Every finding on record at Goldwater Care Gibson City

Based on interview and record review the facility failed to implement its abuse prohibition policy by failing to timely report and investigate allegations of abuse and missing money for three of four residents (R25, R20, R27) reviewed for abuse in the sample list of 36. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents residents have the right to be free from verbal and mental abuse and misappropriation of property. This policy lists humiliation, harassment and threats of punishment or deprivation as examples of mental abuse, and language that includes disparaging and derogatory terms to a resident as verbal abuse. This policy documents all residents have the right to be free from misappropriation of property which is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This policy documents the resident's representative will be notified immediately by telephone and in writing of abuse allegations, these allegations will be immediately reported to the Illinois Department of Public Health (IDPH) and law enforcement must be notified if there is reasonable suspicion a crime has occurred against a resident. This policy documents alleged misappropriation of property or theft will be investigated and the results of the investigation reported to IDPH.1.) On 5/10/26 at 8:24 AM R20 stated at about 3:00 AM an agency Certified Nursing Assistant (identified as V12 CNA) told R20 he was rude, crude, and disgusting when V12 changed his incontinence brief. R20 stated R20's roommate, R25, was the only other person present at the time. R20 stated V12 also told R25 that what was on R25's overbed table was all the drinks that R25 was getting. R20 stated R20 felt V12 was verbally abusive and reported this to unidentified CNAs this morning as well as V1 Administrator at approximately 4:00 AM. On 5/10/26 at 8:24 AM R25 stated around midnight R25 asked the CNA (identified as V12) for a drink of water, the CNA said the water pitcher is right there, I (V12) just filled it up, now you're (R25) not going to get any, and took his water pitcher out of his room. R25 stated R25 reported this to unidentified staff this morning. On 5/10/26 at 10:38 AM V11 CNA stated at approximately 6:00 AM R20 voiced concerns that the night CNA was rude to him and R25 said R25 asked for water and the CNA took his water away from him. V11 stated V11 notified V1 Administrator. At 10:51 AM V10 CNA stated R20 said the night agency CNA was rude, inconsiderate and used degrading words. V10 stated R25 also reported concerns that he wanted a drink of water and the CNA refused to give him a drink. V10 stated this was reported to V10 and V11 at approximately 5:45 AM-6:00 AM and then reported to V1 immediately after. V10 stated R25 is alert and oriented and R20 is pretty accurate. V10 stated I (V10) believe what they (R20, R25) said. V10 stated R20 and R25 feel comfortable with V10 and V11 and report things to them.R20's care plan dated 2/5/26 documents R20 is at risk for abuse, R20 is blind, lives in a community facility and is dependent on staff. This care plan includes interventions to remind R20 to report incidents or concerns to staff and the administrator.The facility's Daily Assignment Sheet dated 5/9/26 documents V12 was the CNA assigned to the [NAME] Hall, where R20 and R25 reside. The Initial Abuse Investigation Report dated 5/10/26 documents R20 alleged verbal abuse from the night CNA identified as V12. V1 Administrator's electronic mail dated 5/10/26 at 10:45 AM documents this allegation was reported to IDPH (over four hours after the allegation was reported to V1 by V10 and V11). There is no documentation that R25's allegation was reported to IDPH or R25's family as of 5/11/26. On 5/10/26 at 8:54 AM V1 Administrator stated V1 worked night shift last night and an agency CNA, V12, worked on R20's/R25's hallway. V1 denied being notified of any complaints from R20 or R25 involving V12 last night. At this time R20's and R25's allegations were reported to V1. On 5/11/26 at 9:37 AM V1 confirmed the initial report does not include R25's allegation and taking items away from a resident would be considered a form of abuse. V1 stated she only included R20 in the initial report since R20 was the one who reported the allegations and V1 was going to include information for both residents in the final report and investigation. V1 stated V1 hasn't done much yet for this investigation and had not yet notified R20's and R25's families and physician. V1 confirmed the two-hour reporting requirement to IDPH and confirmed the initial report was sent 5/10/26 at 10:45 AM. V1 stated V10 and V11 reported concerns to her yesterday morning but was unsure what time that was. 2.) The Lost and Found Form dated 2/17/26 documents V21 Certified Occupational Therapy Assistant reported R27 was missing $16 out of his wallet, noticed when he went to pay for his haircut. This form documents V24, R27's Family, said R27 had the money and the facility replaced R27's money. This form is signed by V18 Social Services Director. R27's Brief Interview for Mental Status dated 4/2/26 documents R27 is cognitively intact.The facility's abuse log with date range January-May 2026 does not include R27's allegation of misappropriation of money. On 5/12/2026 at 10:11 AM R27 stated a couple months ago he had $16 in his wallet that was kept in his dresser drawer. R27 stated R27 went to pay for a haircut and noticed the money was missing from his wallet. R27 stated R27 believes staff went through his belongings and took the money but has no proof of that and didn't witness this. R27 stated R27 felt it was his fault since he didn't hide his wallet good enough. 05/12/2026 at 10:30 AM V21 stated on 2/17/26 R27 was in the therapy room and said he went to pay for a haircut and noticed his money was missing from his wallet. V21 stated R27 told V21 that he kept his wallet in the drawer of his nightstand. V21 stated V21 reported R27's missing money immediately to V1 Administrator and V2 Director of Nursing. On 5/12/26 at 11:09 AM V18 stated V18 spoke with V24 on 2/17/26 who reported R27 in fact had that amount of money as V24 had given him the $16 the week prior to get his hair cut. On 5/12/2026 at 9:57 AM V1 stated V1 did not report R27's missing money to IDPH or law enforcement and an investigation was not conducted.

