and CNA (Certified Nursing Assistant) was trying to have resident sit in shower chair and resident wouldn't let the handle go and was going to the ground and the CNA lowered him to the floor res has no injuries noted or c/o (complaint of ) pain noted at the time POA (Power of Attorney) notified and don (Director of Nursing) and NP (Nurse Practitioner) here and made aware. R47's fall investigation dated 10/17/22 documents resident was in the shower and CNA was having resident stand up to get into the shower chair and was holding the rail to stand up and when the CNA got him to stand up, he wouldn't stay standing so the 2 CNAs lowered to the floor. Therapy to eval for transfers and gait imbalance. R47's Nursing Note dated 12/09/22 at 8:02 PM documents Resident tried to transfer himself from his wheelchair to his bed and fell on the floor. The Note documented Resident stated he hit his head. Neuro checks in place. Brother (V34) called no answer message left. PCP (Primary Care Physician) aware. DON notified. R47's fall investigation dated 12/09/23 documents Resident tried to transfer himself from his wheelchair to his bed and fell on the floor. Resident stated he hit his head. No injuries noted. Resident educated on the importance of waiting for staff to assist him to bed, refer to skilled therapy for balance and transfers. R47's Nursing Note dated 01/09/23 at 2:03 PM documents T (temperature) 98 P (pulse) 96 R (respirations) 20 B/P (blood pressure) 156/90 at approx. 11 AM writer was called into room [ROOM NUMBER] by CNA staff. Writer entered room and found resident on floor besides his bed. Resident had cut above his right eye. Resident had c/o pain to his stomach. Resident stated that he was attempting to pull himself up with side rails and fell OOB. Resident was placed on neuro-checks that were WNL (within normal limits). Writer notified on call nursing supervisor and facility NP. Writer notified resident POA (V34). Resident received new order per (V24) FNP (Family Nurse Practitioner) to be sent to ER (emergency room ) for evaluation. (Local Ambulance Service) arrived to facility at approx. 1:25 PM. Resident taken to (local hospital). R47's fall investigation dated 01/09/23 documents At approx. 11 AM, writer was called into room [ROOM NUMBER] by CNA staff. Entered room and observed resident on floor besides his bed. Resident had a cut above his right eye. Resident had c/o pain to his stomach. Resident stated that he was attempting to pull himself up with side rails and fell OOB (out of bed). Resident was placed on neuro-checks that were WNL. Writer notified on call nursing supervisor and also facility NP. Writer notified resident POA (V34). Resident received new order per (V24) to be sent. Small superficial laceration to right eyelid. Skilled therapy to evaluate for trunk strengthening and balance, abnormal assessment: urinary retention observed, (indwelling) catheter inserted. On 5/5/2023 at 1:10 PM, V2 Director of Nurses (DON) stated when a resident falls, she expects the nurse to immediately assess the resident and to ensure the resident is safe. If staff can pick the resident up off the floor safely, she expects them to. The charge nurse should assess the resident for injuries and pain and assess the root cause of why the resident fell . After each fall V2 expects staff do to document progressive interventions to prevent the resident from falling again. V2 stated she expects the nurse to document the fall details in the resident's nurse's note in the electronic medical record. 45302 3. R62's Undated Face Sheet, documents she was admitted on [DATE]. R62's Care Plan dated 2/16/2021 documents, Resident is at risk for falls psychoactive drug use, diuretic therapy and impaired cognitive skills. Diagnosis of hypertension and is being treated for this. Goal: falls/injuries minimized through the management of risk factors while maintaining maximum independence through the review date. Approaches: administer medications as ordered by MD (physician)/NP (nurse practitioner.) See POS (physician order sheet)/MAR (medication administration record.) Keep call light within reach when in room, ensure that she is wearing proper footwear when ambulating. She is able to transfer and ambulate independently. PT (physician therapy)/OT (occupational therapy) as ordered. Vital signs as ordered. Notify MD/NP of abnormal results. Perform a fall risk evaluation assessment on me quarterly and PRN (when needed.) 7/5/2022 fall without injury skin/pain evaluation PROM (passive range of motion) without issue, skilled therapy for evaluation for reacher. 8/12/2022 fall without injury approach added floor path clear from hazards footwear inspected proper footwear in place at all times. 9/25/2022 fall without injury approach added footwear inspected family representative to bring in proper fitting shoes. No progressive intervention was documented on R62's care plan after the 9/25/2022 fall. R62's Fall Scale, dated 9/25/2022, documents total score 40 which was low to moderate risk action: implement standard fall prevention. R62's Quarterly Minimum Data Set (MDS) dated [DATE] she is severely cognitively impaired, supervision with walk in room and corridor, supervision with dressing, limited assistance with one-person physical assist for personal hygiene. R62's MDS documents R62 is steady at all times during balance during transitions and walking and uses mobility devices. R62's Nurse's Note, dated 10/31/2022 no documentation of fall. R62's Nurse's Note, dated 11/1/2022 at 4:46 AM documents, Resident continues on incident follow up for fall, resident right 3rd digit bruised and edematous, right wrist edematous and bruised, call placed to FNP (family nurse practitioner), and order received for x ray to right hand and wrist. R62's Nurse's Note, dated 11/1/2022 at 8:10 PM V12, LPN documents, 10/31/2022 2 P-10 P shift around 4 PM resident was sitting in common area by the dining room mingling with other residents. Resident attempted to assist another resident from one chair to another causing them both to fall to the floor. Resident was assisted off the floor. Pain/skin assessment, ROM (range of motion) and VS (vital signs) were done. Resident was able to move fingers and wrist but complained of some pain. Tylenol was given. Resident sat at dinner table for supper. After dinner resident went to room to prepare bed with no further complaints and rested quietly throughout rest of shift. Resident ambulates independently and had shoes on. The floor was dry. Resident toilets self. R62's Care Plan was not updated after this fall with progressive interventions. On 5/5/2023 at 1:10 PM, V2 Director of Nurses (DON) stated when a resident falls, she expects the nurse to immediately assess the resident and to ensure the resident is safe. If staff can pick the resident up off the floor safely, she expects them to. The charge nurse should assess the resident for injuries and pain and assess the root cause of why the resident fell . After each fall V2 expects staff do to document progressive interventions to prevent the resident from falling again. V1 expects the nurse to document the fall details in the resident's nurse's note in the electronic medical record. On 5/5/2023 at 8:54 AM V24, Nurse Practitioner stated she was the nurse practitioner for V29, Physician. V24 stated when a resident falls, she expects staff to document what occurred with the fall and if the resident sustained injuries from the fall in the resident's medical record the same day the fall occurred. V24 stated she expected facility staff to follow physician's orders and facility policies and procedures. The Facility's Accident & Incident Documentation & Investigation Resident Incident revised 7/2018, documents Policy: accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC (long term care) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accident and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. The Policy documents The Licensed Nurse assigned at the time of the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director as appropriate. The Licensed Nurse at the time of the incident is responsible for initiating/completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. The Licensed Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth on the Resident Incident Report. The Policy documents The Nurse's Notes could contain the following documentation: date and time of incident: clear, objective facts of what occurred; the last time the resident was seen prior to the incident; An evaluation of the resident's condition at the time of the accident/incident could include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident; an treatment provided; any contacts made or attempted with the resident's physician, family, legal representative or any other health care professional or person involved with resident's care; The resident's outcome and any information concerning the incident and the Nurse's signature, date and time of the charting.

Based on interview and record review, the facility failed to obtain timely emergency medical services for the treatment of a fracture for one of one resident (R62) reviewed for quality of care in a sample of 51. This failure resulted in delay of treatment after R62 fell sustaining an acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid. Findings include: R62's Undated Face Sheet, documents she was admitted on [DATE]. R62's Quarterly Minimum Data Set (MDS) dated [DATE] documents R62 is severely cognitively impaired, supervision with walk in room and corridor, supervision with dressing, limited assistance with one-person physical assist for personal hygiene. R62's MDS documents steady always during balance during transitions and walking and uses mobility devices. R62's Nurse's Note, dated 10/31/2022 no documentation of fall. R62's Bath Skin assessment dated [DATE], V12, Licensed Practical Nurse (LPN) documents, No swelling, bruising or redness to right hand, fingers or wrist at time of fall. R62's Pain Management Evaluation Tool, dated 10/31/2022, form was blank, no pain assessment documented. R62's Nurse's Note, dated 11/1/2022 at 4:46 AM V38, LPN documents, Resident continues on incident follow up for fall, resident right 3rd digit bruised and edematous, right wrist edematous and bruised, call placed to FNP (family nurse practitioner), and order received for Xray to right hand and wrist. R62's Nurse's Note, dated 11/1/2022 at 6:03 AM V38, LPN documents, Resident's family representative notified and Xray company notified of order for Xray to right hand and wrist. Xray will be out today. R62's Patient Xray Report, dated 11/1/2023, documents Right hand, 2 views findings: acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid. Joint spaces preserved. Soft tissues are unremarkable. Impression: distal radial and ulnar styloid fractures. Right wrist 2 views findings: nondisplaced acute fracture of the distal radius as well as an acute ulnar styloid fracture. Joint spaces preserved. Soft tissues are unremarkable. This form was electronically signed by a physician on 11/1/2023 at 9:07 AM. R62's Nurse's Note, dated 11/1/2022 at 11:42 AM V28, LPN documents, Resident had a fall evening shift 10/31/2022, the night nurse called Xray company as residents rt (right) wrist and hand was swollen and resident had a complaint of pain. Xray company called this nurse with results, stated that resident has a distal fracture of the radial and ulnar styloid physician notified, who evaluated resident as well stated to send to ER (emergency room ) for evaluation and treatment. Physician ordered Tylenol 650 mg for pain. DON (Director of Nurses) and ED (Executive Director) notified. R62's Nurse's Note, dated 11/1/2022 at 8:10 PM V12, LPN documents, 10/31/2022 2P-10P shift around 4 PM resident was sitting in common area by the dining room mingling with other residents. Resident attempted to assist another resident from one chair to another causing them both to fall to the floor. Resident was assisted off the floor. Pain/skin assessment, ROM (range of motion) and VS (vital signs) were done. Resident was able to move fingers and wrist but complained of some pain. Tylenol was given. Resident sat at dinner table for supper. After dinner resident went to room to prepare bed with no further complaints and rested quietly throughout rest of shift. Resident ambulates independently and had shoes on. The floor was dry. Resident toilets self. R62's Medication Administration Record (MAR) dated 10/31/2022 documents no pain medication including Tylenol was administered on 10/31/2022 or 11/1/2022. R62's Nurse's Note, dated 11/1/2022 at 8:57 PM V37, LPN documents, Resident sent to local ER via ambulance at 5:00 PM. Resident returned from ER at 8:00 PM with short arm OCL (splint.) Resident has fx (fracture) to radius and ulna styloid. It is recommended that resident follow up with physician in 2-3 weeks. FNP and family representative notified of dx (diagnosis) and return. Resident did have a moderate amount of swelling to hand and wrist before leaving unit. Swelling still present. Radial pulse present. Negative for heat to area. Resident currently in room resting with eyes closed. R62's Local Hospital Discharge Instructions, dated 11/1/2022 documents, Diagnosis pain in right wrist fracture of radius and ulna styloid. On 5/4/2023 at 11:00 AM, V12 LPN stated she worked 8:00 AM to 4:00 PM day shift as the facility's Infection Control Preventionist (ICP.) V12 stated she worked as a nurse on the floor from time to time and on 10/31/2022 and was assigned to R62 evening shift. V12 recalled R62 fell on the evening shift, and she assessed R62 for injuries at that time and there were none. She reported to the night shift nurse that R62 fell . On 5/4/2023 at 2:15 PM V28, LPN stated she worked 5:45 AM to 2:00 PM day shift on 11/1/2022 she received nurse report (unknown name) from the night shift nurse who reported R62 fell . V28 stated when she assessed R62's right arm that afternoon it was swollen and bruised and R62 complained of pain. V28 stated R62's physician, V29, was at the facility that morning and had assessed R62's right wrist and stated to send her to the ER. V28 stated she didn't recall if she called 911 or if she called for a non-emergency ambulance when V29 stated to send R62 to the ER. V28 stated If you don't call 911 it can take hours for the non-emergency ambulance to get to the facility. V28 could not recall if R62 was transferred to the ER prior to leaving the facility that day, if R62 was still at the facility she would have given the next shift nurse report regarding R62's fall and the need to go to the ER. On 5/5/2023 at 1:10 PM, V2 Director of Nurses, DON, stated when a physician tells staff to send a resident to the emergency room , she expects staff to call 911/lights and sirens for a resident that a fall and Xray showed 2 fractures and is symptomatic meaning the resident has swelling, bruising and pain. V2 stated she was not aware of a resident that fell , had a complaint of pain with bruising and swelling and waited at the facility for an ambulance to take her to the emergency room for over 5 hours. On 5/5/2023 at 8:54 AM V24, Nurse Practitioner stated she was the nurse practitioner for V29, Physician. V24 stated when a resident falls, she expects staff to document what occurred with the fall and if the resident sustained injuries from the fall in the resident's medical record the same day the fall occurred. V24 stated when V29 gave the physician's order to send R62 to the hospital after R62 fell , she would have expected staff to get R62 to the hospital pretty quickly within an hour, especially when the Xray report documents R62 had fractures from the fall. V24 stated she expected facility staff to follow physician's orders and facility policies and procedures. The Facility's Notification of a Change in A Resident's Status revised 11/17, documents, Policy: the attending physician/physician extender (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulation. Responsibility: All Licensed Nursing Personnel. Procedure: Guideline for notification of physician/responsible party (not all inclusive) any accident or incident (per Federal and State regulations.) Document in the Interdisciplinary Team (IDT) notes: resident change in condition, physician/physician extender notification and notification of responsible party.

Based on interview and record review the facility failed to prevent misappropriation of resident property for 1 of 1 resident (R26) reviewed for misappropriation of property in a sample of 51. This failure resulted in R26 being upset and being a victim of theft of over $2000.00. Findings Include: On 5/3/2023 at 11:00 AM R26 was sitting up in her room in her chair. R26 stated she lived at the facility in the past and was discharged home then was recently readmitted to the facility. R26 stated she noted there were fraudulent charges on her bank card, but she didn't know what was going on because she had the bank card in her possession. R26 stated her family notified the local police regarding the fraudulent charges on her bank card. R26 stated the police told her and her family that a housekeeper that was employed at the facility took a picture of her bank card at the facility without her knowledge and made all purchases online. R26 stated she didn't know how someone had her bank card and she was told a housekeeper took a picture of her bank card and she spent over $2,000.00 at Amazon and Macy's among other stores. R26 didn't know what the housekeepers name was or if she ever met her. R26 stated she was very upset about the fraudulent charges. R26 stated This lady stole from me, and I don't have money like that. The Facility's Undated Investigation, V1, Administrator documents, (R26) is a [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE]. (R26) admitted with the following diagnoses: displaced intertotrochanic fracture of the left femur, spinal stenosis, heart disease, presence of a cardiac pacemaker, hypertension, hyperlipidemia, and major depression order. The resident is self-responsible and did sign her own paperwork upon admission to our facility. On 2/15/2023 at approximately 8:52 AM, I received a phone call from (V10), detective with local police department. (R26) had reported to her bank that there were charges on her bank card that she did not recognize. As the bank checked the charges, it was found that items purchased were shipped to the address of (V11, Housekeeping). (V10) asked this writer (V1) if I had a staff member by that name and I said that I did. (V11) was a housekeeping aide at the facility. (V10) asked me if she was here and I checked to see that she was clocked in. (V10) let me know the local police department would be coming to the facility to arrest (V11.) As I was on the phone with (V10), I had (V11)'s supervisor remove (V11) from the floor and placed her in the HK (housekeeping) supervisor's office. After hanging up, I waited on the police and directed them to the back of the building and (V11) was arrested on the charge of theft by the officers. They requested her purse and phone and the DON (Director of Nursing) retrieved both items. She was taken into custody without incident. The following was completed immediately: facility immediately removed (V11) from patient care area and sequestered her in office. Facility facilitated arrest of (V11.) IDPH (Illinois Department of Public Health) notified. Called (R26) and her family to give update, resident was readmitted to the facility on [DATE]. Communication between myself and (V10), detective. Administrator interviewed all housekeeping staff for information regarding this incident, with no findings. (V11) was subsequently booked into jail and charged with theft. The case number is 23-3411. I am awaiting information from the local police department about subpoenas of (V11's) of her phone to ensure that none of our other residents were affected by this employee. The staff member (V11) was hired on 6/1/2022. Upon hire, background check was initiated and there were no findings. Another background check was initiated subsequent to this offense, with no findings. The employee (V11) is obviously no longer an employee of this facility. On 5/2/2023 at 4:15 PM V1, Administrator stated R26 was readmitted to the facility. V1 stated the police contacted V1 to ask if V11 worked at the facility and V1 stated V11 was a housekeeper. V1 stated it was determined that the local police investigated R26's card transactions and it was found that V11 had ordered Amazon items and had them sent to her home from R26's bank card. The police came to the facility and arrested V11 and she was terminated the same day. V1 stated staff were interviewed and no staff stated they had knowledge of what V11 was doing. V1 stated the police didn't tell her how much about what V11 spent on R26's bank card. The police had to get a subpoena for R11's cell phone to be unlocked because she wouldn't give them the code and it was told to V1 that there were 13 other card numbers saved in V11's phone when the police unlocked it, but the officer stated no other facility residents were involved that they were aware of. Residents and families of residents were also interviewed after both allegations and no other residents were affected by V11 and no other residents were missing money to the knowledge of V1. V11's Employee File showed the facility did a criminal background check on her prior to hiring her and she documented she received/reviewed and signed the facility abuse policy that included misappropriation of resident funds. The Facility's Abuse Prevention - Illinois Only, revised 10/22 documents The facility is committed to protecting the residents from abuse. Definitions: Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Investigation: the facility will initiate at the time of any finding of abuse or neglect and injuries of unknown origin an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The administrator must immediately report any instance of misappropriation of resident property, as well as report any reasonable suspicion of crime to the Illinois Department of Public Health and in accordance with regulations of with section 1150B of the Social Security Act to the Department of Health as required. Protection: any allegation of misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the residents. All case of misappropriation of property must be thoroughly investigated, documented, and reported to the physician, families and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a suspicion of crime. Reporting: the facility will report any knowledge of actions by a court of law against any employee, which would indicate unfitness for service as a nurse aide or other staff member to the state nurse's aide registry or licensing authorities. Alleged violations involving misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made. Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.