Based on interview and record review the facility failed to report allegations of abuse and misappropriation of property to the state survey agency and law enforcement for three of four residents (R20, R25, R27) reviewed for abuse in the sample list of 36. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 lists humiliation, harassment and threats of punishment or deprivation as examples of mental abuse, and language that includes disparaging and derogatory terms to a resident as verbal abuse. This policy documents all residents have the right to be free from misappropriation of property which is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This policy documents allegations will be immediately reported to the Illinois Department of Public Health (IDPH) and law enforcement must be notified if there is reasonable suspicion a crime has occurred against a resident. This policy documents alleged misappropriation of property or theft will be investigated and the results of the investigation reported to IDPH.1.) On 5/10/26 at 8:24 AM R20 stated at about 3:00 AM an agency Certified Nursing Assistant (identified as V12 CNA) told R20 he was rude, crude, and disgusting when V12 changed his incontinence brief. R20 stated R20's roommate, R25, was the only other person present at the time. R20 stated V12 also told R25 that what was on R25's overbed table was all the drinks that R25 was getting. R20 stated R20 felt V12 was verbally abusive and reported this to unidentified CNAs this morning as well as V1 Administrator at approximately 4:00 AM. On 5/10/26 at 8:24 AM R25 stated around midnight R25 asked the CNA (identified as V12) for a drink of water, the CNA said the water pitcher is right there, I (V12) just filled it up, now you're (R25) not going to get any, and took his water pitcher out of his room. R25 stated R25 reported this to unidentified staff this morning. On 5/10/26 at 10:38 AM V11 CNA stated at approximately 6:00 AM R20 voiced concerns that the night CNA was rude to him and R25 said R25 asked for water and the CNA took his water away from him. V11 stated V11 notified V1 Administrator. At 10:51 AM V10 CNA stated R20 said the night agency CNA was rude, inconsiderate and used degrading words. V10 stated R25 also reported concerns that he wanted a drink of water and the CNA refused to give him a drink. V10 stated this was reported to V10 and V11 at approximately 5:45 AM-6:00 AM and then reported to V1 immediately after. R20's care plan dated 2/5/26 documents R20 is at risk for abuse, R20 is blind, lives in a community facility and is dependent on staff. This care plan includes interventions to remind R20 to report incidents or concerns to staff and the administrator.The facility's Daily Assignment Sheet dated 5/9/26 documents V12 was the CNA assigned to the [NAME] Hall, where R20 and R25 reside. The Initial Abuse Investigation Report dated 5/10/26 documents R20 alleged verbal abuse from the night CNA identified as V12. V1 Administrator's electronic mail dated 5/10/26 at 10:45 AM documents this allegation was reported to IDPH (over four hours after the allegation was reported to V1 by V10 and V11). There is no documentation that R25's allegation was reported to IDPH. On 5/10/26 at 8:54 AM V1 Administrator stated V1 worked night shift last night and an agency CNA, V12, worked on R20's/R25's hallway. V1 denied being notified of any complaints from R20 or R25 involving V12 last night. At this time R20's and R25's allegations were reported to V1. On 5/11/26 at 9:37 AM V1 confirmed the initial report does not include R25's allegation and taking items away from a resident would be considered a form of abuse. V1 stated she only included R20 in the initial report since R20 was the one who reported the allegations and V1 was going to include information for both residents in the final report and investigation. V1 confirmed the two-hour reporting requirement to IDPH and confirmed the initial report was sent 5/10/26 at 10:45 AM. V1 stated V10 and V11 reported concerns to her yesterday morning but was unsure what time that was. 2.) The Lost and Found Form dated 2/17/26 documents V21 Certified Occupational Therapy Assistant reported R27 was missing $16 out of his wallet, noticed when he went to pay for his haircut. This form documents V24, R27's Family, said R27 had the money and the facility replaced R27's money. This form is signed by V18 Social Services Director. The facility's abuse log with date range January-May 2026 does not include R27's allegation of misappropriation of money. On 5/12/2026 at 10:11 AM R27 stated a couple months ago he had $16 in his wallet that was kept in his dresser drawer. R27 stated R27 went to pay for a haircut and noticed the money was missing from his wallet. R27 stated R27 believes staff went through his belongings and took the money but has no proof of that and didn't witness this. R27 stated R27 felt it was his fault since he didn't hide his wallet good enough. 05/12/2026 at 10:30 AM V21 stated on 2/17/26 R27 was in the therapy room and said he went to pay for a haircut and noticed his money was missing from his wallet. V21 stated R27 told V21 that he kept his wallet in the drawer of his nightstand. V21 stated V21 reported R27's missing money immediately to V1 Administrator and V2 Director of Nursing. On 5/12/2026 at 9:57 AM V1 confirmed V1 was aware of R27's missing money. V1 stated V1 did not report R27's missing money to IDPH or law enforcement.

Based on interview and record review the facility failed to protect residents' right to be free from verbal and mental abuse by staff for two of four residents (R20, R25) reviewed for abuse in the sample list of 36.Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents residents have the right to be free from verbal and mental abuse. This policy lists humiliation, harassment and threats of punishment or deprivation as examples of mental abuse, and language that includes disparaging and derogatory terms to a resident as verbal abuse. On 5/10/26 at 8:24 AM R20 stated at about 3:00 AM an agency Certified Nursing Assistant (identified as V12 CNA) told R20 he was rude, crude, and disgusting when V12 changed his incontinence brief. R20 stated R20's roommate, R25, was the only other person present at the time. R20 stated V12 also told R25 that what was on R25's overbed table was all the drinks that R25 was getting. R20 stated R20 felt V12 was verbally abusive and reported this to unidentified CNAs this morning as well as V1 Administrator at approximately 4:00 AM. On 5/10/26 at 8:24 AM R25 stated around midnight R25 asked the CNA (identified as V12) for a drink of water, the CNA said the water pitcher is right there, I (V12) just filled it up, now you're (R25) not going to get any, and took his water pitcher out of his room. R25 stated R25 reported this to unidentified staff this morning. R20's care plan dated 2/5/26 documents R20 is at risk for abuse, R20 is blind, lives in a community facility and is dependent on staff. This care plan includes interventions to remind R20 to report incidents or concerns to staff and the administrator. The Initial Abuse Investigation Report dated 5/10/26 documents R20 alleged verbal abuse from the night CNA identified as V12. The facility's Daily Assignment Sheet dated 5/9/26 documents V12 was the CNA assigned to the [NAME] Hall, where R20 and R25 reside. On 5/10/26 at 8:54 AM V1 Administrator stated V1 worked night shift last night and an agency CNA, V12, worked on R20's/R25's hallway. On 5/10/26 at 10:38 AM V11 CNA stated at approximately 6:00 AM R20 voiced concerns that the night CNA was rude to him and R25 said R25 asked for water and the CNA took his water away from him. At 10:51 AM V10 CNA stated R20 said the night agency CNA was rude, inconsiderate and used degrading words. V10 stated R25 also reported concerns that he wanted a drink of water and the CNA refused to give him a drink. V10 stated this was reported to V10 and V11 at approximately 5:45 AM-6:00 AM. V10 stated R25 is alert and oriented and R20 is pretty accurate. V10 stated I (V10) believe what they (R20, R25) said. V10 stated R20 and R25 feel comfortable with V10 and V11 and report things to them. On 5/12/2026 at 10:32 AM V12 stated V12 worked the [NAME] Hall on night shift on 5/9/26.

Based on interview and record review the facility failed to protect a resident's (R27) right to be free from misappropriation of funds for one of three residents (R27) reviewed for misappropriation of property in the sample list of 36.Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents all residents have the right to be free from misappropriation of property which is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Lost and Found Form dated 2/17/26 documents V21 Certified Occupational Therapy Assistant reported R27 was missing $16 out of his wallet, noticed when he went to pay for his haircut. This form documents V24, R27's Family, said R27 had the money and the facility replaced R27's money. This form is signed by V18 Social Services Director. R27's Brief Interview for Mental Status dated 4/2/26 documents R27 is cognitively intact.On 5/12/2026 at 10:11 AM R27 stated a couple months ago he had $16 in his wallet that was kept in his dresser drawer. R27 stated R27 went to pay for a haircut and noticed the money was missing from his wallet. R27 stated R27 believes staff went through his belongings and took the money but has no proof of that and didn't witness this. R27 stated R27 felt it was his fault since he didn't hide his wallet good enough. 05/12/2026 at 10:30 AM V21 stated on 2/17/26 R27 was in the therapy room and said he went to pay for a haircut and noticed his money was missing from his wallet. V21 stated R27 told V21 that he kept his wallet in the drawer of his nightstand. On 5/12/26 at 11:09 AM V18 stated V18 spoke with V24 on 2/17/26 who reported R27 in fact had that amount of money as V24 had given him the $16 the week prior to get his hair cut. On 5/12/26 at 11:00 AM V1 Administrator and V2 Director of Nursing stated V24 frequently brings cash in for R27. V1 stated V1 gave R27 $5 and confirmed there was no documentation the facility fully reimbursed R27's $16.