Based on interview and record review the Facility failed to complete timely assessments, to notify the physician of a change of condition, to monitor vital signs and to provide medical treatment in a timely manner for 1 of 3 residents (R48) reviewed for care and services in the sample of 8. This failure resulted in R48 being hospitalized on a ventilator and dying on 8/28/2020. This past noncompliance occurred from 8/2/2020 to 8/20/2020. Findings include: R48's Physician order [REDACTED]. R48's Face Sheet documents a [DIAGNOSES REDACTED]. R48's Nurses Notes dated 8/1/2020 documents, at 2 PM, Spoke with (nurse) at local hospital where (R48) was admitted with [DIAGNOSES REDACTED]. R48's Nurses Notes do not have any other documentation for 8/1/2020. There was no documentation in R48's medical records of vitals being performed on R48 for 7/30/2020 or 7/31/2020. The last vitals documented for R48 was on 7/29/2020 at 11:15 PM, and there were no other vitals documented as being taken for R48 on 8/1/2020. On 10/6/2020 at 10:32 AM, V13, Infection Control Preventionist stated, we expect all residents especially those who are positive with COVID-19 to have vitals taken every 4 hours and documented. We had some issues with staff not taking vitals, but I think we are now on top of things. R48's POS dated August 2020 does not document R48 went out to the hospital on [DATE]. R48's Hospital Records arrival date of 8/1/2020 at 12:32 PM, documents, [AGE] year-old sent in from the nursing home because of altered mental status. Patient apparently was seen this morning at the nursing home and found to be less responsive, short of breath, and Emergency Medical System (EMS) was called. Patient does admit to some diarrhea this morning. R48's Laboratory Results taken at the local hospital document R48 had a positive COVID-19 test on 8/1/2020 at 12:50 PM, and it was verified on 8/2/2020 at 7:00 PM. R48's Hospital Records dated 8/2/2020 documents a final [DIAGNOSES REDACTED]. The records document, (R48) looked considerable better on the day of the discharge than on the 3rd (August) so at this point in time, we feel comfortable in discharging her back to the nursing home. R48's Nurses Notes dated 8/5/2020 at 4:24 AM, resident readmitted from (local hospital) New Orders sent to pharmacy, assessment complete. No signs or symptoms of distress noted, will continue to assess and monitor residents. R48's medical chart does not contain any more notes in charts until 8/14/2020 including daily vital signs being performed and documented by the facility. On 10/7/2020 at 8:25 AM, V53, Family of R48 stated, Initially my mom went out to the hospital because her Oxygen was dropping, and they sent her out to the hospital she was tested at the hospital and was positive for COVID-19. That was on 8/1/2020. (R48) while she was in the hospital, she got better so they sent her back to the facility on [DATE]. Then 15 days later (August 20) her oxygen dropped again and they had to send her out again to the hospital but this time she never recovered. I am not sure they were monitoring her and keeping a close eye on her condition. They knew she had COVID I just don't understand. Nurses Notes dated 8/20/2020 (no time documented) R48's oxygen levels were documented at 72. Resident has visible distress of breathing upon this nurse entering room this nurse and certified Nursing Assistant pulled resident up in bed and elevated, Head of Bed (HOB) non-rebreather applied, Oxygen levels increased to 81. This nurse notified on call Physician and orders received to send resident out. 911 dialed and resident transferred to hospital. Family notified and Doctor notified of resident transfer. Report called to (local hospital). R48's medical records do not document any other vitals were taken that day. R48's POS dated 8/20/2020, Send to emergency room for evaluation and treatment. R48's Hospital Records dated 8/21/2020 documents, (R48) is a [AGE] year old Caucasian female with history of dementia, hypertension, [MEDICAL CONDITION], ([MEDICAL CONDITION]), who was reportedly nonverbal and sent to the emergency room from (nursing home) due to shortness of breath. All history is obtained from the chart as she is unable to provide related to chronic [MEDICAL CONDITION]. She was found to be hypoxic in the emergency room and was placed on 10 liters of oxygen. She was recently found to be COVID-19 positive on admission from August 1 to August 5th. She was admitted to the Intensive Care Unit (ICU) for further management. Reason for consultation, Acute hypoxemic [MEDICAL CONDITION]. R48's Hospital Records dated 8/28/2020 [AGE] year-old female with COVID-19, hypoxemic [MEDICAL CONDITION] who initially improved and was weaned to nasal cannula but later developed aspiration, rapid [MEDICAL CONDITION] Fibulation (Afib) and required incubation and mechanical ventilation. She had multiple comorbidities and was frail. This morning she developed [MEDICAL CONDITION] and protocol was implemented but she passed away at 9:26 AM. On 10/6/2020 vital sign sheets were requested for R48 and no vital sign sheets were produced for R48 other than her vitals taken on the selective nurse's notes. On 10/8/2020 at 2:11 PM, V60, Nurse Practitioner stated, For any resident who test positive we expect the facility to monitor vitals, listen to lung sounds, do temperatures, heart rate, Blood pressure, pulse, oxygen levels, to look at the residents for any signs or symptoms of shortness of breath, any respiratory issues going on, look at their level of conscientiousness, (R48) had dementia and when she came back from the hospital I know she was placed on the COVID unit. I was not there every day, but I would expect them to monitor her condition and document their results. The State of Illinois Certificate of Death Worksheet, dated 8/31/2020 documented R48 cause of death, [MEDICAL CONDITION] and COVID-19 on 8/28/2020. The CDC website page, Responding to Coronavirus (COVID-19) in Nursing Homes, Updated 4/30/2020, document the facility should implement the following for residents who have tested positive for COVID-19 or who are experiencing the symptoms of COVID-19: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturations via pulse oximetry and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections; and Consider increasing monitoring of symptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. The Policy provided by the facility for COVID Monitoring dated 7/7/2020 documents, It shall be the policy to utilize accepted Infection Control Methods to prevent and Control the Spread of a respiratory illness, caused by Novel Coronavirus (COVID-19). Older adults and patients with comorbid conditions are at an increased risk for more severe illness. Actively monitoring for Coronavirus is an important aspect of the ongoing infection control program. Temperatures are taken daily of all residents and staff. This policy was outdated and does not follow the Center for Disease guidelines for increased monitoring for at least 3 times daily. Prior to the survey date, the facility took the following actions to correct the noncompliance. 1. This tag was corrected on 9/10/2020. This Plan of Correction in response to the statement of deficiency demonstrates our good faith and desire to continue to improve the quality of care and services rendered to our residents. This plan of correction constitutes a written allegation of compliance with Federal Medicaid and Medicare requirements. F684. 1- R17 no longer resides in the facility as of 8/22/2020. R41 no longer resides in facility as of 8/4/2020. 2. Any resident in the facility has the potential to be affected by this alleged deficient practice. 3. The Director of Nursing (DON) or designee completed in-service training on or before 9/10/;2020 with nursing staff regarding residents' assessment including vital signs and notifying the physician and resident representative of changes in resident condition and documenting notifications in the medical records. 1:1 retraining by the Director of Nursing, any employee who has not completed required education will not be allowed to work until education completed. The DON or designee will audit for changes in condition and notification daily times 14 days then weekly times 2 weeks then monthly for on-going compliance until resolved through Quality Assurance and Performance Improvement process. 4. The results of the auditions will be presented to the Quality Assurance Performance Improvement Committee by the Director of Nursing or designee for review and further recommendations as deemed necessary until issues is resolved.