Based on interview and record review the facility failed to investigate an allegation of misappropriation of property for one of four residents (R27) reviewed for abuse in the sample list of 36. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents all residents have the right to be free from misappropriation of property which is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This policy documents alleged misappropriation of property or theft will be investigated and the results of the investigation reported to the Illinois Department of Public Health.The Lost and Found Form dated 2/17/26 documents V21 Certified Occupational Therapy Assistant reported R27 was missing $16 out of his wallet, noticed when he went to pay for his haircut. This form documents V24, R27's Family, said R27 had the money and the facility replaced R27's money. This form is signed by V18 Social Services Director. The facility's abuse log with date range January-May 2026 does not include R27's allegation of misappropriation of money. On 5/12/2026 at 10:11 AM R27 stated a couple months ago he had $16 in his wallet that was kept in his dresser drawer. R27 stated R27 went to pay for a haircut and noticed the money was missing from his wallet. R27 stated R27 believes staff went through his belongings and took the money but has no proof of that and didn't witness this. R27 stated R27 felt it was his fault since he didn't hide his wallet good enough. 05/12/2026 at 10:30 AM V21 stated on 2/17/26 R27 was in the therapy room and said he went to pay for a haircut and noticed his money was missing from his wallet. V21 stated R27 told V21 that he kept his wallet in the drawer of his nightstand. V21 stated V21 reported R27's missing money immediately to V1 Administrator and V2 Director of Nursing. On 5/12/2026 at 9:57 AM V1 Administrator confirmed V1 was aware of R27's missing money. V1 stated V1 did not report R27's missing money to IDPH or law enforcement and an investigation was not conducted.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R1, R2) of three residents reviewed for abuse in the sample list of 6.Findings:The facility's Abuse Prevention and Reporting- Illinois policy dated 10/24/22 documents the facility affirms the residents' right to be free from abuse and prohibits abuse and mistreatment of residents. This policy documents physical abuse is the infliction of injury that occurs other than by accidental means and includes hitting, slapping, pinching, and kicking.The facility's Abuse Investigation Checklist documents on 2/28/26 at 10:20 a.m. an allegation of physical abuse involving R1 and R2. R1 and R2 were in the hallway together when R2 reached out with flat hand and pushed R1 in the chest away from him. R6, Housekeeper witnessed the altercation, separated R1 and R2, and notified the V1, Administrator (Abuse Coordinator). The facility's Abuse Investigation Checklist documents that on 3/13/26 at 1:00 p.m., an allegation of physical abuse occurred involving R1 and R2. V7, Certified Nurse Assistant (CNA), observed R2 strike R1 on the right forearm. V7 separated R1 and R2 and notified V1.R2's Minimum Data Set (MDS) dated [DATE] documents that R2 has moderate cognitive impairment with fluctuating disorganized thinking. R2's Care Plan dated 1/8/25, with revisions on 3/24/25, indicates that R2 has mood disturbances related to dementia, new health concerns, and changes in environment. Interventions dated 1/8/25 direct staff to monitor, document, and report to the physician as needed any indicators that R2 may be at risk of harming others, including increased anger, labile mood, agitation, feelings of being threatened by others, thoughts of harming someone, or possession of weapons or objects that could be used as weapons.R1's MDS dated [DATE] documents R1 as cognitively intact.On 3/20/26 at 11:12 a.m., R1 stated that one day he and R2 were talking in the hallway when R2 reached out and pushed him in the chest with his hand. R1 also stated that during another incident, R2's wheelchair became caught on a piece of equipment in the hallway. R1 stated he attempted to assist by moving the wheelchair when R2 struck him on the right forearm.On 3/20/26 at 10:40 a.m., V6, Housekeeper stated that she was cleaning a resident's room when she overheard R1 and R2 talking in the hallway. V6 stated she could not hear what they were saying, but when she stepped out to get supplies from her housekeeping cart, she observed R2 push R1 in the chest with one hand. V6 stated R1 then yelled, Ouch, he pushed me.On 3/20/26 at 3:07 p.m., V1, Administrator confirmed that the reported incidents on 2/28/26 and 3/13/26 occurred. V1 and V2, Director of Nursing stated that R1 sometimes enters R2's personal space, which R2 dislikes, and R2 sometimes responds with physical behaviors. They reported that both residents are being monitored closely and that staff are attempting to keep them separated.

Based on observation, interview, and record review, the facility failed to ensure a care planned fall intervention was implemented for one (R1) of three residents reviewed for accidents on a sample list of four. R1's Care Plan dated 2/5/26 documents R1 admitted to the facility on [DATE], with diagnoses of Parkinson's Disease with Dyskinesia, with Fluctuations, Asthma, Depression, Atrial Fibrillation, Anemia, Obstructive Sleep Apnea (Adult), Essential (Primary) Hypertension, Gastroesophageal Reflux Disease without Esophagitis, Polyosteoarthritis, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Protein-Calorie Malnutrition, and Dysphagia.R1's Care Plan dated 2/5/26 documents R1 needs assistance of at least one staff member for all daily living activities, that R1 has physical mobility impairment and is non-weight bearing, and that R1 is high risk for falls with intervention added on 6/19/25 of low bed and observe for resident to be positioned in the middle of the bed. The Care Plan also documents R1 is at high risk for bleeding due to anticoagulant use.R1's Minimum Data Sheet (MDS) section C dated 2/4/26 documents R1 is cognitively intact.R1's MDS section GG dated 2/5/26 documents R1 as totally dependent on staff for activities of daily living.R1's Unwitnessed Fall Report dated 1/25/26 documents R1 was found lying prone on the floor next to the bed at 1:30 AM. The Report documents R1 made a statement that R1 rolled out of bed, and did not hit R1's head, but had some pain in the chest area. The Report documents R1 was assessed and placed back in bed by mechanical lift.R1's Hospital Records dated 1/25/25 document R1 was found on the floor with time on the floor unknown, that R1 has severe Parkinson's with tremors and cannot get out of bed or ambulate on own and that R1 is on blood thinner but was not transported to hospital at the time R1 was found on the floor stating R1 had no pain. The Hospital Records document R1 complained of pain to mid substernal chest and right sided rib area. The Hospital Records document R1 was diagnosed with four acute right side rib fractures and was admitted to the hospital to control pain and monitor for bleeding related to blood thinner.R1's Computed Tomography Scan Report dated 1/25/26 documents acute anterior right 3rd through 6th rib fractures with old rib fractures noted as well.On 2/19/26 at 11:38 AM, V10 Certified Nursing Assistant (CNA), stated that she was the aide assigned to R1 the night of 1/25/26. V10 stated that at approximately 1:00AM she observed R1 in bed sleeping and then went down the hall to the nurse's station and ate lunch with the other CNA and two nurses on shift that night. V10 stated when they finished lunch, she started rounding on her residents and observed R1's feet on the ground from the doorway. V10 stated she found R1 lying on his left side using his right arm to prop himself up on the ground next to his bed. V10 stated R1 was upset stating he had been hollering for help, but no one came. V10 stated that she has never heard R1 yell before and that he struggles with speaking after his stroke. V10 stated R1 stated R1's chest hurt and V10 alerted the nurse and V12 Licensed Practical Nurse (LPN), V13 LPN, and V11 CNA came to R1's room. V12 took R1's vitals and assessed R1 for injuries and used a mechanical lift with a sling to place R1 back in bed. V10 stated that R1's bed was high at the time of the fall and R1's side rails were in the up position. V10 stated she is new to the facility and had no knowledge of R1 being a fall risk or that his bed needed to be lower. V10 stated R1's bed was in the position it was always in. V10 stated R1 had an air mattress on R1's bed at the time of the fall. On 2/19/26 at 12:13PM, V11 CNA stated that he was sitting in the Activity Room watching the hallway for call lights when V12 LPN asked for his assistance in R1's room. V11 stated R1 was on the floor next to R1's bed complaining of pain in his chest area. V11 stated R1's bed was waist high and the side rail bar on the right side of the bed was up. On 2/19/26 at 12:20 PM, V12 LPN stated that on 1/25/26 around 1:30AM she was alerted to R1 being on floor by V10. V12 stated R1 appeared to be in semi-prone position lying on his left side with his right arm up and over his head. V12 stated at the time of the fall R1 had half rails on his bed and the bed was waist high when R1 was found. On 2/19/26 at 11:56AM, R1 was sitting in a high-back, reclining wheelchair next to R1's bed. The mechanical lift sling was under R1 and R1 was leaning to the right side in the chair with R1's right arm held across R1's mid-chest. A low air loss mattress was on R1's bed and a quarter rail was noted to the left side of the bed flush with the wall. No rail was noted to right side of R1's bed. The distance from the top of the mattress to the floor measured 33 inches, and the distance from the top of the bed rail to the floor measured 39 inches. On 2/19/26 at 11:58AM, R1 stated that he rolled out of bed and was hollering for help to get up. R1 stated he was not clear on how he managed to fall up and over the side of the bed to the floor but that he was alone when he fell. R1 stated he has tremors related to his Parkinson's disease and maybe he was thrashing around in his sleep. R1 stated the aide V10 came in and got the nurse. R1 stated he told the staff his chest hurt on his right side, and it still hurts. R1 stated he has no use of his left arm after the stroke. R1 confirmed that his bed is usually higher than where it is currently. This surveyor stood next to bed and R1 indicated that the bed is normally at the same level as this surveyor's waistline which measured at 42inches.On 2/19/26 at 12:30PM V2 Director of Nursing (DON) confirmed R1's Care Plan documents interventions entered on 6/19/25 for R1's bed to be in low position and R1 to be positioned in the middle of the mattress. V2 stated that R1's bed is not a low bed and doesn't go all the way to the floor. V2 stated that R1's bed should not have been in a high position while R1 was sleeping in bed. V2 stated there is a binder at the nurses' station with all fall risk residents in it, they have alert messages on the electronic medical record, and all staff receive fall prevention training at time of hire.The Facility Policy Incidents and Accidents dated 4/7/2019 documents an accident is defined as any happening not consistent with the routine operation of the facility that results in bodily injury other than abuse.The Facility Policy Fall Prevention Program dated 11/21/2017 documents safety interventions will be implemented for each resident identified as a risk, and all assigned nursing personnel are responsible for ensuring ongoing precautions are in place and consistently maintained.