Based on observation interview and record review, the facility failed to develop and implement infection control procedures to prevent the spread of COVID-19 infection by: failing to implement transmission based precautions, implementing procedures for COVID -19 positive staff and/or symptomatic staff; encouraging residents to wear masks and socially distance from others, utilizing personal protective equipment and perform hand-hygiene and ensuring the environment is clean and sanitary. This failure has the potential to affect all 81 residents living in the facility. This failure resulted in an Immediate Jeopardy (IJ) which began on 8/9/20 when 11 residents, R13, R15, R17, R18, R20, R21, R23, R24, R25, R26 and R28 who resided on the Memory Care unit, tested positive for COVID-19 and the facility failed to implement transmission-based precautions and isolate these resident from residents without COVID-19. Subsequently on the Memory Care Unit, three additional residents, R9, R16 and R27 tested positive for COVID-19. Due to these residents' comorbidities and vulnerabilities, this failure increases their risk for severe illness from COVID-19 and possible death. The Immediate Jeopardy was identified on 8/26/20. On 8/26/20 at 2:13 PM, V1, Administrator, V2, Director of Nurse, V35, Director of Clinical Operations and V12, Clinical Operations Consultant were notified of the Immediate Jeopardy. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 8/27/20 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1.On 8/17/2020 at 11:10 AM, V1, Administrator, stated The COVID-19 positive residents are located on the COVID-19 Unit (100-hall). But we do have a couple of residents that came back positive over the weekend that are on the Memory Unit. The facility provided a list on 8/17/20 of residents on the Memory Unit who currently tested positive for COVID-19. The following 15 residents were on this list: R9, R12, R13, R15, R16, R17, R18, R20, R21, R23, R24, R25, R26, R27, and R28. On 8/26/20, the facility provided the Line List for COVID-19 Outbreaks in Long Term Care Facilities. The Line List documented that 2 residents, R42 and R6 tested positive for COVID-19 on 7/27/20. The last documented resident on the line list, R44, was noted to be positive on 8/15/20. At that time, the line list documented 60 residents had tested positive for COVID-19. On 9/2/20, at 11:45 AM, V39, Local County Health Department (LCHD) Staff Nurse, stated that the facility was required to notify the Local County Health Department the total number of residents and staff who tested positive for COVID-19 and the total number of deaths which were related to COVID-19. V39 stated that on 8/31/20, the facility had reported to the LCHD 76 residents and 35 staff persons had tested positive for COVID-19. V39 stated the facility reported 19 deaths related to COVID-19. 2. The following observations were conducted on the Memory Unit on 8/17/20 and 8/19/20: On 8/17/2020 at 11:15 AM when entering the Memory Care unit, there were residents in the dining room, without masks and without maintaining social distancing. There were no signs on the residents' rooms' doors indicating any of the residents were on transmission-based precautions. All the residents' room doors were opened to the hallway. V14 and V15, Certified Nurse's Assistants were working on the Memory Unit. On 8/17/20, from 11:20 AM through 11:38 AM, V14 and V15 identified the residents in each of the rooms and if they had tested positive or negative for COVID-19. V14 and V15 stated that many of the residents who had tested positive with COVID-19 were still residing with roommates who had tested negative for COVID-19. V14 and V15 stated the following residents had tested positive for COVID-19: R9, R12, R13, R15, R16, R17, R18, R20, R21, R23, R24, R26 and R28. V14 and V15 stated those positive residents are roommates with the following residents who had tested negative for COVID-19: R10, R11, R14, R19, R22, R27 and R29. On 8/17/20 at 11:37 AM, R21, who was identified as testing positive for COVID-19, was ambulating in the hallway. At that time, R21 was not wearing a mask and was walking by other residents and staff without socially distancing. None of the staff attempted to redirect R21 at that time. On 8/17/2020 from 11:40 AM through 1:16 PM, during the mealtime, residents were gathered in the dining room/activity area for lunch. None of these residents were wearing masks. Residents were sitting at square tables that sat four residents each. The tables were approximately three feet apart. While residents were seated at these tables, these residents could not socially distance 6 feet apart. R25, R16, R27, R26, R13, R18, R28 were all identified as residents who tested positive for COVID-19. These residents were seated at tables with R14, R30, R22, R19, R29 and R31 who had all tested COVID-19 negative. On 8/17/2020 at 11:43 AM and throughout the mealtime, R27, who has been identified as COVID negative, was ambulating in the dining room and up and down the hall without wearing a mask. R27 was not socially distancing from other residents and staff did not intervene or provide redirection. At 1:16 PM R27 was walking in the dining room and the hallway, coughing. R27 was not wearing a mask. V14, V15, and V16 did not intervene or redirect. The staff did not encourage R27 to perform hand hygiene. On 8/17/2020 at 11:50 AM R12, who has been identified as testing positive for COVID-19, was ambulating in the dining room and in the hallway without a mask. At no time did staff, including V14 and V15, provide redirection or attempt to cue R12 to wear a mask. On 8/17/2020 at 12:00 PM, in the dining area, R22, who has been identified as COVID negative, was sitting at a table with R26, and R13, who have been identified as testing positive for COVID-19. R22 coughed and sneezed in her hand. R22 did not cover her mouth or nose when she sneezed. R22 was not wearing a mask. V14, V15, and V16, Licensed Practical Nurse did not attempt to cue or assist R22 with hand hygiene after she coughed. On 8/17/2020 at 12:06 PM R23, who has been identified as COVID-19 positive, was sitting at table in the dining room, coughing without a face mask. R23 did not cover his mouth when coughing. V14, V15, and V16 did not encourage or cue R23 when he was coughing to cover his mouth. On 8/19/20, at 5:50 AM, on the Memory Care Unit, none of the residents' rooms' doors had signage that any of the residents were on transmission-based contact-droplet precautions. At that time, V14 and V30, Licensed Practical Nurse/LPN were working on the Unit. V14 stated that those residents who tested positive for COVID-19 were located from rooms 309 to 316. At that time, R43 and R13 were standing in the hall outside their rooms with no masks on. V14 provided no redirection to go back to their rooms. V14 stated R43 did not have COVID-19 but R13 was positive for COVID-19. V14 and V30 stated the residents were all moved on 08/17/20 and again on 08/18/20 due to some of the residents sharing rooms with positive residents. V14 and V30 stated they were not sure why the negative residents were still sharing the same hall, especially since they have many that wander the halls all day. V14 and V30 stated they did not know if they were supposed to use new PPE when going in and out of positive resident rooms and stated they wear the same gowns unless they leave the unit. On 08/19/20 at 6:30 AM, V26, CNA came onto the Memory Care unit to work. V14 stated to her Why are you on this unit, because you're positive (tested positive for COVID-19) and we still have negative residents? V26 told her she was told to come to this hall to work. V26 went into every room on the hall with the same gown, gloves, mask and face shield to check on residents. V26 took R13 by the arm and walk her back into her room from the hallway. V26 then went into R17's room and reposition R17 in bed. Both residents in this room, have COVID-19 infection. V26 continued up and down the hall in and out of resident rooms. At 7:25 AM, V26 was informed by V15, CNA she needed to be on the North hall to work. V26 exited the Memory Care hall through the 200-hall then went directly to the North hall double doors. V26 did not doff her PPE when leaving the Memory Care unit. The facility's undated Line List for COVID-19 Outbreaks in LTC Facilities, undated, was provided on 8/26/20. The Line list documented V26 had an onset of COVID-19 on 8/14/20. On 08/19/20 at 7:45 AM, on the Memory Unit, V25, Maintenance and V32, Housekeeping, began hanging a plastic sheet-like barrier with a zipper in the middle. The plastic sheet was hanging from the ceiling to the floor starting at resident rooms [ROOM NUMBERS]. The plastic was attached from the ceiling to the floor around two small poles attached to either wall. There was an approximate 1-1.5-inch gap between the wall and the poles on either side. The plastic was not secured to the ceiling, floor or walls for an airtight seal. V32 stated he was told to come assist V25 and assumed it was to separate the positive (tested positive for COVID-19) residents from the negative ones. While V25 and V37 were putting up the plastic, R27 was wandering the hall between the positive and negative side. On 8/19/2020 at 8:10 AM R12, who has been identified as testing positive for COVID-19 with symptoms of fever, was walking up and down the hallway coughing and made no attempt to cover her mouth. R12 was not wearing a mask. R12 did not maintain social distancing as she walked pass R33, who has been identified as COVID negative. On 8/19/2020 at 8:15 AM R27, who was identified as newly COVID positive, was walking in the hallway coughing, and was not wearing a mask. R27 walked through the zipper area of the plastic and opened the fire doors into the common area. R27 did not maintain social distancing as she walked past R33, who has been identified as COVID negative, sitting in the hallway. V15 redirected R27 and walked with R27 through the hall, again walking pass R33, to her room. At 8:17 AM, V15 stated (R27) is confused and will not remember or understand the redirection. At 9:00 AM, again, R27 came through the plastic sheeting from the positive side to the negative. V14 was in another resident's room passing breakfast tray and was informed by V31 that R27 had come through the plastic barrier. V14 then retrieved R27 and returned her to her room. On 8/19/2020 at 8:35 AM R7 was walking in the hall coughing in her hand with a runny nose. R7 did not have a mask on. R7 did not maintain social distancing when walking pass R21, who has been identified as positive, who was standing in the hallway. On 08/19/20 from 5:50 AM to 11:20 AM, R43 was wandering in the hall of the Memory Care unit. Staff were observed to redirect R43 multiple times back into her room, but she would stay for a short time and would come back out into the hall. R43 did not wear a mask and was not asked by any staff to wear one. At 6:15 AM, V14 stated they do not have masks for the residents. On 8/17/2020 at 11:40 AM V14, CNA was working on the Memory Unit. V14 stated We do have multiple residents that are positive for COVID. The positive and negative residents are in the same room. The positive residents do wander in rooms of negative residents or vice versa. In and out of each other's room. We try to redirect but with only 2 CNAs it can be difficult. They (residents) don't understand and will do it again. The residents eat in dining room. I don't know what precautions were put in place for the COVID positive residents. No one is on droplet isolation. On 8/17/2020 at 11:50 AM V15, CNA working on the Memory Unit, stated The residents wander in and out of each other's room. You will find them laying in each other's beds. If the 2 CNAs are in the rooms no one is here to watch the others. We do have positive residents on the hall. The residents are not separated. They (positive) are in the rooms with the negative residents. Not sure of any precautions put in place. No isolation. If there was isolation there would be a sign on the door. The residents with the infection would be moved and separated from the other residents. We have not done that. All the residents do wander in and out of the rooms and up and down the hall. On 8/17/2020 at 11:57 AM V27, Housekeeper, was working the Memory Unit.V27 stated I don't know of any residents on isolation. I know there are residents that are positive but don't know who they are. On 8/17/2020 at 1:30 PM V16, Licensed Practical Nurse (LPN), was questioned regarding how she knows who is positive for COVID-19. V16 stated I go and ask. They (Administration) get the results and then will tell us. But I don't wait. I go to them and ask. I need to know. Currently do not have any residents on droplet isolation or precautions. If they were there would be a sign on the door to report to the nurse. Biohazard containers would be in the room and supplies outside the door. Residents that are positive are in the rooms with negatives. No separation has been done. And we have residents with symptoms. On 8/17/2020 at 2:45 PM V17, Agency CNA, was working on the evening shift on the Memory unit. V17 stated I don't know of any residents on any isolation. I assume the nurse would tell us, but the nurse is not back here. If there were residents on isolation there would be barrels in the hallway and signs would be outside the door. But none are down here. On 8/17/2020 at 2:48 PM V18, CNA, was working the evening shift on the Memory unit. V18 stated It's my first day down here. I have not received report of residents on precautions. I'm not aware of any droplet precautions. On 8/17/2020 at 2:49 PM V19 CNA, was working the evening shift on the Memory unit. V19 stated If any residents were on precautions, we would be told that by the nurse. I have not received that information. There would be supplies and signs outside doors. On 8/17/2020 at 2:50 PM V20, Laundry Aide, was entering and exiting rooms, delivering residents' laundry on the unit and stated I don't know anyone on any isolation or precautions. I don't know anyone with COVID 19. I come in, do my job and go home. On 8/17/2020 at 3:00 PM V5, Minimum Data Set/Care Plan Coordinator, stated The process for residents that are positive for COVID is those residents are placed on precautions standard and droplet precautions and in isolation. We do have residents with positive results on the unit. The COVID positive residents and the negative residents should not be in the same room. The rooms don't allow for 6 feet, social distancing and if both residents were not positive then 1 resident would have to be moved. The residents should have been moved immediately. None of the residents should be eating in the dining room. Each resident should have a mask on. The COVID 19 results came back Saturday (8/15) and we are starting to make some room changes. There were residents with results on 8/10 and symptoms that should have had room changes and placed on droplet isolation before today. On 8/19/2020 at 9:36 AM V28, Nurse Practitioner, FNP, stated When resident test positive for COVID I would expect the resident to be placed on droplet isolation immediately. I would expect the residents that are negative and the residents that are positive to be separated. On 8/19/2020 at 11:40 AM V1, Administrator stated If a resident's COVID 19 results were positive. Droplet precautions are to be put into place immediately upon receiving results. Not a week later. The residents should wear face mask and the staff should encourage them. On 8/24/2020 at 4:34 PM, when asked if a resident tested positive for COVID 19 what would be your expectation of the facility, V36, Medical Director, stated I would expect the positive residents to be separated from the negative residents and placed on Contact and Droplet isolation immediately. The residents on the memory unit have memory issues with other comorbidities. Having the negative and the positives together puts the negative residents at risk for getting [MEDICAL CONDITION]. Each resident responds differently. Due to the residents' vulnerability this could be life threatening. The following residents are located on the Memory Care Unit and have tested positive for COVID-19: R13's August 2020 POS documented she has [DIAGNOSES REDACTED]. R13's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R15's August 2020 POS documented she has [DIAGNOSES REDACTED]. R15's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R17's August 2020 physician's orders [REDACTED]. R17's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R18's August 2020 POS documented she has a [DIAGNOSES REDACTED]. R18's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R20's August 2020 POS documented he has [DIAGNOSES REDACTED]. His Laboratory Result, dated 8/09/2020, documented he had tested positive for COVID-19. R21's August 2020 POS documented she has a [DIAGNOSES REDACTED]. R21's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R23's August 2020 POS documented he has a [DIAGNOSES REDACTED]. R23's Laboratory Result, dated 8/09/2020, documented he had tested positive for COVID-19. R24's August 2020 POS documented he has [DIAGNOSES REDACTED]. R24's Laboratory Result, dated 8/09/2020, documented he had tested positive for COVID-19. R25's August 2020 POS documented she has a [DIAGNOSES REDACTED]. R25's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R26's August 2020 POS documented she has [DIAGNOSES REDACTED]. R26's Laboratory Result, dated 8/09/2020, documented she had tested positive for COVID-19. R28's Face Sheet, not dated, documented she has [DIAGNOSES REDACTED]. R28's Laboratory Result, dated 8/09/2020, documented she had tested Positive for COVID-19. R9's August 2020 physician's orders [REDACTED]. R9's Laboratory Result, dated 8/15/2020, documented she had tested positive for COVID-19. R16's August physician's orders [REDACTED]. R16's Laboratory Result, dated 8/15/2020, documented she had tested Positive for COVID-19. R27's August 2020 POS documented she has [DIAGNOSES REDACTED]. R27's Laboratory Result, dated 8/17/2020, documented she had tested positive for COVID-19. R27's current Care Plan did not have documentation that R27 was positive for COVID-19 infection or interventions in place. R12's August 2020 POS documented she has [DIAGNOSES REDACTED]. R12's Care Plan, dated 8/8/20 documented she had tested positive for COVID-19 and should be placed on Isolation Droplet precautions. After multiple request, the facility was unable to provide a laboratory test result confirming R12 had COVID-19. The Facility's Coronavirus (COVID-19) Policy, revised 7/7/20, documented Any resident suspected of having Coronavirus will be placed on Standard, Contact and Droplet Precautions as per CDC guidelines. The Policy documents The infected resident will remain in his/her room on precautions with the door closed, if possible. The asymptomatic roommate will be moved to a private room, if available or to the Designated Unit, for observation pending consultation with the local health department. The Centers for Disease Control (CDC) website page, Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/2020, documented the facility should implement the following for residents who have tested positive for COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE; Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing; Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit); If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission; If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit; Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). The CDC website page, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on July 15, 2020, documents Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. The website page documents Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow. Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. 3. R5's POS, dated August 2020, documented R5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities, undated, documented R5 had the onset of COVID-19 on 8/7/20. The Line list documented she had tested positive for COVID-19 but did not document when the positive laboratory results were received. On 08/17/20, R5 was in a room located on the positive COVID-19 unit on the 100-hall. R5's Nurse's Notes and Daily Care Guide, both dated 8/20/20, documented she resided on the 100-hall, the COVID-19 positive unit. On 08 25/20, at 11:30 AM, R5 was observed in a room on the Memory unit (300 hall). There was no signage on her room door indicating she was on any type of transmission-based precautions. On 08/25/20, 12:30 PM V16, LPN stated R5 was just moved to the Memory unit on 08/24/20. V16 stated she was not sure if R5 had COVID-19 or not. On 08/19/20 at 12:45 PM, V1, Administrator, was asked for vital signs, nurse's notes for August 2020 and any information on when R5 was tested for COVID-19 and the results. As of 08/28/20 at 3:00 PM, there was no additional documentation given by the facility. 4. On 8/17/2020, at 11:45 AM, V7, LPN, I found out yesterday (8/16/2020) I was positive. I was sick all last week and I worked. V7 stated (V1) knew I was sick with cough, no taste/smell, low grade temp, and a headache too. She (V1) told me to come to work even when I had symptoms. On 8/17/2020, throughout the day shift on the COVID-19 positive unit, V7 was coughing often and her eyes were blood shot. V7 appeared very fatigued and winded. V7's lab report documents the specimen was collected on 8/14/2020. The laboratory results dated [DATE] documents V7 is positive for COVID-19. On 8/26/2020, at 8:30 AM, a telephone interview was conducted with V7. V7 stated she was at home quarantining with symptoms of a cough, shortness of breath, loss of taste/smell as well as extreme fatigue. V7 could be heard coughing during the conversation. V7 also stated, The last day I worked was 8/18/2020. I worked a double on the memory care unit. As a nurse manager, I am not on the staffing pattern but I fill in when staffing is low. I help answer call lights and pass trays every day I work. 5. On 8/19/20 at 7:25 AM, V29, Registered Nurse (RN) was passing medication on the COVID-19 positive hallway (North Hall). V29 stated she had just come back today after being off due to having positive COVID-19. V29 stated she had been symptomatic during her time off. V29 stated she had not been feeling well for a few days prior to being tested but continued to come to work. V29 stated her symptoms started on 08/06/20 and she was not tested until 08/08/20. V29 stated she was at work on 08/10/20 when she was informed, she had tested positive for COVID-19. She stated she was told to finish her shift and go home. She stated she then was off from 08/11/20 to 08/18/20 and returned 08/19/20. She stated she will be retested [DATE] by facility staff. The facility's Line List for COVID-19 Outbreaks in Long-term Care Facilities documented V29 had onset of COVID-19 symptoms on 8/7/20 and had tested positive for COVID-19. The CDC website page, Preparing for COVID-19 in Nursing Homes updated on 6/25/20, documents As part of routine practice, ask HCP (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19; Remind HCP to stay home when they are ill; if HCP develop fever (T100.0F) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). The website page document Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19; Actively take their temperature and document absence of symptoms consistent with COVID-19; and if they are ill, have them keep their cloth face covering or facemask on and leave the workplace. The CDC website page, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 -Infection (interim Guidance), updated on 8/10/20, documents Healthcare Personnel (HCP) with mild to moderate illness who are not severely immunocompromised can return to work when at least 10 days have passed since symptoms first appeared, at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. The website page documents Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. The facility's policy, titled, Coronavirus dated 5/29/2020, documents, Staff members who have signs and symptoms of respiratory infection while on the job should: immediately stop work and self-isolate at home. 6. On 8/17/2020, at 10:45, V1 stated, All residents who have tested positive for COVID-19 reside on the North Hall in the facility. We are wearing the yellow reusable gowns until they enter the (COVID isolation) unit. When staff enter the unit, they are to use the blue disposable gowns. V1 stated that all residents on the COVID-19 unit are on droplet contact precautions. V1 stated that all staff are expected to wear blue disposable gowns, gloves, goggles/and or face shields. On 8/19/2020, V25, Maintenance, entered the double doors to the North COVID isolation hall in a reusable cloth yellow gown and proceeded past the shower curtain that was being used as a plastic barrier to the rest of the hall. At that time, V35, Director of Clinical Operations, stated, You need to put on a blue gown before entering this area. V25 stated, Oh, that's new today. On 8/19/2020, at 12:25 PM, V25, was in the hallway of North hall and stated he was just checking the rooms, and it was his first time wearing the blue isolation gowns. V25 continued to state, I had just been wearing the yellow (gown). On 8/17/2020, at 11:11 AM, V5, MDS Coordinator, exited the North COVID isolation hall through the double doors wearing a blue disposable gown over a yellow reusable gown. V1 instructed V5 that she was to doff the blue gown before exiting the isolation hall. At this time, V1 stated, She should have removed the blue gown before exiting the unit. The facility's policy, titled, Coronavirus dated 5/29/2020, documents, Preventing Illness: 1. The best way to prevent the illness is to avoid being exposed to [MEDICAL CONDITION] and properly using/wearing PPE when needed. 7. On 8/17/2020, at approximately 11:45 AM, V7, LPN/Unit Manager, stated, We have no housekeeping staff back here (on the COVID-19 unit). It doesn't help prevent the spread of infection. On 8/17/2020, at 11:55 AM, the floors were visibly soiled and sticky throughout the North COVID isolation hall. At this time, V5, LPN stated, We haven't had housekeeping back here in over a week. On 8/17/2020, at 12:30 PM, R1, who resides on the COVID-19 unit, stated, They do not clean my room. On 8/17/2020, at 1:00 PM, V1 stated, Honestly, I don't know when the last time it (the COVID Isolation hall) was cleaned. Housekeeping called off today. We will call in evening shift to do housekeeping. We should be cleaning high touch surfaces 4 times a day. On 8/19/2020, at 8:45 AM, R1 stated, They still have not cleaned my room since we talked about it the other day (8/17/2020) and the bathroom stinks. The facility's policy, titled, Coronavirus dated revised 7/7/20, documents, Environmental Cleaning with an approved disinfectant should be completed daily, or when visibly soiled and for terminal cleaning after infection has resolved. Clean all high touch point areas. The Policy documents An approved disinfectant will be used for cleaning the rooms of residents with Coronavirus. Attention should be given ro bedside tables, handrails, call buttons, windowsills, and toilets. 8. On 08/19/20 at 5:45 AM, upon arrival to the front door to the facility, V30, Licensed Practical Nurse (LPN) was standing and smoking in front of the entrance. V30 gave this surveyor the code to get into the building and stated no one was available to do any screening at this hour. There was no one at the front desk or in the lobby area. V30 did not attempt to screen the surveyor. The CDC website page, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on July 15, 2020, documents to Screen everyone (patients, HCP (Healthcare Personnel, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are p (TRUNCATED)