Based on observation, interview and record review the facility failed to protect residents' right to be free from physical abuse by another resident. This resulted in R1's abuse by R2, R3's abuse by R2, and R7's abuse by R5. R1, R2, R3, R5, and R7 are five of eight residents reviewed for abuse in the sample list of 12. Findings include:The facility's Abuse Prevention and Reporting- Illinois policy dated 10/24/22 documents the facility affirms the residents' right to be free from abuse and prohibits abuse and mistreatment of residents. This policy documents physical abuse is the infliction of injury that occurs other than by accidental means and includes hitting, slapping, pinching, and kicking. 1.) The facility's Abuse Investigation Checklist documents on 12/10/25 at 5:00 PM an allegation of physical abuse involving R1 and R2. R2 hit R1 on the left side of R1's face while in the dining room, which was witnessed by V3 Certified Nursing Assistant (CNA). There were no injuries. V3's statement documents R2 pointed at R1 as they were seated at the same table and then R2 slapped R1 on the left cheek. V3 attempted to get to them as fast as V3 could and removed R2 from R1's table. R2 started hitting V3. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has poor recall and memory impairment. R2's active care plan documents R2 has Alzheimer's Disease. This care plan includes a problem area dated 4/12/24 that R2 can be combative when approached and includes an intervention to be aware of R2's whereabouts and R2 should be in the dining room or lobby when up in wheelchair. R1's MDS dated [DATE] documents R1 as cognitively intact. On 12/22/25 at 9:08 AM R1 was interviewed but did not recall the incident where R1 was slapped. On 12/23/25 at 9:35 AM V3 CNA stated: R1's/R2's altercation occurred in the dining room just prior to supper. R1/R2 were seated next to each other, R2 was fidgeting with a clothing protector and pushed it towards R1. R1 pushed it back to R2 and I removed the clothing protector. Then V3 saw R2 lean over the table and put R2's finger in R1's face, but V3 could not hear what was said. R2 then put her hand next to R1's face and threatened to hit R1. V3 tried to get to them to intervene, but then R2 open handed smacked R1 on the left side of R1's face. There was no redness or injury and R1 just kind of looked at R2 like a deer in the headlights. R1 is always quiet, but R2 is like a switch that turns on/off and R2 has been involved in prior altercations with staff/residents. As V3 removed R2 from the table R2 started hitting V3. 2.) The facility's Abuse Investigation Checklist documents an allegation of verbal and physical altercation between R2 and R3, who both have dementia/Alzheimer's Disease. On 11/22/25 at 11:45 AM R3 spoke to R2 and R2 hit R3 in R3's right arm, witnessed by V14 CNA. There were no injuries. V14's statement documents V14 was pushing a resident into the dining room for lunch and came around the corner to see R2 pushing a transfer chair. V15 (R3's Family) was pushing R3 in a wheelchair through the lobby and past R2. R3 asked R2 what R2 was doing, R2 brought her fist up and hit R3 in his right upper arm. V15's statement documents R3 was very excited that V15 was visiting and R3 speaks with incorrect words at times. As they passed into the hallway from the lobby, R3 yelled at R2 something like what are you doing and a lot of times cuss words are mixed up in R3's wording. R2 responded by hitting R3's arm. R3's MDS dated [DATE] documents R3 has severe cognitive impairment and have verbal and physical behaviors directed towards others 1-3 days during the 7 day review period. On 12/22/25 at 12:19 PM V14 CNA stated V14 witnessed R2's/R3's altercation.V17 was pushing R3 through the doorway of the 200 hallway. R3 said hi to R2 as they passed. R2 took her fist and hit R3 in his right arm. V14 confirmed R3's actions were intentional and not by accident. R3 had no signs of injury. 3.) The facility's Abuse Investigation Checklist documents an allegation of verbal and physical altercation between R5 and R7, who both have Alzheimer's/Dementia. On 11/14/25 at 4:00 PM in the front lobby, R7 was yelling, R5 told R7 to shut up, and then R5 hit R7 on R7's right thigh, witnessed by V5 CNA. V5's statement documents R7 was in the front lobby yelling like R7 does, V5 heard R5 yell back and V5 went to separate R5 and R7. As soon as V5 got to them, R5 hit R7 on R7's right thigh which left a small red mark. R5's MDS dated [DATE] documents R5 has severe cognitive impairment. R5's active care plan documents R5 is at risk for abuse/neglect and R5 can have aggressive behavior. This care plan includes an intervention dated 4/26/25 documents if staff hear R5 raising her voice redirect R5 with coffee or snacks and encourage R5 to move away from whomever R5 is talking to or move the other resident away from R5. R7's MDS 9/24/25 documents R7 is rarely/never understood and has poor recall and memory impairment. On 12/22/25 at 8:54 AM R5 was self propelling her wheelchair down the 200 hallway. Attempts were made to interview R5, who became increasingly agitated with conversation and R5 cursed at the surveyor. On 12/22/25 at 3:06 PM V5 CNA stated V5 witnessed R5's/R7's altercation. R7 yells a lot and can be loud, which triggered R5 who hit R7 with an open hand on R7's thigh initially causing a red mark. R7 yelled ow when it happened, but otherwise had no overall response/reaction and no other injuries. V5 stated R5 and R7 have yelled back and forth between each other so we try to keep them apart. V5 confirmed R5's actions were intentional and not accidental. V5 stated R5 was upset with R7 and told R7 to shut up, and V5 attempted to get to them to separate R5/R7 before R5 hit R7.

Based on observation, interview, and record review the facility failed to develop and implement interventions to address dementia related behaviors for four of eight residents (R2, R3, R5, R7) reviewed for abuse in the sample list of 12. Findings include: 1.) The facility's Abuse Investigation Checklist documents an allegation of a verbal and physical altercation between R2 and R3, both of whom have dementia/Alzheimer's disease. On 11/22/25 at 11:45 AM, R3 spoke to R2, and R2 struck R3 on R3's right arm. The incident was witnessed by V14, Certified Nursing Assistant (CNA).V14's statement documents that V14 was pushing a resident into the dining room for lunch and came around the corner to observe R2 pushing a transfer chair. V15 (R3's family member) was pushing R3 in a wheelchair through the lobby past R2. R3 asked R2 what R2 was doing, at which time R2 raised her fist and hit R3 on his right upper arm.The facility's Abuse Investigation Checklist also documents that on 12/10/25 at 5:00 PM, there was an allegation of physical abuse involving R1 and R2. R2 struck R1 on the left side of R1's face while in the dining room. The incident was witnessed by V3, CNA. Documentation notes that R2 has mood swings and can be aggressive, including toward family members, and that it is best for R2 to sit at a dining room table where staff are also seated.V3's statement documents that R2 pointed at R1 while they were seated at the same table and then slapped R1 on the left cheek. As V3 removed R2 from the table, R2 began hitting V3.R2's active care plan includes a problem area dated 4/12/24 identifying that R2 can be combative when approached. The care plan includes interventions dated 4/12/24 and 4/24/24 to be aware of R2's whereabouts, to have R2 remain in the dining room or lobby when up in a wheelchair, and to report behaviors to psychiatric services following any encounters with other residents. The care plan has not been updated with new interventions following R2's altercations with R1 and R3.There is no documentation indicating that R2 was evaluated by psychiatric services following these altercations.On 12/22/25 from 12:03 PM to 12:13 PM, R1 and R2 were seated next to each other in the dining room, and no staff were seated at their table. At 12:13 PM, V33, Dietary Aide, confirmed this and stated that the previous Tuesday R1 and R2 were not seated next to each other. V23, CNA, entered the dining room and told V34, Dietary Aide, that R2 was not supposed to be sitting there and moved R2 to a different table. At 12:18 PM, V34 stated she was not aware that R2 was not supposed to sit with R1 and that R1 and R2 had been seated beside each other the previous Wednesday when V34 last worked.On 12/22/25 at 12:19 PM, V14, CNA, stated she witnessed the altercation between R2 and R3. V17 was pushing R3 through the doorway of the 200 hallway. R3 said hello to R2 as they passed. R2 raised her fist and struck R3 on his right arm. V14 confirmed that R2's actions were intentional and not accidental.On 12/23/25 at 9:35 AM, V3, CNA, stated that the altercation between R1 and R2 occurred in the dining room just prior to supper. R1 and R2 were seated next to each other, and R2 was fidgeting with a clothing protector and pushed it toward R1. R1 pushed it back, and V3 removed the clothing protector. V3 then observed R2 lean over the table and place her finger in R1's face, though V3 could not hear what was said. R2 then placed her hand near R1's face and threatened to hit R1. V3 attempted to intervene, but R2 then open-handedly struck R1 on the left side of R1's face. There was no redness or injury observed, and R1 appeared startled. V3 stated R2 is like a switch that turns on and off and has been involved in prior altercations with staff and residents. As V3 removed R2 from the table, R2 began hitting V3. V3 was unsure what new interventions were implemented following the altercation, including whether dining room seating was changed.On 12/22/25 at 12:30 PM, V1, Administrator, stated R2's dining room seating was changed immediately following the altercation with R1 and confirmed R2 is not supposed to sit next to R1. At 1:20 PM, V1 stated R2's Celexa dosage was decreased on 11/12/25, when R2 was last evaluated by psychiatric services. V1 stated the primary physician would be asked to re-evaluate R2 to determine if the Celexa dosage could be increased back to the prior level due to the timing of the medication reduction and subsequent altercations. On 12/23/25 at 8:00 AM, V1 confirmed that no new interventions were implemented following the altercation between R2 and R3 and that R2's care plan had not been updated.