Based on observation, interview and record review, the facility failed to complete timely assessments, to notify the physician of a change in condition and to provide medical treatment in a timely manner for 2 of 2 residents (R17, R41) reviewed for care and services in the sample of 45. This failure resulted in R17 and R41experiencing a medical decline in condition without timely treatment. Findings include: 1. R17's August 2020 physician's orders [REDACTED]. R17's Laboratory Result, dated 8/09/2020, documented she had tested Positive for COVID-19. R17's Care Plan, dated 08/10/2020, documented R17 had a positive COVID-19 test. It documented R17 was placed on isolation/droplet precautions, staff were to monitor vital signs and oxygen saturations levels (SPO2) as ordered. R17's Nurse's Note, dated 8/13/2020 at 4:07 PM, documents Resident decrease SPO2 to 84% room air. Oxygen applied at 3 liters by nasal cannula increased to 98%. Temperature of 99.2 at 4:07 PM down to 97.7. Resident fatigued, complained of extreme pain to back and all over. Continue routine pain meds and prn narcotics slightly effective. No SOB (Shortness of Breath) noted. Respirations even non labored at this time. Added to report sheet, to be monitored every shift. POA (Power of Attorney) contacted and message left. R17's Departmental Nursing Notes, dated 8/14/2020 at 1:04 AM, documents T99.7 (temperature)-80 (pulse)-20 (respirations)-106/68(blood pressure). Oxygen saturation 94% on oxygen at 2 liters. HOB (Head of Bed) elevated-lungs clear with no cough or SOB. There was no documentation in R17's medical records that the facility staff was monitoring R17's vitals on 8/15, 8/16 and 8/17/20. R17's Departmental Nursing Notes, dated 8/18/2020 at 12:17 AM, documents T (temperature) 99.1-72 (pulse)-20 (respiration)-114/68 (blood pressure). O2 sat 97% no distress noted. There was no documentation in R17's medical records on 8/18/20 for the 6:00 AM-2:00 PM shift and the 2:00 PM -10:00 PM shift that the facility was monitoring R17's vital signs. On 8/19/2020 at 8:40 AM R17 was lying in bed. V14, Certified Nurse's Aide/CNA, placed R17's tray on the over bed table. R17's face was red in color. R17 was taking slow shallow breathes. Her oxygen tubing was lying on the bed and not on her face. At 8:43 AM, V14 stated This is not normal for her. She has changed. She (R17) feels hot. She says she doesn't feel good. She (R17) is positive for COVID 19. This is not like her. She used to get up out of the bed, transfer herself to the wheelchair and roll herself out in the hallway. She would eat pretty good. She has not been eating at all. She drinks her drinks sometimes. She has been coughing, sneezing and has had fever. She hasn't been getting up. This has been going on about 2 weeks. I have reported it to the nurse. I tried to get her temperature, but I was told the thermometer wasn't working and they would get me a new one. On 8/19/2020 at 9:28 AM V8, Licensed Practical Nurse, entered R17's room. V8 applied R17's oxygen tubing to her nose. V8 did not attempt to get R17's oxygen saturation level prior to putting the O2 on R17. V8 then left the room and proceeded off the unit. V8 returned approximately 10 minutes later and performed an oxygen saturation test. R17's results were 92% with oxygen being delivered per nasal cannula at 2 liters. On 08/19/20 at 10:10 AM, V14, CNA stated none of the residents have had their SPO2 (oxygen saturation level) levels checked. She stated vital signs were taken once per shift and normal vital signs taken are blood pressure, temperature, and pulse. On 8/19/20, at 10:12 AM, V30, LPN stated vital signs are only done once per shift. On 8/19/20, at 10:15 AM, V14 stated there were no vitals taken for the day shift. The Vital Sign sheet had no documentation that R17's vitals were being monitored. There was no documentation in R17's medical record on 8/19/20 from 8:40 AM until 4:52 PM the facility was monitoring R17's vital signs. R17's Departmental Nursing Notes, dated 8/19/2020 at 4:52 PM, documents R17's temperature was 97.5 degrees F, her respirations were 20, her blood pressure was 208/92 and her pulse was 72. The Note documented resident resting comfortably in bed with eyes closed. Medications administered per MAR (Medication Administration Record) and resident tolerated meds well. This nurse notified (V28), Nurse Practitioner, about residents elevated BP (blood pressure), he stated to recheck in 1 hour after medications given. NP (sic) 142/78 assessment complete, lung sounds clear and bowel sounds present x4. No s/s of distress noted. Will continue to monitor and observe. The Note did not document at what time staff rechecked R17's blood pressure. There is no documentation in R17's medical record from 8/19/20 at 4:52 PM until 8/20/20 at 5:25 PM regarding if facility staff were monitoring R17's condition and her vital signs. R17's COVID 19 Assessment, dated 8/20/2020 at 5:25 PM, documents Temperature-Fever-yes 99.5 pulse ox 96%/RA (Room air). There is no documentation in R17's medical record from 8/20/20 at 5:25 PM until 8/21/20 at 8:30 PM that facility was monitoring R17 condition and her vital signs. R17's COVID 19 Assessment, dated 8/21/2020 at 8:30 PM, documents R17 displayed the following COVID 19 symptoms: Malaise, loss of appetite and loss of taste or smell with oxygen in use. R17's vital signs were documented as follows: Temperature 96.6 Respiratory Rate 22. Pulse Ox 94% with oxygen at 2 liters per nasal cannula. R17's heart rate 100 beats per minute. Blood Pressure 133/73. There is no documentation in R17's medical record from 8/21/20 at 8:30 PM until 8/22/20 evening shift (2:00 P-10P) that the facility was monitoring R17's condition and her vital signs. R17's COVID 19 Assessment, dated 8/22/2020 2-10p, documents R17 displayed the following COVID 19 symptoms: Malaise, loss of appetite and aches all over. R17's vital signs were documented as follows: Temperature 97.3 pulse ox 94%. R17's heart rate 105 beats per minute. Blood pressure 124/58. There is no documentation in R17's medical record from 8/22/20 evening shift until 8/23/20 at 1:39 PM the facility was monitoring R17's condition and her vital signs. There was no documentation V28 had been notified of R17's condition. R17's Departmental Nursing Notes, dated 8/23/2020 at 1:39 PM, documents At approximately 10:30 A.M. Writer was on hall passing meds when a member of CNA staff reported to writer that resident appeared to have stopped breathing. Writer saw resident at approx. (approximately) 10am and resident presented with labored breathing but was still breathing. Writer contacted POA at 10:35 am. Writer contacted general medicine at approx 10:40 am and also writer contacted Madison county coroner at 10:45A.M. Writer currently awaiting coroner arrival. There was no prior documentation of R17's labored breathing or if the facility contacted the doctor of this. On 8/19/2020 at 11:00 AM V8, Licensed Practical Nurse (LPN), stated with regards to where the nursing staff would have charted/documented R17's assessments and vital signs We document in the progress notes in the computer. There are nurses that don't have computer access. They have to document on paper. If it is not in the nurses notes in the computer or on paper, then it wasn't done. On 9/2/2020 at 12:30 PM V13, Infection Control Nurse, stated When a resident has a change in condition, I would expect the resident to be monitored every shift. The nurses would perform full assessment on the resident. The physician would be notified of any changes in the resident's condition. On 9/3/2020 at 9:22 AM V28, Advanced Practice Registered Nurse, stated I was not notified of (R17's) elevated heart rate. With her being positive for COVID and having changes in condition, I would expect the staff to monitor and assess her at least every shift. I would expect the staff to notify me with changes in R17 condition. It is possible that she would have been sent to the hospital. I will send residents to the hospital unless the family requests them to stay in the facility. The Facility's Notification of a Change in a Resident's Status Policy, dated 1/2015, documents The attending physician/responsible party will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations. 1. Guideline for notification of physician/responsible party (not all inclusive): a. Significant change in/ or unstable vital signs (Temperature, B/P, Pulse, Respiration). e. Symptoms of an infectious disease. 2. Document in the notes: a. resident's change in condition. b. Physician notification. c. Notification of responsible party. 2. R41's physician's orders [REDACTED]. On 08/04/20 at 2:29 PM, R41's Nurse's Note written by V29, Registered Nurse (RN) documented R41 was afebrile (without fever) with an oxygen saturation of 84% (normal reading is typically between 95-100 %). It documented R41 was not feeling well and not eating. There was no documentation that the physician was notified at that time. On 08/05/20 at 2:27 AM, V8, LPN, documented a late entry for 08/04/20 with no entry time. R41's Nurse's Notes documented R41 was alert and oriented x (times) 1 (normal A & O x 2-3), oxygen saturation 80%, heart rate 99, respirations 26 and temperature 101.5 (degrees Fahrenheit/F). It documented R41 was lethargic with malaise (general feeling of illness/discomfort), diarrhea and skin turgor poor. It documented V8 called V28, Advanced Practice Registered Nurse/APRN, and then sent R41 to the hospital. There was no documentation of R41 being closely monitored or additional assessments being done after 2:29 PM on 8/4/20. On 08/25/20 at 2:00 PM, V29 stated R41 was not feeling well the day she went out to the hospital and had several episodes of diarrhea through the night and that morning, not eating and just not wanting to get out of bed much. V29 stated R41's oxygen saturation levels were low, but after repositioning her it came up. V29 stated that the charting entry comes at the end of the shift and events may have happened earlier in the day. V29 stated she could not remember the exact time of day when the above entry happened with R41 but stated she had been told by staff R41 had not eaten breakfast or lunch. V29 denied calling the doctor or family at that time, stating she did not know if these symptoms were from COVID related infection or not. V29 stated she thought R41 was COVID-19 positive at the time. On 08/25/20 at 2:15 PM, V8 stated R41 was having trouble breathing with episodes of diarrhea throughout the day and was not her usual self. She stated later in the evening (could not remember exact time of day), R41 had a fever, was confused and oxygen saturation levels were low in the 80's. V8 stated she called V28 and was told to send R41 to the hospital. V8 denied knowing how long R41 had these symptoms. V8 stated she was not aware if R41 was COVID-19 positive. V8 stated she could not recall if she had notified the family of R41's change in condition or transfer to the hospital. On 09/02/20 at 12:20 PM, V13, LPN/Infection Preventionist, stated during the months of June and July 2020, the facility did not have testing supplies for COVID-19. She stated none of the residents were tested for COVID-19 until 8/7/20. V13 stated she would not have known for sure if R41 was positive or not because she was not in the facility on 08/07/20 when all were tested . On 09/03/20 at 8:35 AM, V28, APRN, stated he recalled being informed that R41 was having difficulty breathing, but no other details. V28 stated he could not remember what time of day he was contacted but did recall telling staff to send R41 to the hospital. V28 stated he thought R41 was positive for COVID-19. V28 stated he would have expected the facility staff to notify him of an oxygen saturation level in the 80's. He stated he would have expected the facility staff to monitor R41 more frequently, document any changes and notify him of a change in condition. V28 stated he would order to have any resident that was having difficulty breathing to the hospital for evaluation. V28 stated he was not sure if a delay in sending R41 to the hospital contributed to her death because he did not assess her at that time. On 09/03/20 at 11:52 AM, V48, R41's daughter, stated the family was not notified of R41's change in condition or that she had been transferred to the hospital on [DATE]. She stated the hospital notified them on 08/05/20 at 2:00 PM that R41 was admitted on [DATE] with a [DIAGNOSES REDACTED]. V48 stated R41 required assistance with all ADL's due to her left leg being contracted. R48 stated she felt like there were so many changes in staffing that there was no continuity of care for R41 and that not being notified of changes was part of the staff not knowing when R41 had a change from her usual condition. The State of Illinois Certificate of Death Worksheet, dated 08/13/20, documented R41's causes of death as Hypoxemic [MEDICAL CONDITION] and Novel [MEDICAL CONDITION] Infection. The CDC website page, Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/2020, documented the facility should implement the following for residents who have tested positive for COVID-19 or who are experiencing symptoms of COVID-19: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections; and Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms.

Based on observation, interview, and record review, the facility failed to monitor, assess and implement intervention to prevent weight loss for 1 of 3 residents (R7) reviewed for nutritional status in a sample of 45. This failure resulted in R7 experiencing a 16-pound weight loss in one month and hospitalization for dehydration. Findings include: R7's Dietary Notes, dated 7/28/2020 documents R7's weight on 7/3/2020 was 153 pounds with no significant weight loss. R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is independent with eating; requiring no encouragement or cues. The MDS documented she is cognitively impaired. R7's current Care Plan, documented I am at risk for weight loss due to my [DIAGNOSES REDACTED]. R7's care plan lists the goal as, I will have no complications in my nutritional status and maintain a stable weight thru my next review: 10/30/20. The approaches include, Offer me a substitute if you notice I am not eating what is served. and Weigh me monthly and PRN (As needed). R7's physician's orders [REDACTED]. R7's Nurse's Notes, dated 8/11/20, documented that R7 was complaining of an upset stomach which she associated with a stomach ulcer. R7's Nursing Notes document that on 8/18/2020, at 7:12 PM, R7 was repeatedly complaining of stomach pain and refused dinner. There was nothing documented as to what interventions were attempted such as offering a substitute or providing encouragement. On 8/19/2020, at 12:00 PM, R4, R7's roommate, stated She (R7) has not been eating. R7's Nurse's Notes, dated 8/21/20 at 12:46 PM documented R7 continued to complain of upset stomach. On 8/25/2020, at approximately 12:00 PM, R7 had her lunch tray in front of her, untouched. At this time, R7 stated, I can't eat. I think my ulcer is back. I haven't eaten in 3 or 4 days. V49, Licensed Practical Nurse/ LPN provided R7 a supplement drink. R7 took one sip out of it. There was no documentation in R7's medical record regarding if the facility assessed R7's continued refusal of food and stomach pain. R7's Care Plan was not updated to address R7's refusal of food and stomach pain. On 8/25/2020, at 2:00 PM, V5, Licensed Practical Nurse (LPN) stated that the medical director had written an order to discontinue weights due to the scale being located off the isolation hall. On 8/27/2020, at 2:17 PM, V36, Medical Director, stated that he did not write the order to discontinue the weights, nor was he aware they had been. R7's Nursing Notes document that on 8/28/2020, R7 experience nausea, vomiting and stomach pain. R7's POA (Power of Attorney) was contacted and requested R7 be sent to the emergency room for evaluation. On 9/1/2020, at 2:15 PM, V34, R7's family member, stated R7 had been admitted to the hospital and was severely dehydrated. R7's Dietary Notes, dated 8/28/2020 documents R7's current weight was 137 and that R7 had experienced a significant weight loss of 10.46%. The Dietary Note documented recommendations to add to weekly weight and begin health shake three times daily with meals. On 9/3/2020, at 1:20 PM, V36, stated, A 10% weight loss from not eating is harmful to the patient and could have potentially been the cause of her (R7's) hospitalization . Some residents require a lot more cueing in order to eat. As of 9/3/2020 at 3:51 PM, after multiple request, the facility had still not provided an appetite log for R7.

Based on observation, record review and interview, the facility failed to prevent the formation of pressure ulcers and provide pressure relief for 1 of 3 (R2) reviewed for pressure ulcers in the sample of 10. This failure resulted in the worsening of R2's 5 pressure ulcers. Findings include: R2's Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status score of 8, moderately impaired cognition and requires one-person physical assist for bed mobility. R2's Physician orders, dated 8/1/2019, documents [DIAGNOSES REDACTED]. R2's Departmental Notes, dated 7/23/2019, documents that R2 went to the local hospital Emergency Department for a displaced femoral fracture. R2's Physician's Orders, upon return from hospitalization , were dated 7/29/2019. On this date, there was no documentation in the Departmental Notes regarding R2's readmission to the facility or an assessment completed regarding R2's skin condition. R2's Evaluation of Pressure Ulcer Risk, dated 7/29/2019, documents he is at risk for pressure ulcers due to his incontinence of bowel and bladder and being bedfast. The Evaluation documented that if R2 is at risk then interventions should be placed on care plan. The first Departmental Note written after R2's readmission, dated 7/31/2019 at 4:10 AM, documents, Resident has several bandages to (bilateral lower extremities). This Departmental Note did not document R2 had any pressure ulcers. R2's Weekly Skin report, dated 7/31/2019, documents, R2 had a right lower leg skin tear that measured 7.0 centimeters (cm) by (x) 6.5 cm x 0.1 cm. The Skin Report documents R2 had a right knee skin tear, measuring 1.5 cm x 1.4 cm x 0.1 cm. The Weekly Skin Report documented that R2 had a skin tear on his right hip and knee, and the skin tear on the knee remained scabbed. R2's Physician's Orders, dated 7/31/19, documented Cleanse skin tear to right inner knee with wound cleanser, apply xeroform( non-adherent dressing used to maintain a moist wound environment, and is made of fine mesh gauze [MEDICATION NAME] with [MEDICATION NAME]) and dry dressing change daily and PRN (as needed) until healed and Cleanse skin tear to right lower inner leg with wound cleanser, apply xeroform and dry dressing, change daily and PRN until healed. There was no Physician order for [REDACTED]. R2's Care Plan, dated 4/9/2015, documents undated interventions of Turn and reposition during care and activities and PRN (as needed). The Plan documents, Weekly skin assessments. It continues, Observe skin for changes during care daily. Report any changes to the nurse immediately. On 8/8/2019 at 8:30 AM, R2 was lying in bed on his back, with his bilateral knees bent and touching and legs drawn up towards his abdomen. R2's left arm was drawn up to his chest. V7, Certified Nurse Assistant, (CNA) was holding R2 on his back while V8, CNA, went to get V5, License Practical Nurse (LPN) to perform wound care. V7, CNA, was able to hold R2 contracted legs apart. No padding was noted in between R2's legs while in bed. No dressings were on R2's pressure ulcers on the left inner thigh, left inner knee and right inner knee. The pressure ulcer to the right inner knee measured approximately 3 to 4 centimeters (cm) with yellow mucous like tissue (slough) in the center of the ulcer and the edges were white in color. The pressure ulcer to the left inner knee measured approximately 3 to 4cm, with dark brown to black tissue (eschar) in the center of ulcer and the edges were white. The pressure ulcers to the right and left inner knees were adjacent to each other. The pressure ulcer to the left inner thigh, measure approximately 2 to 3 cm. The center of the ulcer has yellow slough and the edges were pink. On 8/8/2019 at 8:50 AM, V5, License Practical Nurse (LPN), came into the room and removed the dressings to R2's right lower leg (shin). R2's right lower shin pressure ulcer measured approximately 7 cm in length and approximately 4 cm in width. The center of the ulcer had black eschar and some yellow slough noted to the edges. V5 removed R2's dressing from his right hip. The pressure ulcer to R2's right hip approximately measured 7 cm round with black eschar in the center of the ulcer and yellow slough around the edges. At 9:00 AM, V5, LPN, stated, He didn't have any open areas on his skin when he went to the hospital. He came back with all of these (open areas) and these are not skin tears, they look like pressure sores to me. On 8/8/2019, R2 remained in bed, in a (concave) mattress, on his right side, without benefit of repositioning from 9:30 AM until 11:45 AM based on 15 minutes or less observation intervals. There was not a departmental note in R2's chart documenting V17, R2's Physician, was notified of the increase in size or changes of the pressure ulcers from 7/31/2019 to 8/8/2019. The facility's Weekly Pressure Wounds report, dated 8/12/2019, documented R2 had an unstageable pressure ulcer to his right lower leg measuring 8.2 cm x 6.0 cm, granulation eschar/necrotic tissue. The report documented he had an unstageable pressure ulcer to his right knee measuring 2.6 cm x 2.2. cm, granulation/eschar/necrotic tissue. The Report documented he had an unstageable right hip pressure ulcer measuring 5.5 cm x 8.9 cm with granulation eschar/necrotic tissue. The Report documented he had an unstageable left knee pressure ulcer measuring 2.8 cm by 5.0 cm with granulation eschar/necrotic tissue. The Report documented he had an unstageable pressure ulcer to his left thigh measuring 2 cm x 3.8 cm. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. R2's Physician orders, dated 8/12/2019, documents change in pressure ulcer dressings, added a nutritional supplement and asked for a wound specialist consult. On 8/7/2019 at 9:00 AM, V4, R2's Healthcare Power of Attorney, stated, He (R2) has open sores and they (staff) are not turning him like they should. On 8/8/2019 at 3:45 PM, V2, Director of Nurses (DON), stated that she expects the residents to be turned and repositioned every 2 hours and as needed, especially if they have pressure ulcers. On 8/8/2019 at 9:55 AM, V2, DON, stated, He (R2) was readmitted from the hospital with the open areas to his right hip, right shin, right and left inner knees and left inner thigh and our wound nurse (V14), who is on vacation this week, mislabeled these. I looked at them yesterday (8/7/2019) and these are not skin tears, these are pressure ulcers. On 8/12/2019 at 1:23 PM, V14, Wound Nurse, stated, The areas to his right hip, right leg and inner knees were skin tears when he returned to the facility (on 7/29/2019) but they are pressure sores now. V14 continued, There are not measurements for last week (week of 8/5/2019) because I wasn't here, I was on vacation. V14, also stated, I will get him a low air loss bed, it should be here tomorrow. The facility's policy, Turning and Positioning Program, dated 7/2018, documents, 1. Turning schedule will occur at designated times. 2. Charge Nurse is responsible for visually observing and assisting with the turning and positioning as needed. The facility's policy, Pressure ulcer/injury and skin conditions guide for wound evaluation documentation, dated 11/2017, documents, Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form/Skin Condition Form as appropriate. It continues, The Director of Nursing Services and/or designated Licensed Nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The resident's current care plan will also be reviewed.

Based on interview and record review the facility failed to ensure residents were free from verbal and/or physical abuse for 3 of 4 residents (R23, R81 and R100) reviewed for abuse in the sample of 32. This failure resulted in psychosocial harm for R23 in that, a reasonable person would react to such a situatuion with feelings of anxiety, distress, frustration and fear. Findings include: 1. R23's Physician order [REDACTED]. R23's Minimum Data Set ((MDS) dated [DATE] documents R23's Brief Interview of Menal Status (BIMS) score was a 3, which represents severe impairments for decision making. R23's Care Plan dated 07/2018 documents I have a [DIAGNOSES REDACTED]. I am unable to follow instructions, and I don't communicate well. R23's Care Plan also documents approach me from the front in an unhurried manner. I require assistance with my Activities of daily living due to Alzheimer's. R23's Incident Report Form dated 08/15/17 documents an allegation of abuse was received. V13's Witness Statement from the Facility Incident Report Form dated 08/15/17 documents V13 Housekeeper stated Around 1:50 PM I was called down the hall by (V14 Certified Nursing Assistant/CNA) to help her with (R23). (R23) cannot speak or feed herself. (V14) got upset with the resident, because she wet the bed. (V14) was trying to rush and change (R23). (V14) stated she was tired of her F------g A- -. She was also calling (R23) b- - - -h. (V14) was pushing and shoving (R23) around in the bed and cursing. (V14) left (R23's) clothing half way down. (V14) slapped her with a glove 'mess' (bowel movement) on it. The facility's untitled letter dated 08/17/17 documents on 08/15/17 at approximately 2:00 PM V13 reported V14 for using profanity and wiping R23's face with a soiled glove. V14 was suspended pending the outcome of the investigation. The letter also documents that R23's medical doctor, Illinois Department of Public health, and Resident Representative were all notified. The untitled letter further documents that V14 did admit that ,while she was providing care, she stated to V13 she sh-t on my arm. V14 was terminated for inappropriate communication, while providing care. On 5/16/18 at 2:00 PM, V1, Administrator, confirmed V14 was terminated due to the abuse allegation. 2. R100's Physician order [REDACTED]. R100's Minimum Data Set (MDS), dated [DATE] ,documents in part, R100 has a Brief Interview for Mental Status (BIMS) score of 8 out of 15 (moderate impairment). On 05/16/2018 at 3:30 PM, V1, Administrator stated (V10) was terminated for an incident with (R100). I believe she was fired. A written statement from V10, Certified Nursing Assistant, (CNA) dated 08/21/2017 stated (R100) called out at 4:15 AM 'ish' to watch the game I told him it was not on, his roommate then got up to turn the television on and (R100) kept yelling he wanted to watch the game. I told him the game was not on and let him know what time it was on, he acted like he could not hear me. I got closer and told him the game was not on and to stop yelling so his roommate can sleep that is when he pulled my hair I asked him to let go and he would not while trying to pull away he turned out of his bed to kick me so smacked his hand away from my hair then reported the incident to the nurse on duty. A written statement from V11, Licensed Practical Nurse (LPN), dated 8/21/2017 documented, I was at the nurses' station and heard resident yelling out 'turn the ball game on' several times, then (V10) came to me and said somebody need to call his son, I asked why what happened, and the CNA said she was trying to tell the resident that there wasn't any ball game on and the resident said he couldn't hear her and when she got closer to resident's ear he pulled her hair and she hit his hand away and then the resident tried to kick her. At this time the call light was on so I went to answer call light. I ask the resident what is it that he needs and he stated he spilled water on the bed and needs linen changed. I then told resident it would be a minute, everybody is busy and I then asked did he pull the CNA's hair and he stated No, I didn't pull her hair and she hit me right here pointing to left side of face and right here pointing to right wrist, then asked is it red. No redness to face but the right wrist had some redness. I then told CNA to come off floor and clock out. This was 4:30 AM. The Facility Report dated 08/23/2017 documents in part, On 08/21/2017 at 4:30 AM, (R100) reported to his nurse that his CNA, (V10), struck him on the left side of his face and right wrist. (V10) was immediately suspended pending the outcome of the investigation. Charge nurse assessed (R100) for injury; Pain/Skin Evaluation were completed with redness to the right wrist noted/ (R100) denies pain. Physician Resident Rights and State were made aware of the incident. An investigation was initiated. The Category One Violation Employee Corrective Counseling Memorandum documents Category One Violation as 'Termination of Employment' for (V10) on 08/25/2018. On 08/21/2017 at approximately 4:30 AM (R100) reported to his nurse that his CNA (V10) struck him on the left side of his face and right wrist. (V10) was immediately suspended pending the outcome of the investigation. Charge nurse assessed (R100) for injury: Pain/Skin Evaluations were completed with redness to the right wrist noted. (R100) denied pain. Physician, Resident Representative were made aware of the incident. Conclusion is listed on separate document dated 08/23/2017. Category 1.13- Conduct is immoral, improper, fraudulent or inappropriate in the workplace. 3. R81's POS dated (MONTH) (YEAR), documents R81 has a [DIAGNOSES REDACTED]. R81's MDS dated [DATE] documents a BIMS score of 15 out of 15 (cognitively intact). On 05/16/2018 at 9:36 AM R81 stated, I am a large woman and I had diarrhea and (V16) Certified Nursing Assistant (CNA), she wiped me but she only did the outside. I told her to dig in there and get that stuff out and she acted like I was bothering her. My private area was burning and it needed cleaned. When I asked the (V16) she told me I was a pervert. I told (V1, Administrator) about it and she asked me if this was a nursing issue or if I felt I was verbally abused? I told her I feel emotionally and verbally abused and I do not want that CNA to ever give me care again. Then about a week later (V1) came back to me and asked me again if I felt like I was verbally abused or just an issue with care not being given correctly and I responded whatever as we had already discussed this and I felt awkward and like she just was going to do whatever she wanted to do. I again said Please don't let that CNA take care of me ever again. On 05/16/18 at 11:13 AM, V1 stated I did not suspend (V16) the CNA because after talking with the resident she stated it was not abuse. The Facility Incident Report dated 05/11/2018 documents in part, Resident reported that her CNA on evening shift yelled at her during care on 05/10/2018. Patient reported this allegation talked to (V1) at approximately 12:30 PM. V16's Individual Employee Time Card dated 05/10/2018 documents V16 worked 3:51 PM to 10:01 PM. On 05/11/2018 V16 worked 5:43 PM to 5:56 AM. The timecard does not documentV16 was suspended pending the investigation. The Facility Incident Report dated 05/11/2018 documents Resident reported that her CNA on evening shift yelled at her during care on 05/10/2018. Patient reported this allegation talked to Executive Director at approximately 12:30 PM. R81's statement dated 05/11/2018 documents, (V16), yelled at me because I wanted her clean me up again. V1, Executive Director, What did they say?, I don't know what she said but I didn't like it. She was talking to (V18, CNA).

Based on interview and record review, the facility failed to timely identify a significant change in condition and failed to assess/monitor for that significant change for 2 of 3 residents (R2, R4) reviewed for change in condition in a sample of 5. This failure resulted in R2's overall decline in functional ability due to an undiagnosed fractured femur for 4 days resulting in hospitalization and admission to Hospice. Findings include: 1. R2's Admission Record documents R2 was admitted to the facility on [DATE] following hospitalization for [MEDICAL CONDITION] with Collapse, urinary tract infection and history of fall. R2's Electronic Health Record (EHR) Departmental Notes, dated [DATE], at 12:35 PM, written by V10, Licensed Practical Nurse (LPN), documents, Therapy noted swelling to left knee area. Family here. Had FNP (facility Nurse Practitioner) look at it, denied pain or discomfort. NP ordered XRAY to area and relaying to therapy to not work with area til Xray results are received. An addendum entered by V10 at 2:26 PM documents, Called (mobile xray) and scheduled XRAY to right knee. There was no documentation or assessment as to extent of R2's leg swelling, discoloration if any, any change or limitation in range of motion or ability to bear weight. R2's EHR Departmental Notes, dated [DATE] at 12:24 AM, written by V12, LPN, did not address R2's swollen leg. The Note at 3:39 AM later that morning, documents she left a message with the general medicine with right knee x-ray results. The Radiology Report of R2's Right Knee x-ray, dated [DATE] documents the conclusion as: Modest arthritis of the right knee, old fracture deformity of the distal femur metaphysis, grossly intact hemiartroplasty along the medical aspect of the joint. R2's EHR Departmental Notes, dated [DATE] at 11:33 AM, entered by V10 did not document anything regarding R2's right knee swelling. At 1:31 PM later that day, V10 documents monitoring to right knee, continues to have swelling and noted discoloration to right side of knee. In bed resting. U/A (urinalysis) is still pending. Called for lab results. There is no documentation that V3, R2's Primary Care Physician, was notified of the continued swelling and the newly noted discoloration. The nurse notes did not document the extent of the swelling and discoloration. R2's EHR Departmental Note dated [DATE] at 12:18 PM by V12 and documents [MEDICAL CONDITION] and bruising to R2's right knee continues with no c/o pain voiced. Again, there is no description or status of R2's leg regarding the [MEDICAL CONDITION] and bruising to determine if it was more extensive or not. R2's Departmental Notes, dated [DATE] at 1:44 PM, V4, Registered Nurse (RN) documents Right upper leg from knee to upper thigh continues [MEDICAL CONDITION], TED hose on. Stated right leg has pain if it is moved too fast. Pedal pulse present. Leg warm. Appetite poor, refused to eat meal offered, soup refused. Took fluids fair. Bruising to right leg outer thigh, under thigh and inner thigh area continues. There is no documentationV4 noted the change and notified R2's Physician, V3, or his nurse practitioner, V9. R2's Departmental Note, at 10:08 PM on [DATE], written by, V13 (RN) documents Resident remained in bed this shift The Note continued to document Assist required for dinner, resident consumed approximately 40% of meal and was fed by staff. Resident continues to have swelling of rt (right) leg from thigh to knee as reported by day shift, no redness or extreme warmth to Rt leg noted, TED hose in place, 2+ [MEDICAL CONDITION] present, able to flex and dorsal flex rt foot stated painful to touch rt thigh. Again, there is no documentation V13 notified V3 and V9 of R2's complaints of pain. R2's Departmental Notes, dated [DATE] at 9:45 AM, written by V4 and documents Right upper leg continues swollen, stated only hurts when weight applied to leg. Appetite poor, only ate few bites at breakfast, fluid intake fair this am, Bruising continues to right upper thigh area. R2's Departmental Note, dated [DATE] at 3:05 PM, written by V4 documents 1pm resident noted to have change in condition. Hands and feet cold and pale in color. Pulse Ox (oximetry) 75% on room air applied O2 (oxygen) @ (at) 3L (Liter)/min (minute) bring up to 82%. Noted rubbing with expiration in bilateral upper lobes. Has not voided this shift Responds to verbal stimuli only. The Note documented R2 was transported to the emergency room via an ambulance. Emergency Medical Services (EMS) Report dated [DATE] at 12:39 PM documents pt (patient) was found alert in his bed not accompanied by with anyone. Pt was assessed and no palpable blood pressure was able to be obtained initially from EMS. Once staff arrived RN reported that he has been acting abnormal all today and is complaining of right leg pain. The area was visualized and bruising was noted from his calf to groin bruising was noted on his posterior only. He denied any other complaints. Pt was in a warm room but his extremities were cool to touch resulting in an accurate pulse ox reading. Pt was transferred to EMS cot and taken by ambulance to the hospital. The Hospital Physician Documentation dated [DATE] at 1:11 PM documents on admission, the Patient's speech is incomprehensible, patient present to the ED (Emergency Department) by EMS (Emergency Medical Service). The Exam completed by V14, ED Physician, documents The patient does not display signs of respiratory distress, and under Appearance, he documents normal except for affect area, significant amount of ecchymosis noted to posterior right leg from inguinal region down to mid calf and swelling of the hamstring, posterior aspect of right knee and right calf moderate amount of swelling with tenderness to palpation noted to left knee. R2 was diagnosed with [REDACTED]. The hospital History and Physical (H&P) dated [DATE] documents the same [DIAGNOSES REDACTED]. The H&P documented R2 was evaluated for Hospice, transitioned to Hospice and where he expired on [DATE]. On [DATE] at 2:20 PM, V10 stated she had taken care of R2 since his admission and that he came into the facility for strengthening and therapy so he could return home. V10 stated on [DATE], R2 was in bed and the night nurse (V12 LPN) had told her R2 had a decline and also therapy had said he had declined from the day before. V10 stated therapy (V6 PTA, Physical Therapy Assistant) told her his knee was swollen with slight redness outer right side of knee. V10 stated she looked at R2 and noted the swelling/redness then asked the Nurse Practitioner (NP), V9, who was in the building to look at him. V10 stated V9 looked at him and ordered a urinalysis and a right knee x-ray. V10 identified V11 Certified Nurse's Aide (CNA) as not reporting anything unusual to her on [DATE]. On [DATE] at 2:45 PM, V6, PTA, recalled noting R2's swelling on [DATE] and reporting it to V10. V6 stated she also reported it to V7, Physical Therapist, her supervisor. V6 stated R2 required two person assist to transfer from the wheelchair to the bed that afternoon and usually he was contact guard or supervision. V6 stated R2 was not guarding his leg that day but did state he was having some pain. V6 stated she saw R2 the next day on [DATE] and he was in bed talking to people who weren't there and was very different than he usually was. V6 stated she did leg exercises on [DATE] since the x-ray was negative but R2 did not come to therapy after [DATE]. Physical Therapy (PT) Daily Treatment Notes dated [DATE] documents R2 ambulating with a front wheeled walker with contact guard for safety and he was instructed in proper hand placement when ascending/descending for sit to stand and w/x (wheelchair) to/from bed transfers. PT daily notes dated [DATE] entered by V7, PT, documents no gait today secondary to B (bilateral) knee pain and pain ,[DATE] before tx (treatment). On [DATE], the PT notes document PT (patient) is very confused when attempting all bed mobility and transfers today. Assessed BLE (bilateral lower extremities) after transfer with Pt R (Right) knee swelling medially, instability with warmth (no redness). Notified nurse practitioner to who stated to hold rest of TX (treatment) and that she will order x-ray. Notes dated [DATE] document V6 continued to do exercise on R2 and Pt exhibiting confusion with TX, notified RN. RN stated Rt knee x- ray was negative for FX (fracture) and only showing arthritis. A PT note documented at 9:23 AM on [DATE] documents pt unable to verbalize pain rating. Occupational Therapy (OT) Daily Treatment notes dated [DATE] documents resident completed bilateral resistance exercises with minimal resistance. Communicated with caregiver today regarding his treatment with OT and she was pleased and stated that he should be home shortly. On [DATE], an OT note documents standing with walker support and SBA (stand by assist). On [DATE], the OT documents R2 completely omnicycle for 15 minutes with resistance of 2 with activity output of 0%. On [DATE], the OT Note documents Transferred from w/c to bed with Max A (assist) due to weakness and required constant verbal instruction for placement on body throughout transfer. On [DATE], the OT Note documents further decline transfer from supine to sitting at edge of bed with mod (moderate) A (assist.) Required tactile and verbal instruction to complete transfer. On [DATE], the OT documents Patient very confused on this date. Could not figure out how to utilize utensils. Spoke to CNA who concurred with confusion and weakness. R2 state that his knee was in a lot of pain, x-ray came back resulting in arthritis findings. Transferred back to bed with Max x (times) 2. On [DATE] at 2:45 PM, V7, Physical Therapist (PT) stated he also saw R2's leg swelling on [DATE] and prior to the swelling in the earlier part of the week. V7 stated R2 was able to take a few steps with the walker. V7 stated after [DATE], R2 was maximum assist. V7 stated typically he would fill out a stop and watch for a condition change but did not on [DATE] as the NP saw R2. V7 stated he would expect the nurses to notify the physician of such a functional change as R2 had and to continue to monitor it. On [DATE] at 2:55 PM, V3, Primary Physician, stated he understood that his Nurse Practitioner saw R2 the day the swelling was first identified and ordered an x-ray of the knee which was negative. V3 stated he typically likes to wait a week to re-x-ray unless the resident is exhibiting changes in condition such as R2 did with increased bruising, swelling and overall decline in functional ability. V3 stated the original x-ray may have been done when the fracture was non-displaced and with movement, the fracture may have become displaced causing the change. V3 agreed that continued monitoring would have been warranted. V3 also stated that mobile x-rays do not catch all the details that a hospital based one would and the fracture may have been there but undetected by the mobile x-ray when done on [DATE]. V3 stated he was not aware of the increase/extent of the swelling or bruising nor was he aware of the overall functional decline R2 exhibited in the three days following the negative mobile x-ray. V3 stated he would have expected the nurses to monitor or any change and notify him or at least the NP of the changes as he would have sent him to be reevaluated at the hospital. On [DATE] at 3:34 PM, V9 NP stated when she first saw R2 on [DATE], he had lateral right knee swelling with no bruising. V9 stated he was in his wheelchair in his room and she was told by the PTA, V6, that he was complaining of some pain in his knee as well. V9 stated R2 told her he was having pain when he stood but could flex/extend with no pain while in the wheelchair. V9 stated she ordered the x-ray and a urinalysis not knowing he was already on an antibiotic for a urinary tract infection at the time. V9 state mobile x-rays do not pick up everything and that she would have sent him out to the hospital or at least ordered another x-ray had she been informed of the increase in swelling/bruising and not being able to bear weight. V9 stated she would have expected the nurses to assess and monitor him to changes and to inform either her or V3 if they occurred. On [DATE] at 11:15 AM, V16, Certified Nurse's Aide (CNA), stated he had taken care of R2 routinely since his admission to the facility and that at the beginning of the week, he was a stand by assist to supervision for transfer to a total lift by Friday [DATE]. V16 stated R2's leg on [DATE] was swollen from his knee to the mid thigh area with purple/brick red bruising to the outer knee and posterior aspect of his knee. V16 stated R2 had minimal confusion prior to this and that on Friday, he was more confused but denied pain saying he was okay. V16 stated R2's eating/drinking declined also and on [DATE], he was still somewhat continent but not on Saturday. V16 stated the nurses were aware of R2's condition. On [DATE] at 3:06 PM, V14, emergency room Physician, recalled R2 stating he came in with a severe femur fracture and the nursing home could not give him any information as to how long R2 had the bruising and extensive swelling on his right knee. V14 stated the swelling was so extensive he had to cut R2's pants off and the swelling went from his groin area to below his knee. V14 stated the bruising was also extensive. V14 stated the nurses should have noted it at the nursing home. V14 stated he talked with two nurses, one was the head nurse who also couldn't identify when the injury occurred and the other stating it occurred in the bathroom when staff was transferring him and he got his leg caught on the toilet seat/frame. V14 stated both of them said R2 was unable to ambulate and was a 2 person assist for transfers. V14 stated R2 was alert to self only and was unable to identify pain or the severity of it when he presented to the emergency room . V14 stated he had the conversation with the family when they chose Hospice. On [DATE] at 2:23 PM, V17 Director of Emergency Services at the hospital stated R2's admitting [DIAGNOSES REDACTED]. On [DATE] at 3:00 PM, V2, Director of Nurses stated she observed R2 on [DATE] and noted the swelling but not any bruising. V2 stated she did not see him after [DATE]. The facility's policy/procedure entitled Notification of a change in a resident's status dated ,[DATE] documents the policy as: the attending physician/physician extender (Nurse Practitioner, physician assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in resident's condition, per standards of practice and Federal and/or State regulations. Under Procedure, it documents the guideline for notification includes, in part, change in level of consciousness, abnormal complaints, and unusual behavior. 2. R4's Admission Record documents R4 was admitted to the facility on [DATE]. R4's Minimum Data Set ((MDS) dated [DATE] documented R4's Brief Interview of Mental Status (BIMS) score to be 11, or moderately cognitively impaired. The MDS also documents R4 to be continent of bowel and bladder. R4's EHR Nurse's Notes documented R4 to be usually incontinent on [DATE] at 12:30 AM. On [DATE] at 3:57 AM, the nurse notes document R4 to be incontinent bowel but did not document any other information regarding this. On [DATE] at 1:04 PM, [DATE] at 2:00 AM, [DATE] at 12:23 AM and on [DATE] at 12:47 AM to be usually continent of b&b (bowel and bladder). On [DATE] at 12:00 PM, the EHR Nurses Note documents R4 remained in her room thought out the day. Complain of diarrhea. PRN given. There was no further documentation regarding R4's diarrhea. On [DATE] at 12:21 AM, EHR Nurse note document again, R4 was usually continent of B&B. On [DATE] at 12:45 PM, the EHR Nurse's Note documents Resident had1 small loose stool this am, received [MEDICATION NAME] as ordered with no further stools. R4's EHR Nurse's Note, dated [DATE], documents she was discharged to home with her son. R4's History and Physical records dated [DATE], documents R4 was presented to the hospital with diarrhea, cough, congestion, and feeling unwell. The note continues to document upon arrival to ER (emergency room ) was diagnosed with [REDACTED]. On [DATE] at 9:45 AM, V18, R4's family representative/son, stated R4 had diarrhea most of the time she was at the facility and the facility did not take measures to identify and/or treat the [MEDICAL CONDITION]. V18 stated she ended up in the hospital two days after discharge. R4's Elimination Reports document R4 to have loose stools the following dates and times: [DATE] at 1:27 PM, [DATE] at 5:51 AM, [DATE] at 1:13 PM, [DATE] at 10:15 PM, [DATE] at 1:21 PM which was large, [DATE] at 7:49 PM and [DATE] at 4:12 AM. The Medication Administration Record [REDACTED]. There was no documentation of notification to V3, R4's Physician, of the continued diarrhea from [DATE] to discharge on [DATE]. On [DATE] at 11:15 AM, V16, Certified Nurse's Aide (CNA), stated he works full time on R4's hallway. V16 stated R4 had diarrhea most of the time she was at the facility which was watery, foaming at times. V16 stated he did not recall if it had any odor to it as she was usually continent and had the bowel movements in the toilet. V16 stated he had reported the diarrhea to the nurses on several occasions.

Based on record review and interview, the facility failed to supervise toilet use for 2 of 5 residents (R2 and R5) reviewed for falls in a sample of 21. This failure resulted in R5 falling and sustaining a fracture of the left hip. The findings include: 1. R5 is a [AGE] year old female. The physician's orders [REDACTED]. R5's Minimum Data Set (MDS), dated [DATE], documents R5 required extensive assistance for transfers, was not steady, only able to stabilize during transfer and moving on and of the toilet with staff assistance, did not walk and used a wheelchair. The MDS documents she has severe cognitive impairment. R5's Care Plan, dated 10/30/2013, document in part, that R5 is at risk for falls related to impaired mobility, impaired safety awareness, use of psychotropic medication, history of falls prior to placement and [DIAGNOSES REDACTED]. The Facility Incident Report, dated 10/26/2015, documents R5 had a fall on 10/26/2015 at 4:51 PM. The Report documents Resident complained of pain following fall, x-ray at hospital performed revealed fracture. Final Investigation will follow. Administrator notified 10/26/2015 at 5:45 PM, Medical Doctor notified 10/26/2015 at 6:00 PM, Family Notified 10/26/2015 at 6:05 PM. The Facility's Post Incident Actions with an Incident date of 10/25/2015, at 7:40 PM, documents in part, (E4, Licensed Practical Nurse,LPN) was assisting another resident in his room at which time the nurse was notified that (R5) had fallen in her room. (E4) went into (R5's) room upon entry nurse found (R5) lying on her floor. (R5) stated that she was unaware that she could not walk by herself at that time (E4) assessed (R5) no bruises or injuries at this time. Resident was assisted to her bed. Resident denies any pain or discomfort at this time. Resident room well lit. Resident room free of clutter. Will continue to monitor. R5's Care Plan was not revised after this fall. There was no documented entries on 10/25/15 in R5's Nurse's Notes which was the date of R5's fall. The first Nurse's Note regarding the fall is dated 10/26/2015 at 3:19 PM, documents in part, Resident currently on Instruction Follow Up (IFU) in relation to a fall. Resident had complained about left hip. Resident has bruising to left elbow and reddening to left hip area. Writer placed call to general medicine and received order per phone for a bilateral hip x-ray. The next entry in the Nurse's Notes, dated 10/26/2015 at 6:37 PM, document in part, At around 7:40 PM, (E4) was alerted by (E5), Certified Nursing Assistant (CNA) that (R5) had fallen. (E4) went into (R5) room. Upon entry found (R5) lying on floor. Resident had no bruises or injury. Resident was offered ice. Resident refused. Resident was offered pain medication resident denies any pain or discomfort. Resident states she is sorry about what happened she forgot she could not walk by herself. The following Nurse's Note, dated 10/26/2015 at 8:04 PM, document in part, Resident x-ray results obtained resident has fracture to left hip. (R5) transported to hospital. The x-ray report, dated 10/26/2015, documents in part, (R5) sustained a fracture involving the left femoral neck with modest displacement. The Facility's Final Incident Report, dated 10/27/2015, documents in part, (R5) was attempting to ambulate without assistance when she lost her balance landing on her left side. Charge nurse assessed (R5) for injury. Physician made aware of the incident. On 10/26/2015 (R5) had redness noted to left hip with bruising and complaints of low groin pain. (R5) was assessed with [REDACTED]. On 7/21/16, at 1:00 PM, E2, Director of Nurse's, stated R5 had only one fall resulting in a fracture which occurred on 10/25/15, not 10/26/15 as documented in the Facility Incident Report. E2 said this was a documentation error. On 07/21/2016 at 9:00 AM, E4 stated (E5) was toileting (R5) in her room. I was in the hallway with another resident who was leaving the dining room. The other resident's knee began to buckle and I yelled out for help. (E5) immediately came to assist me. (R5) was left alone in the toilet. (E5) went back into (R5's) room and found her on the floor. I then went into the room and found (R5) on the floor. I assessed her and there were no bruises or injuries and we put her back to bed. My shift was almost over I work 7 PM-10 PM and I left. On 07/21/2016 at 9:18 AM, E5 stated I was toileting (R5) when I heard (E4) calling out for help. I left (R5) alone (she was on the toilet) to help (E4). When I came back into (R5's) room I found her on the floor. I came and got (E4). Yes, (R5) was complaining about pain. We eventually got an x-ray and (R5) had fractured her hip. (R5) was complaining about pain in her hip after she fell . On 07/20/2016 at E7, CNA stated Yes, I remember (R5) falling. She was trying to go to the bathroom she was ambulating and fell . Yes, she was complaining of pain right away. I believe she broke her hip. 2. R2's Physician order [REDACTED]. R2's MDS, dated [DATE], documents R2's balance moving on and off the toilet is not steady, and she is only able to stabilize with staff assistance. R2's MDS also documents R2's balance moving from surface to surface is not steady, and can only be stabilized with staff assistance. R2's MDS also documents R2 needs extensive assistance with a one person physical assist for toileting. R2's Care Plan, dated 03/2016, documents R2 has a personal history of falls. The Care Plan documents R2 uses an alarming self releasing belt while up in a wheelchair. R2's Nurse's Note, dated 07/04/16, at 10:42 AM documents E19, Certified Nursing Assistant (CNA) responded to a call light, and observed the resident sitting upright on the floor of the rest room. R2's Resident Incident Report, dated 07/04/16, documents R2 was trying to toilet herself, E19 went into the restroom, when E19 observed resident sitting on the floor. On 07/21/16 at 8:50 AM, E19 stated (R2) fell on the Fourth of July. I had taken her to the bathroom, and put her on the toilet. She asked for brief privacy. I heard someone else call out, and I went to check. The other resident wanted to go to the toilet, and I told her I would be back. When I reentered the room (R2) was sitting on the floor with her pants up. On 07\22\16 at 1:45 PM, E1, Administrator stated If the resident is Care Planned to need assistance, unless there is an emergency they should be near by to help.

Based on record review and interview, the facility failed to operationalize the facility's abuse policy by failing to report an allegation of abuse to the administrator immediately, allowing a Certified Nursing Assistant to have direct contact with residents after a potential abuse incident, delaying the initial investigation of potential abuse and to thoroughly investigate injuries of unknown origin. This had the potential to affect all of the 89 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/3/12, the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. Findings include: 1. The facility's Abuse Prevention Policy, not dated, documented "1. Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 2. The Administrator must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator must be called at home or must be paged and informed of such incident." The Policy's Investigation Section documented "The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. 2. On 8/1/12 at 10:25 AM, an interview was conducted with E16, Certified Nurse's Assistant (CNA) . E16 stated in March 2012 she was assisting E13 (CNA) with transferring R3 into a shower chair. E16 stated R3 was calm but was repeating herself. E16 stated E13 told R3 to "shut the fu-- up" and called R3 a "bi---." E16 stated while E13 was saying these things to R3 she was poking R3 in the forehead. E16 stated she did not report this incident to any facility staff after this incident occurred. E16 stated in May 2012 she reported the incident which occurred between E13 and R3 to E11, Licensed Practical Nurse (LPN). E16 stated E11 encouraged her (E16) to report the incident to the E1, Administrator, and E2, Director of Nurses (DON). E16 stated she did not report this incident to E1 or E2. On 8/1/12 at 9:00 AM, an interview was conducted with E17 (CNA). E17 stated a few months prior, she and E18 (CNA) were standing at the nurse's station and overheard a CNA tell E11 that E13 pushed another resident in the forehead and call this resident a "bi---". E17 stated she and E18 report this allegation to E19, Human Resource Director (HRD), immediately. E17 stated she and E18 went to E2's office and reported the allegation to E2. E2 told them the allegation could not be investigated because it was hearsay. E17 stated "We got very mad because we are told at every meeting to report any allegation of abuse but when we did, she wouldn't investigate it." On 8/1/12, at 9:55 AM, an interview was conducted with E11(LPN). E11 confirmed that in May 2012, E16 reported to her that E13 called R3 and [***] and was poking R3 in the middle of her head. E11 stated she told E16 to report the incident to E1 and E2. E11 stated she did not personally report this allegation to E1 and E2. E11 stated she was aware E16 did not report the allegation but stated E17 and E18 (CNAs) reported the allegation to E19, HRD. On 8/1/12 at 12:05 PM, an interview was conducted with E1. E1 stated he was not aware of the above allegation of abuse until today (8/1/12). The facility failed to immediately report an allegation of abuse to E1 which delayed the investigation of the allegation. This allowed E13 to have direct contact with R3 after the alleged incident in March 2012 occurred. 3. R3's Resident Incident Report dated 5/19/2012 at 10:00 AM documented "Called to shower room by (E8), CNA. Resident noted to have large purple bruise from left wrist to left elbow. Resident questioned and doesn't recall what happened." On 7/27/12, at 9:50 AM, an interview was conducted with E1. E1 stated the Department was not notified of this allegation. On 8/2/12, at 3:30 PM, an interview was conducted with E1. E1 stated the only statements obtained regarding this incident were from E5 and E20. The facility's Investigation for this incident was reviewed. The only statements obtained regarding R3's bruise were written by E5 (LPN and E20 (LPN). The facility did not conduct a thorough investigation by obtaining statements from all direct care staff who had cared for R3 around the time her bruise was discovered. Furthermore, the facility failed to report this injury of unknown origin to the Department. 4. R3's Resident Incident Report dated 7/23/12 at 3:00 PM documented "(E6, Certified Nurse's Aide, CNA) wheeled resident down from hallway into dining room when bruise was noticed by (E7, Memory Unit Manager), and E6, CNA." E6's statement dated 7/23/12 documented " As I brought (R3) into the dining room (E7) and myself noticed a bruise on her forehead, when I asked her what happened she said 'someone hit me.' I asked who hit her and she said 'I don't know.' About 30 minutes later I asked again what happened to her head, she replied 'Don't worry about it it'll go away'. I told her I needed to know but she kept saying 'It'll go away. '" On 7/26/12 at 3:30 PM, E7 was interviewed. E7 confirmed she noticed the bruise on R3's forehead around 2:15 PM on 7/23/12. E7 stated she asked R3 multiple times how she sustained the bruise and R3 did not know. E7 stated she contacted E13 because E13 had taken care of her earlier that day. E7 stated E13 said she noticed the bruise on R3's forehead and forgot to tell the nurse. E4, Registered Nurse (RN) statement dated 7/23/12 documented "On 7/23/12, I came to work on the Memory Unit. I noticed that (R3) had a half-dollar size bruise to her forehead. (E6 and E7) noticed as well and was reported to day shift nurse right before change over. I asked how it happened and no one knew. (E7) called (R3's) day shift CNA to find out if she knew. She called (E13) and (E13) stated she did notice it in shower, she put ice on bruise and failed to report it to (E5, Licensed Practical Nurse, LPN). (E5) stated that she didn't notice the bruise during day shift." E4's statement did not document that R3 had initially reported to staff she was hit by someone. On 7/27/12 at 3:30 PM, E5 was interviewed. E5 stated on 7/23/12 at around shift change E7 came to her and asked if she knew anything about the bruise on R3's forehead. E5 stated she was not aware of the bruise. E5 stated E13 was R3's CNA that day. E5 stated E13 did not report she had discovered a bruise on R3's forehead. R3's Incident Report Form - IDPH (Illinois Department of Public Health) Notification, dated 7/24/12 at 8:30 PM documented "Resident (R3) identified with a bruise yesterday, investigation started. Resident initially stated she didn't know how it happened. Today resident alleged someone hit her. Investigation to continue. Administrator immediately notified." E3 (LPN) on 7/24/12 at 8:40 PM documented in R3's nurse's note "This evening at approximately 7:30 PM I interviewed the resident concerning the bruise on her forehead. Initially the resident stated she did not know how it occurred. I asked once again and the resident stated that someone who worked here had hit her. There resident stated that they were a white female with black hair." On 7/27/12 at 2:50 PM, an interview was conducted with E3. E3 stated the evening of 7/24/12, E9 (CNA) reported R3 alleged she had been hit. On 7/26/12, at 3:00 PM, an interview was conducted with E9, CNA. E9 stated on 7/24/12 after dinner, she and E10, CNA were documenting in the hallway and E10 noticed the bruise on R3's forehead. E9 stated "I asked (R3) to come over and then asked her what happened to her forehead. (R3) said 'Nobody hurt me and put her head down.' " E9 stated she again asked R3 what happened to her forehead and R3 responded "She hit me." When asked if she (E9) had given a statement to E1 regarding this incident, E9 stated "No, they didn't ask me or (E10) to give a statement." On 7/27/12 at 11:05 AM and interview was conducted with E13. E13 stated she gave R3 a shower around 9:00AM-10:00 AM. She stated "I noticed some small bruises on her arms and a purple one on her forehead." When asked if she reported the R3's bruise to the nurse, E13 stated "I usually put them on my shower sheet but I didn't. She has a lot of bruising." The facility's final investigation regarding this incident was reviewed. E13 failed to report R3's bruise of unknown origin. The facility failed to immediately report to E1 and investigate R3's initial allegation of abuse which was reported to E6 on 7/23/12. Statements obtained through investigation were reviewed. The facility only interviewed and obtained statements from staff who observed R3's bruise. The facility did not conduct a thorough investigation by obtaining statements from all direct care staff who had cared for R3 around the time her bruise was discovered to determine the cause of the bruise. 5. The Facility Data Sheet, dated 7/26/12 documents that the facility has 89 residents living in the facility. The Immediate Jeopardy was identified to have begun at the time of the March 2012 incident (date unknown) when E16 identified potential verbal and physical abuse of R3 by E13. The facility failed to notify E1 immediately of this incident and the facility failed to remove E13 immediately from direct resident care. E1 was notified of the of Immediate Jeopardy on 08/02/11 at 8:45 AM. The surveyor confirmed through record review and interview that the Facility took the following actions to remove the Immediate Jeopardy. 1. E13 was suspended pending the outcome of the investigation as of 8/1/12. 2. All employees who had knowledge of and or witnessed the alleged abuse and failed to report per facility policy were suspended pending the investigation as of 8/1/12. 3. All employees will be re-inservices on abuse, definitions of abuse and required reporting of abuse. Inservicing will take place for all employees on shift as of 12:00 PM on 8/2/12. Additionally, inservices will be given at the beginning of each shift through Saturday 2:00 PM. No employee will be allowed to return to work until they have been in-services. 4. All employees will be provided with E1's phone number to effectively report allegations or suspicions of abuse or neglect immediately. Completed 8/2/12. 5. Systems will be reviewed to insure proper and timely notification of allegations or suspicion of abuse or neglect to appropriate parties, including responsible parties, physicians, IDPH, and police as appropriate. Completed 8/2/12 6. All employees will be interviewed during their first shift after above identified interviewing to ensure understanding of policy and to determine if they are aware of any possible abuse or neglect that may not have been reported. To be completed during shift after the above mentioned inservice. Completed 8/2/12 7. All resident's will be interviewed to ensure they feel safe, have not bee mistreated, nor have any unreported concerns regarding abuse or neglect. To be completed by 8/2/12. .

Based on record review and interview, the facility failed to report an allegation of abuse to the administrator immediately, allowed a Certified Nursing Assistant to have direct contact with residents after a potential abuse incident, delayed the initial investigation of potential abuse, and to thoroughly investigate injuries of unknown origin. This had the potential to affect all of the 89 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/3/12, the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. Findings include: 1. On 8/1/12 at 10:25 AM, an interview was conducted with E16, Certified Nurse's Assistant (CNA). E16 stated in March 2012 she was assisting E13 (CNA) with transferring R3 into a shower chair. E16 stated R3 was calm but was repeating herself. E16 stated E13 told R3 to "shut the fu-- up" and called R3 a "bi---." E16 stated while E13 was saying these things to R3 she was poking R3 in the forehead. E16 stated she was scared because she was a new CNA and had not worked at the facility very long. E16 stated she left R3 and E13 alone in the shower room. E16 stated after the incident occurred, she did not report this incident to any facility staff. E16 stated in May 2012 she reported the incident which occurred between E13 and R3 to E11, Licensed Practical Nurse (LPN). E16 stated E11 encouraged her to report the incident to the E1, Administrator, and E2, Director of Nurse's (DON) . E16 stated she did not report this incident to E1 or E2. On 8/1/12 at 9:00 AM, an interview was conducted with E17 (CNA). E17 stated a few months prior, she and E18 (CNA) were standing at the nurse's station and overheard a CNA tell E11 that E13 pushed another resident in the forehead and call the resident a " bi---". E17 stated she could not recall the CNAs name who initially reported this allegation to E11. E17 stated she and E18 report this allegation to E19, Human Resource Director (HRD), immediately. E17 stated E19 notified E2. E17 stated she and E18 went to E2's office and reported the allegation to E2. E2 told them the allegation could not be investigated because it was hearsay. E17 stated "We got very mad because we are told at every meeting to report any allegation of abuse but when we did, she wouldn't investigate it." On 7/27/12 at 4:00 PM, an interview was conducted with E19 (HRD). E19 stated a few months ago E17 came to her and said she had overheard another CNA say E13 had hit another resident. E19 stated she immediately called E2. E19 stated the allegation was not investigated because E2 stated it was hearsay. On 8/1/12, at 9:55 AM, an interview was conducted with E11(LPN). E11 confirmed that in May 2012, E16 reported to her that E13 called R3 a "bi---" and was poking R3 in the middle of her head. E11 stated she told E16 to report the incident to E1 and E2. E11 stated she did not personally report this allegation to E1 and E2. E11 stated she was aware E16 did not report the allegation but stated E17 and E18 (CNAs) reported the allegation to E19, HRD. On 8/1/12 at 10:55 AM, an interview was conducted with E2. When asked if E18 and E19 reported an allegation that E13 hit another resident E2 stated "I do not recall being told that. I cannot imagine I would have said that." On 8/1/12 at 12:05 PM, an interview was conducted with E1. E1 stated he was not aware of the above allegation of abuse. The facility failed to immediately report an allegation of abuse to E1 which delayed the investigation of the allegation. This allowed E13 to have direct contact with R3 after the alleged incident in March 2012 occurred. 2. R3's Resident Incident Report dated 5/19/2012 at 10:00 AM documented "Called to shower room by (E8), CNA. Resident noted to have large purple bruise from left wrist to left elbow. Resident questioned and doesn't recall what happened." E5's (LPN) Statement, dated 5/19/12, documented "This writer was called to shower room by (E8), CNA. Resident noted have a large oval shaped bruise to her R (Right) forearm that goes from her wrist to elbow. Underside of (R) forearm free of bruising. It appears that resident bumped her arm on a hard object due to shape of bruising. No apparent finger marks noted." E5's Statement documented "When questioned, resident was not aware she had a bruise & was unaware how it happened." On 7/27/12 at 3:30 PM, an interview was conducted with E5. She stated R3 had a significant bruise from her left wrist to her left elbow purplish/red in color. E5 stated "It covered her entire forearm area. It was significant." The facility's Investigation for this incident was reviewed. The only statements obtained regarding R3's bruise were written by E5 (LPN and E20 (LPN). The facility did not conduct a thorough investigation by obtaining statements from all direct care staff who had cared for R3 around the time her bruise was discovered. On 7/27/12, at 9:50 AM, an interview was conducted with E1. E1 stated the Department was not notified of this allegation. On 8/2/12, at 3:30 PM, an interview was conducted with E1. E1 stated the only statements obtained regarding this incident were from E5 and E20. 3. R3's Resident Incident Report dated 7/23/12 at 3:00 PM documented "(E6, Certified Nurse's Aide, CNA) wheeled resident down from hallway into dining room when bruise was noticed by (E7, Memory Unit Manager), and E6,CNA. Both parties informed this nurse of bruise to forehead. See Statement. Half-sized bruise to forehead." E6's statement dated 7/23/12 documented " As I brought (R3) into the dining room (E7) and myself noticed a bruise on her forehead, when I asked her what happened she said 'someone hit me.' I asked who hit her and she said 'I don't know.' About 30 minutes later I asked again what happened to her head, she replied 'Don't worry about it it'll go away. I told her I needed to know but she kept saying 'It'll go away. ' " E7's statement dated 7/24/12 documented "(R3) came out to ice cream social on 7/23/12 at 2:15 PM. When she came to the dining room I noticed she had a bruise on her forehead. I asked her how she got it and (R3) said 'someone hit me' and started laughing. (R3) then said 'I'm kidding. I don't know what happened.' Day nurse was still here & she had no clue about the bruise. I called resident's CNA, (E13) to ask if she knew about it. (E13) said she noticed it during her shower but forgot to tell the nurse & forgot to put it on her shower sheet." On 7/26/12 at 3:30 PM, E7 was interviewed. E7 confirmed she noticed the bruise on R3's forehead around 2:15 PM on 7/23/12. E7 stated she asked R3 multiple times how she sustained the bruise and R3 did not know. E7 stated she contacted E13 because E13 had taken care of her earlier that day. E7 stated E13 said she noticed the bruise on R3's forehead and forgot to tell the nurse. E4, Registered Nurse (RN) statement dated 7/23/12 documented "On 7/23/12, I came to work on the Memory Unit. I noticed that (R3) had a half-dollar size bruise to her forehead. (E6 and E7) noticed as well and was reported to day shift nurse right before change over. I asked how it happened and no one knew. (E7) called (R3's) day shift CNA to find out if she knew. She called (E13) and (E13) stated she did notice it in shower, she put ice on bruise and failed to report it to (E5, Licensed Practical Nurse, LPN). (E5) stated that she didn't notice the bruise during day shift." On 7/27/12 at 10:50 AM, E4 was interviewed. E4 stated when she came on shift at around 2:30 PM, the other nurse was working on things regarding R3's bruise. E4 stated she did write up the incident report. E4 stated R3 said the bruise was no big deal and did not accuse anyone of abuse. On 7/27/12 at 3:30 PM, E5 was interviewed. E5 stated on 7/23/12 she did observe the bruise on R3's forehead. E5 stated R3 did not have a bruise on her forehead during the morning medication pass. E5 stated at around shift change E7 came to her and asked if she knew anything about the bruise on R3's forehead. E5 stated she was not aware of the bruise and E13 had been her CNA that day. E5 stated E13 did not mention any bruise to her. E5 stated she observed the bruise on R3's forehead. E5 stated the bruise was "a bluish/purple hue. Swelling was fresh. How could you have missed that?" R3's Incident Report Form - IDPH (Illinois Department of Public Health) Notification, dated 7/24/12 at 8:30 PM documented "Resident (R3) identified with a bruise yesterday, investigation started. Resident initially stated she didn't know how it happened. Today resident alleged someone hit her. Investigation to continue. Administrator immediately notified." E3 (LPN) on 7/24/12 at 8:40 PM documented in R3's nurse's note "This evening at approximately 7:30 PM I interviewed the resident concerning the bruise on her forehead. Initially the resident stated she did not know how it occurred. I asked once again and the resident stated that someone who worked here had hit her. There resident stated that they were a white female with black hair." On 7/27/12 at 2:50 PM, an interview was conducted with E3. E3 stated the nurse the previous evening found the bruise on R3's forehead. E3 stated the next evening she (E3) was working and E9,(CNA), came to her and said she had been hit. E3 stated she interviewed R3 and R3 stated "Someone hit me but I forgave them." E3 stated she asked R3 who hit her and R3 stated "the white lady with black hair." E3 stated E13, CNA, is the only employee who meets that description. E3 stated "(R3) is confused at times, but she is not one to say things like that." E14's, LPN, statement dated 7/24/12 documented "(E3) came to TCU (Transitional Care Unit) nurse's station et (and) stated that (R3) told her someone hit her. This nurse spoke c (with) the resident. I asked her what happened to her head resident without hesitation stated 'someone hit me and called me a [***] .' I then asked her if she knew who it was. Resident replied 'I don't know.' I then asked her what the person looked like she stated ' a white girl with long dark hair.' Resident began to cry et stated 'please don't let her hurt me again.' " On 7/26/12, at 3:22 PM, E14 was interviewed. E14 stated that on 7/24/12, E3 came to him and said R3 stated someone had hit her. E14 stated he spoke with R3 and she stated "I was hit by a girl and called a "bi---". E14 stated she could not recall the girl's name but did describe the girl as a white girl with long black hair." E14 stated R3 is confused, but she has never alleged abuse before. On 7/26/12 at 4:30 PM, an interview was conducted with R3. R3 was lying in her bed. When asked how she got the bruise on her forehead, R3 responded "She hit me." When asked who hit her, R3 responded "I don't remember." When asked what the person looked like who hit her, R3 responded "She had long black hair." When asked if she was white or black, R3 responded "White." When asked what happened, R3 responded "I was in bed. She hit me and then called me a "bi---" and told me I was going to hell." R3 began to cry and looked the other way and stated "I can't remember why she hit me." When asked if she told any of the staff about her head she responded "Yes I told them when they asked about my head." When asked who questioned her about her head she responded "The guy who runs this place." Again when asked what the person looked liked who hit her and she stated "Just like I said long black hair." When questioned regarding if the person was white or black she responded "White." R3's Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 10 (moderately impaired cognition). Her care Plan, review dated of 6/29/12, did not document R3 had a history of [REDACTED]. On 7/26/12, at 3:00 PM, an interview was conducted with E9, CNA. E9 stated she got R3 up on 7/24/12 around 5:00 PM. E9 stated she noticed a bruise on R3's forehead but did not question on R3 how she got the bruise. E9 stated after dinner, she and E10, CNA were documenting in the hallway and E10 noticed the bruise on R3's forehead. E9 stated "I asked (R3) to come over and then asked her what happened to her forehead. (R3) said 'Nobody hurt me and put her head down.' " E9 stated she again asked R3 what happened to her forehead and R3 responded "She hit me." E9 stated R3 could not recall the name of the person who hit her but described a white female with long black hair. E9 stated she immediately told her nurse, E3. When asked if any staff person fit the description R3 gave she stated "Yes. (E13)." When asked if she had given a statement to E1 regarding this incident, E9 stated "No, they didn't ask me or (E10) to give a statement." On 7/27/12 at 11:05 AM an interview was conducted with E13. E13 stated she did not get R3 up on the morning of 7/24/12. E13 stated "Midnights get her up." E13 stated she gave R3 a shower around 9:00AM-10:00 AM. She stated "I noticed some small bruises on her arms and a purple one on her forehead." When asked if she reported R3's bruise to the nurse, E13 stated "I usually put them on my shower sheet but I didn't. She has a lot of bruising." E13 stated she was aware R3 had accused "a white female with black hair" with hitting her (R3). E13 stated she was suspended on 7/25/12 but came back to work on 7/26/12. The facility's Abuse Prevention Policy, not dated, documented "1. Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitue abuse; and to determine the director of the investigation. 2. The Administrator must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator must be called at home or must be paged and informed of such incident." The Policy's Investigation Section documented "The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. 4. The Facility Data Sheet, dated 7/26/12 documents that the facility has 89 residents living in the facility. The Immediate Jeopardy was identified to have begun at the time of the March 2012 incident (date unknown) when E16 identified potential verbal and physical abuse of R3 by E13. The facility failed to notify E1 immediately of this incident and the facility failed to remove E13 immediately from direct resident care. E1 was notified of the of Immediate Jeopardy on 08/02/11 at 8:45 AM. The surveyor confirmed through interview and record review that the Facility took the following actions to remove the Immediate Jeopardy. 1. E13 was suspended pending the outcome of the investigation as of 8/1/12. 2. All employees who had knowledge of and or witnessed the alleged abuse and failed to report per facility policy were suspended pending the investigation as of 8/1/12. 3. All employees will be re-inservices on abuse, definitions of abuse and required reporting of abuse. Inservicing will take place for all employees on shift as of 12:00 PM on 8/2/12. Additionally, inservices will be given at the beginning of each shift through Saturday 2:00 PM. No employee will be allowed to return to work until they have been in-services. 4. All employees will be provided with E1's phone number to effectively report allegations or suspicions of abuse or neglect immediately. Completed 8/2/12. 5. Systems will be reviewed to insure proper and timely notification of allegations or suspicion of abuse or neglect to appropriate parties, including responsible parties, physicians, IDPH, and police as appropriate. Completed 8/2/12. 6. All employees will be interviewed during their first shift after above identified interviewing to ensure understanding of policy and to determine if they are aware of any possible abuse or neglect that may not have been reported. To be completed during shift after the above mentioned inservice. Completed 8/2/12. 7. All resident's will be interviewed to ensure they feel safe, have not bee mistreated, nor have any unreported concerns regarding abuse or neglect. To be completed by 8/2/12.

Based on observation, record review, and interview; the facility failed to assess indwelling catheter to prevent injury from the catheter, failed to properly position catheter drainage bags and tubing for one (R6) of two residents with catheters, and failed to provide incontinent care to prevent urinary tract infections for two (R5, and R9) of six residents observed for incontinent care in the sample of 17. This failure resulted in an open sore to the penis and erosion of the meatus for R6. Findings include: 1. On 6/9/11 at 8:55 AM, R6 was seated in his wheelchair across from the Nurses Station. R6 had a catheter drainage bag secured under the wheelchair. R6's drainage tubing was resting on the floor under his wheelchair. The urine in the drainage tube was dark yellow, cloudy, with sediment noted in the tubing. E17, Treatment Nurse, wheeled R6 to his room. The catheter tubing remained on the floor as R6 rolled down the hallway and into R6's room. After E17 placed R6 at the bedside, she noted the drainage tubing on the floor, and adjusted the tubing to get it off the floor. At 11 AM, E10, Certified Nursing Assistant, CNA, transferred R6 from the wheelchair to the bed. The catheter tubing fell on the floor during the transfer. E10 placed the catheter drainage bag on the bed, where it remained throughout catheter/perineal cleaning. As E10 removed R6's adult diaper, there was drainage noted in the diaper. The drainage was a moderate amount of yellow-brown thick liquid. There was a white, open ulcerated area on the tip of the penis, near the meatus. The meatus was eroded approximately 1/2 inch from the catheter. This surveyor could not determine if the drainage was from the open area or the eroded area of the meatus. There was no anti-tug strap on R6's leg to prevent tugging on the catheter. At 2:15 PM, Z2, Nurse Practitioner, had just examined R6. She stated R6 had an ulcerated area on his penis. She stated there was an erosion noted on R6's meatus. R6 stated, "It appears to have been open before, healed over, then re-opened again." Z2 stated, "We have discontinued his catheter for now. If he has problems voiding, we'll re-insert the catheter." 2. According to R9's Nurses Notes, he was treated for [REDACTED]. An Instant Care Plan was initiated for each UTI, and indicated R9 should be assessed for pain, administration of medication as ordered, monitor for effectiveness and increase fluid intake. A review of R9's Care Plans does not show a plan of care for problems, goals or interventions for R9's frequent UTI's. A review of R9's Registered Dietician's (RD) note dated 2/11/11 documents R9's estimated needs for fluids was 2520ml each day. The RD Note dated 5/27/11 documents R9's estimated needs are 2280ml. fluid per day. R9's diet is pureed and eats meals, but he has a gastrostomy tube ([DEVICE]) with water flushes of 120m three times per day up until 5/25/11 when the flush was increased to 200 ml three times a day. A review of the Meal Report which documents solids, fluids and caloric intake for R9 from 4/20/11 through 6/7/11 documents that R9's daily fluid intake ranged from 510ml a day to the high of 1760ml. These figures include flushes for the [MEDICATION NAME] tube feeding of [MEDICATION NAME]. In an interview with E2, Director of Nursing, DON, on 6/8/11 she stated that R9 was not dehydrated, and there was not a Care Plan for hydration for UTI's. On 6/8/11 at 1PM, during incontinent care when E5, Certified Nurse Aid, CNA, cleansed R9's groin, there was a dark brown substance was noted on the disposable wipe. E5 cleansed the groin area on each side, and then continued with cleansing R9's buttocks, hips etc., when she stated she had completed the care, she was asked to re-cleanse R9's groin area. It was observed there was still brown matter on the disposable wipe and E5 used at least 8 additional wipes to assure R9 was properly cleansed. 3. The MDS dated [DATE] documents R5 is incontinent of bowel and bladder, and requires extensive assistance with personal hygiene. The History and Physical dated 6/23/10 documents R5 has a history of urinary tract infections [MEDICAL CONDITION]. On 6/07/11 at 1:20 PM, E1 and E13, CNA's, transferred R5 from the geriatric chair to the bed. R5's incontinent brief was heavily soaked with urine and feces. E11 used a disposable wipe to cleanse R5's vagina three times, without changing the surface area of the wipe. E11 used the same gloves to remove R5's soiled brief and dispose of it. R5 began urinating, while on her right side. Without changing gloves, E11 used a clean wipe and again cleansed R5's vaginal area four times, without changing the surface area of the wipe. Using the same gloves, E11 obtained a clean wipe, sprayed peri-wash on it, and cleansed from R5's vagina to her sacrum numerous times without changing the surface area of the cloth. E11 applied a clean incontinent brief to R5 using soiled gloves. E11 tucked unused disposable wipes back into the plastic package, and placed them on the bedside stand. E11 used the soiled gloves to turn R5 to her left side, but did not cleanse R5's right side where she was laying when she urinated on herself. E11 applied a clean brief to R5, and pulled up her urine soaked pants with the soiled gloves. The facility's policy and procedure entitled, 'Incontinent Care' reads, "Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water or peri-wash." The procedure does not address the changing of the surface areas of the washcloth. The procedure documents removing and discarding gloves and washing hands before placing a dry brief on the resident or replacing clothing that had been removed.

Based on interviews, observations and record review, the facility failed to apply and/or respond to a personal alarm ensure that 2 (R1 and R2) of 3 sampled residents reviewed for falls. R1 sustained a subdural hematoma after getting up unassisted and falling to the floor when staff failed to apply her personal alarm to the wheelchair. Findings include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis, in part, Alzheimers, Dementia with behaviors and Anxiety state. R1's Minimum Data Set (MDS) of [DATE] identifies R1 as requiring extensive assistance of 1 for transfer and ambulation and has moderately impaired cognitive skills (decisions poor;cues/supervision required). MDS of [DATE] identifies R1 as having severe cognitive impairment (never/rarely made decisions.) MDS documents R1 required extensive assistance of 2 for transfer and does not ambulate. R1's RISK ASSESSMENT FOR FALLS show a score of 17 on [DATE] and [DATE], a score of 19 on [DATE] and a score of 21 on [DATE]. Assessment shows a score of 10 or greater is high risk for falls. R1's most recent Care Plan dated [DATE] documents R1 is at risk for falls related to impaired thought process and use of psychotropic medications and history of hypotensive episodes. Care Plan goal is R1's falls/injuries will be minimized through management of risk factors thru next review of [DATE]. Care Plan approaches, in part: Observe gait while ambulating - stand by assist as needed; Remind resident to use walker while ambulating; Provide wheel chair if gait unsteady or resident complains of feeling dizzy. A note written on [DATE] states R1 given wheel chair due to unsteady gait and a line was drawn thru the approaches of observing gait/stand by assist and remind to use walker while ambulating. Care Plan documents 5 falls between [DATE] and [DATE]. Care Plan shows a fall on [DATE] with approach to have staff to remind R1 to use walker when ambulating. Care Plan shows a fall on [DATE] with approach to use a sensor alarm in wheel chair and therapy screen. Care Plan documents another fall on [DATE] with abrasions and subdural hematoma. Care Plan approach was to send to the emergency room (ER). Observe for signs and symptoms of pain and discomfort, meds as ordered, notify MD of change of condition. Treatments as ordered (abrasions). Therapy screen. Keep in supervised areas and bed alarm. Care Plan shows another fall on [DATE] with approach to use broda chair and therapy screen. Resident Incident Report of [DATE] states R1 was ambulating to the Dining Room not using her walker, R1 tripped over her feet and fell to the floor. Witnesses state R1 did not hit head. R1 has a small skin tear to right elbow. Area Cleansed. R1 was wearing Diabetic shoes that fit her well. Witnesses state R1 lost her balance just prior to fall. No other injuries noted at this time. R1 denies any complaint of pain or discomfort. Skin tear to right elbow. Report identifies R1 as having Dementia and Confusion/Disorientation and Incontinency. Facility Action was to remind R1 frequently to remember to use walker when ambulating. Nurses Notes of [DATE] stated R1 was ambulating to the Dining Room and not using her walker, tripped over feet and fell . R1 obtained a small skin tear to the right elbow. Nurses Notes up to [DATE] show R1 was being treated for [REDACTED]. Nurses Notes of [DATE] document R1 had right arm pain with elbow bruised and swollen down to right forearm and hand. Xray was ordered of elbow and was negative. Arm had increased swelling and warm to touch. Antibiotic was ordered for Cellulitis of the right arm. Weekly Safety Meeting Note of [DATE] states R1 was being reviewed due to fall on [DATE]. R1 was up walking without her wheeled walker. Assessed by a nurse and a skin tear was noted. "Intervention was put in place to remind resident to use wheeled walker while she is up ambulating." (Yet MDS of [DATE] identifies R1 as requiring extensive assistance of 1 for transfer and ambulation and has moderately impaired cognitive skills (decisions poor;cues/supervision required.) There is nothing in the note of R1 being treated for [REDACTED]. Nurses Note of [DATE] show an order for [REDACTED]. Nurses Notes of [DATE] state R1 has a decline in mobility and now using a wheel chair for mobility. Referred to therapy for evaluation. Nurses Notes of [DATE] state appetite remains poor. R1 not ambulating independently with wheeled walker anymore due to weakness and generalized decline. Uses walker at times. During interview on [DATE] at 10:55AM, with E7, CNA, E7 stated she took care of R1 routinely. E7 stated staff would put R1 by the Nurses Station to be watched. R1 would get up and walk without her walker and without supervision. She would try to get up and out of the chair. This happened quite frequently. She would be found walking without her walker. This went on for months. E7 stated R1 was confused. It was not uncommon for her to get up on her own and leave her walker. R1 was able to ambulate before she had a decline and then was in a wheel chair. During interview with E8, Licensed Practical Nurse, on [DATE] at 11:07AM, E8 stated she worked with R1 on a part time basis. R1 had intermittent confusion. E8 stated it was a daily struggle to get R1 to use her walker. She would forget to use it or didn't want to use the walker. She was always trying to get up without her walker and assistance from staff. When she went to the wheel chair they put on an alarm. With Alzheimers she would forget not to get up out of her wheel chair without assistance. If not right with her she would try to get up out of the wheel chair. Resident Incident Report of [DATE] documents staff reported that R1 was on the floor in the Dining Room. Another resident stated that R1 tried to use another resident walker to stand up out of her wheel chair. R1 lost balance and fell to the floor. R1 states that the back of her head hurt. Neuro checks initiated and within normal limits at this time. As needed Tylenol given for pain. No other injuries noted at this time. Medical risk factors are fall history, Confusion/Disorientation and Incontinency. Facility Action was for sensor pad alarm to be put into place. Resident Incident Report of [DATE] states Nurse was called to dining room per visitor, found resident laying on left side of body. Resident has swelling to left shoulder, complaining of severe pain to area. R1 has a small puncture wound about left eye. R1 has abrasions to face and chin. R1 has a large hematoma to left knee. R1 has a broken upper front tooth. Immobilized on floor and sent to ER. Medical risk factors identified are fall history , inability to understand directions, confusion/disorientation and incontinency. Immediate Post incident Action: Resident kept in well supervised areas. Make sure alarms are on and working properly. Nurses Note of [DATE] state Hospice referral was made related to subdural hematoma with no intervention. During interview with E2, Director of Nursing (DON) on [DATE] at 10:10AM, E2 stated R1 was identified as having frequent falls. At 2:30PM, E2 stated a new staff member had gotten R1 up without putting the alarm on. E2 stated that the staff member was counseled. On [DATE] at 12 noon, E1 Administrator, confirmed that R1 was to have on an alarm. The Certified Nurse Aide (CNA) didn't realize that R1 was to have an alarm and failed to put the alarm on R1 and R1 fell with injury of subdural hematoma. On [DATE], E2 requested Surveyor to review and gave a copy of the Facility Quality Assurance Meeting report of [DATE]. E1 stated the facility identified the problem with R1's fall and this was their corrective action. Report documents "Problem Identified: CNA failed to apply Sensor alarm." Report documents that there was a 100% audit of all safety devices and Nursing Staff were inserviced to ensure alarms are in place with completion date of [DATE]. Facility report sent to Illinois Department of Public Health on [DATE] concerning R1's fall on [DATE], states an investigation was started and completed. "Upon completion of the investigation, it was founded that the Residents care plan was being followed and was appropriate." This conflicts with the Care Plan note of [DATE] that documents a new intervention of a sensor alarm in wheel chair and interviews with E1 and E2 that the alarm was not on at the time of the fall. On [DATE] at 2:15PM, E2 stated she thought because they identified the problem and counseled the CNA, she could put in the report that the Care Plan was being followed. Resident Incident Report of [DATE] states staff reported to the Nurse that R1 was on the floor at the Nurses Station this AM prior to breakfast. R1's chair alarm was sounding. Upon assessment, it was noted that R1 was bleeding from her mouth. R1 was laying face down on the floor with wheel chair on top of her. Wheel chair was safely removed from on top of R1 and R1 extremities were examined. R1 was assessed and staff safely transferred R1 back into the wheel chair. R1 did not want to move her right shoulder. Stat Xray of right shoulder was ordered and Tao to skin tear to right forearm until healed. Xray showed no fracture. Immediate Actions Taken: Applied ice to mouth, immobilized the arm, Xray of arm and pain meds given for discomfort. Hospice Notes of [DATE] document, "Per facility staff patient fell in am. Bruise noted to R (right) chin & L (left) knee. Open area noted to lower R lip & tissue missing from upper lip." Nurses Note of [DATE] document R1 expired. 2. According to the Admission Record, R2 was admitted on [DATE] from the hospital after hip surgery for [REDACTED]. The Admission Information identifies her as a fall risk. physician's orders [REDACTED]. The MDS dated [DATE] indicates she has no cognitive impairment and requires extensive assist of one staff for transfers and is receiving therapy. The MDS also identified balance deficits with sitting and standing and was not steady unless she had human assistance. The RISK ASSESSMENT FOR FALLS dated [DATE] thru 4//30 identify R2 as being at high risk for falls. The care plan dated [DATE] documents the fall risk was due to impaired mobility, use of psychotropic drugs, impaired safety awareness and dementia/impaired cognition. Interventions written at the time included transfers with mechanical lift and 2 assists, observe frequently to anticipate needs, alarm bed and chair, keep in view of staff, do not leave resident unattended without safety device, and give reminders not to ambulate or transfer without assistance. Nurses notes written on [DATE] at 10:43am document "resident continues to remove her alarm and hoyer pad from her chair. resident is instructed no to do so, that it is there for her safety, resident continues to stand up and try and walk around. Resident is instructed on why not to do this." No changes are noted to the care plan in response to R2 removing her alarm and standing/attempting to walk. Nurses notes dated [DATE] document at 10:34am, "is often confused" and "at times very lethargic" and "resident has increased agitation this shift, resident is up from chair walking behind chair, resident is assisted back to sitting position. Resident continues to remove alarm from chair." The care plan fails to reflect that R2 is removing her alarm and failed to place interventions to address this issue. On [DATE] at 9:04pm, the nurses write "alert to name only. Remains very confused and restless. Continues to attempt to get up and stand. Bed alarm in place." Nurses notes written on [DATE] also indicate R2 continues to be confused and attempts to get up. On [DATE] at 11:25am, the notes document "resident continues to get out of chair and try and walk around, resident reminded of the need to stay in chair" and at 9:06pm, the notes document "dismantles body alarm, requires constant supervision." There is no evidence the facility took into account R2's cognitive impairment and her poor safety awareness and attempted other interventions in an effort to keep her from getting up unassisted and falling.. On [DATE] at 7:19am, a RESIDENT INCIDENT REPORT indicates she pulled herself up out of her wheel chair and slid to the floor. "IMMEDIATE POST INCIDENT" action indicates staff are to "keep in sight." This was added to the care plan although it was already on as of [DATE]. On [DATE] at 3:35pm, a RESIDENT INCIDENT REPORT again documents that R2 fell . The narrative indicates "found resident laying in hallway adjacent to south nurses station. Resident had removed clip alarm." Following the fall on [DATE], the care plan shows an addition of a sensor alarm due to R2 removing the clip alarm. Notes provided from a safety meeting by E2, Director of Nursing on [DATE] also indicates R2 was turning off sensor alarm and getting up without assistance so staff was alerted to put alarm low "out of reach" and keep R2 is supervised areas, 1:1 with nursing." R2 was found on the floor again with no witnesses on [DATE] at 2pm. The incident report documents "Immediate Post-Incident action" as "Make sure alarm is placed on resident and keep resident in well supervised areas." The facility failed to ensure that the alarm was attached appropriately and that she was in supervised areas as implemented two days earlier on [DATE]. Nurses notes dated [DATE] at 5:04pm documents R2 is restless and agitated and had to stay with the nurse due to continuously getting out of the chair, and continues to remove alarm from her person. However, there is no further evidence the facility considered other devices more appropriate given R2's cognitive impairment and her continuing to remove the alarm and getting up unassisted. On [DATE] at 1:21pm, R2 is documented as continuing to get up and walk. On [DATE], the nurses notes documents staff using a reclining chair for R2 and that she needs repeated cues and reminders from staff and that she remains "non-weight bearing." although the notes continues to document her getting up walking unassisted. The nurses notes dated [DATE] indicates R2 turned off her alarm and attempted to get up unassisted on [DATE]. No injuries were noted. According to RESIDENT INCIDENT REPORTS dated [DATE] indicates R2 removed her alarm and fell and on [DATE], R2 was documented as "sliding" out of her wheelchair to the floor with the alarm sounding but staff not able to respond before she landed on the floor. Both falls are identified as "unwitnessed" on th fall reports. The care plan repeats the "keep in supervised areas" and "resident educated to inform staff of needs". In addition, it includes "bed alarm on" in response to R2 slipping from her wheelchair. On [DATE], the care plan has an intervention added to do a bowel and bladder screen. On [DATE] at 6:01pm, R2 was "found" on the floor of the dining room when staff heard yelling and an alarm sounding. She had a large bump on the front top of her head and two 1 inch indentations across the middle of her forehead red in color. Neurochecks were initiated and ice was applied to her head. She was transferred to bed. At 8:45pm that evening, R2 became increasingly lethargic responding only to hard chest rubs with periods of apnea. She was transported to the emergency room and returned to the facility. She sustained multiple bruises about the face from the fall. The care plan indicates staff initiated a therapy screen for positioning and device for safety, and "educated staff to keep resident in supervised areas" following the fall on [DATE]. However, there is no explanation as to why the fall on [DATE] was unwitnessed and why she wasn't in a supervised area of the facility as indicated in there care plan multiple times. On [DATE], a "self release belt" was applied to R2. On [DATE] at 8:30pm, R2 removed her shirt which had the alarm attached to it and she slid to the floor. Staff witnessed it but "wasn't able to reach quick enough" to prevent her from sliding to the floor. The report fails to indicate whether a sensor alarm or self release belt was in place at the time of this fall. Interventions added include, again, "resident to be kept in constant supervision," and laid down after receiving medications. The care plan has an intervention dated [DATE] which reads "reapplied self release belt" due to resident unhooking belt. According to the RESIDENT INCIDENT REPORTS for R2, 7 of the 7 falls were unwitnessed even though one of the initial interventions dated [DATE] was to "keep in view of staff" and repeated interventions on the care plan dated [DATE], [DATE], [DATE], and [DATE] for staff to keep R2 without view and/or in supervised areas. On [DATE] at 12noon, E2 Director of Nursing (DON) said that some of R2's fall were witnessed and stated that the section of the report identifying them as "unwitnessed" was wrong. Of the 7 falls, R2 slid out of her chair for 3 of them ([DATE], [DATE] and [DATE]). However, there is no interventions preventing her from sliding out of the chair in the careplan. On [DATE] at 10:58am, R2 was observed in her wheelchair. She had on a self release safety belt which she could not undo when asked at the time. R2 was transferred with one assist using a gait belt to bed. She required numerous cues/directions to assist in the transfer and participated very little at the time. She had a sensor pad alarm on her wheelchair when she stood up. On [DATE] at 12 noon, E2, Director of Nursing stated the facility wanted to start low with alarms and such and that she didn't want to restrain her. E2 did confirm R2 was confused and repeatedly tried to get up unassisted anyway. E2 also provided a time line which shows in addition to 1:1 nursing at times with alarm checks, the facility also increased Namenda and Ativan due to agitation on [DATE], added Seroquel ([DATE]) to R2's drug regime, and increased her Risperdal on [DATE], [DATE], [DATE] in an effort to reduce her attempts at getting up. E2 did acknowledge that psychotropic medication does increase fall risk as stated in R2's care plan. E2 stated she thought R2 would not tolerate anything more restricting than the alarm but confirmed no other devices had been attempted until the self release device was added on [DATE]. According to the facility's policy entitled "FALLS MANAGEMENT PROGRAM", it uses an interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care. Recommendations include nursing to complete an assessment on admission, re-admission, quarterly and with significant change. Examples of Interventions to decrease falls/injuries include bed/chair alarms, velcro seat belts, low beds, wedges, cushions, dycem, restraints, etc.

Based on record review and interview, the facility failed to provide the appropriate treatment with an effective antibiotic for one (R2) of three sampled residents with a history of infection. This failure resulted in a change in mental status and a hospitalization for R2, with the [DIAGNOSES REDACTED]. Findings include: R2's physician's orders [REDACTED]. The Minimum Data Set, dated dated [DATE] assesses R2 as moderately impaired with cognition and decision making, requires extensive assistance from staff for bed mobility, transfers, personal hygiene, is incontinent of bowel, has an indwelling urinary catheter, gastrostomy tube, and propels himself in a wheelchair. On 1/24/11, a review of R2's physician's orders [REDACTED]. At that time, R2 was receiving [MEDICATION NAME] 100 mg per gastrostomy tube twice daily, per physician's orders [REDACTED]. The Nurses Note of 1/03/11, at 8:58 PM, documents R2 was seen by Z1, Nurse Practitioner, (NP) for Z2, Physician, and new orders were received for a change in the tube feeding solution and a complete blood count to be done on 1/04/11. A Dietary Note, dated 1/06/11, at 2:55 PM, documents R2 has had a 2 pound weight loss in one week, is receiving an antibiotic for a urinary tract infection, and has a low hemoglobin level of 9.5, (normal-14.0-18.0) and low hematocrit level of 27.2 (Normal-40.0-54.0) as of the 1/04/11 report. The Nurses Notes from 12/27/10 through 1/09/11 document R2 continued to have hematuria with the catheter draining amber urine with sediment and mucous. A Resident Incident Report, dated 1/09/11, at 9:00 PM, reports R2 was found on the floor next to his bed. The Nurses Note, dated 1/09/11, at 9:19 PM reports R2 was found on the floor vomiting, with no injury and Z2 was notified. A Nurses Note, dated 1/10/11, at 9:40 PM, documents Z1 had seen R2, and new orders were received. The Dietary Note , dated 1/16/11, at 11:05 AM, documents R2 had a three pound weight loss that week, experiencing a GI (gastrointestinal) upset and treatment for [REDACTED]. A physician's orders [REDACTED]. The Nurses Note of 1/17/11, at 8:43 PM documents Z1 examined R2, and an order for [REDACTED]. Z1 ordered R2 to be sent to the hospital for evaluation. A Urinalysis report, documents R2's urine was collected on 12/31/10, received 1/01/11, and reported to the facility on [DATE]. The report documents the hard copy was received at the facility on 1/04/11. The results of the urine culture document R2's urine with over 100,000 colonies per milliliter of the bacteria, Proteus mirabilis. The sensitivity report shows this bacteria is resistant to [MEDICATION NAME] ([MEDICATION NAME]). The hospital's urine culture report, collected 1/17/11, updated 1/19/11, shows results of over 100,000 colonies per milliliter of yeast growth in R2's urine, with white blood cells of 10-20 (0-5), and over 100,000 colonies per milliliter of a Gram positive organism. On 1/27/11, at 2:30 PM, Z1 reported she was not informed of the results of the urine culture and sensitivity report, dated 12/31/10, when she saw R2 at the facility on 1/03/11, Z1 reported the report may have come to the facility after her visit. Z1 reported she saw R2 during the day shift of 1/03/11. Z1 confirmed she was not aware the bacteria R2 had in his urine was resistive to [MEDICATION NAME] until 1/10/11, when she ordered a more effective antibiotic, [MEDICATION NAME]. Z1 reported the reason R2 developed yeast in his urine was due to the use of antibiotics for treatment of [REDACTED]. Z1 confirmed the excoriation to R2's buttock and coccyx was probably due to the diarrhea and yeast. On 1/27/11, E2, Director of Nursing, (DON) confirmed the facility failed to timely notify Z1 or Z2 of the urine culture and sensitivity report for R2 collected on 12/31/10. E2 stated, "I don't know what happened." The facility's policy and procedure entitled, 'Notification of a Change in a Resident's Status', reads, in part, "Guideline for notification of physician/responsible party (not all inclusive): symptoms of an infectious process, abnormal lab findings, change in level of consciousness, unusual behavior...Document in the Interdisciplinary Team ( IDT) notes: resident change in condition, physician notification, Notification of responsible." No time frame for reporting a change in condition or abnormal lab findings is addressed in the policy.