Based on interview and record review the facility failed to ensure resident medical records are complete/accurate by failing to document resident to resident altercations and family and physician notifications for four of eight residents (R2, R3, R5, R7) reviewed for abuse in the sample list of 12. 1.) The facility's Abuse Investigation Checklist documents an allegation of a verbal and physical altercation between R2 and R3, both of whom have dementia/Alzheimer's disease. On 11/22/25 at 11:45 AM, R3 spoke to R2, and R2 struck R3 on R3's right arm. The incident was witnessed by V14, Certified Nursing Assistant (CNA).V14's statement documents that V14 was pushing a resident into the dining room for lunch and came around the corner to observe R2 pushing a transfer chair. V15 (R3's family member) was pushing R3 in a wheelchair through the lobby and past R2. R3 asked R2 what R2 was doing, at which time R2 raised her fist and struck R3 on his right upper arm.V15's statement documents that R3 was very excited about the visit and that R3 sometimes uses incorrect words. As they passed from the lobby into the hallway, R3 yelled at R2 something like, What are you doing, with profanity sometimes mixed into R3's wording. R2 responded by striking R3's arm.R2's and R3's medical records do not include documentation of this altercation, nor documentation that their families and physicians were notified.On 12/22/25 at 1:24 PM, V16, Licensed Practical Nurse (LPN), confirmed she was the nurse for R2 and R3 at the time of the 11/22/25 altercation. V16 stated that documentation of altercations is completed at the discretion of V1, Administrator. V16 confirmed that documentation and physician/family notification would typically be recorded in a nursing note.2.) The facility's Abuse Investigation Checklist documents an allegation of a verbal and physical altercation between R5 and R7, both of whom have Alzheimer's disease/dementia. On 11/14/25 at 4:00 PM in the front lobby, R7 was yelling, R5 told R7 to shut up, and then R5 struck R7 on R7's right thigh. The incident was witnessed by V5, Certified Nursing Assistant (CNA).V5's statement documents that R7 was yelling in the front lobby, as was typical behavior. V5 heard R5 yell back and went to separate R5 and R7. As soon as V5 arrived, R5 struck R7 on the right thigh, leaving a small red mark.R5's and R7's medical records do not include documentation of this altercation, nor documentation that their families and physicians were notified.On 12/22/25 at 1:50 PM, V1 stated there should be a nursing note documenting a brief summary of the incident, including physician and family notification. V1 stated there was no incident report completed for this altercation.The facility's undated Medical Record Policy documents that progress notes will indicate significant changes in resident condition when they occur, and nurses will document nursing notes including behaviors, physician notification, and family notification.

Based on observation, interview, and record review the facility failed to provide toileting assistance/incontinence care in a timely manner for two residents (R4, R12) of five residents reviewed for bowel and bladder in a sample list of 12. Findings Include: The facility's Call Light Policy, reviewed 2/2/18, states: Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. All residents who have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility at the bedside or another reasonably accessible location. All staff should assist in answering call lights. Nursing staff members shall go to the resident's room to respond to the call system and promptly cancel the call light when the room is entered. Bathroom call lights should be viewed as emergencies and given immediate attention. The facility's Incontinence Care Policy, reviewed 1/16/18, states: Purpose: To prevent excoriation and skin breakdown, provide comfort, and maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with assessed incontinent episodes or at least every two hours and will be provided perineal and genital care after each episode. 1.) R4's Care Plan, updated 10/27/25, includes the following diagnoses: Cerebral Infarction, Hyperlipidemia, Hypertension, Gastroesophageal Reflux Disease without esophagitis, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Nondominant Side, and Protein-Calorie Malnutrition. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact and requiring staff assistance with Activities of Daily Living (ADLs). R4's Care Plan, updated 10/27/25, documents that R4 requires check and change for incontinence. Provide (R4) with good peri-care and use barrier creams as needed. On 12/22/25 at 10:00 AM, R4 stated, My family members work here and all the staff help me and treat me good. They come in as soon as they can and help me when I put on my light, but sometimes at night they are busy and it's a long wait. R4 appeared clean, with no obnoxious odors observed. R4's nails and hair appeared clean and groomed. On 12/22/25 at 10:15 AM, V12 (R4's family member) stated that on 11/22/25, R4 went all day without being checked for incontinence or changed, and when V11, a family member, visited late in the afternoon, R4's call light was on and R4 had been incontinent of feces. V12 stated V8, Certified Nurse's Aide (CNA), and V9, Certified Nurse's Aide (CNA), answered the call light and said they would be back to clean R4. After 45 minutes, V11 cleaned R4 and assisted her to her wheelchair. V8 or V9 did not return. On 12/22/25 at 12:00 PM, V11, a Certified Nurse's Aide (CNA) and R4's family member, stated, I was called in to work on 12/1/25, and R4's call light was on. I went in to change R4, and she had dried feces all over her. I scrubbed it off, but it caused R4 pain and made her skin red and irritated. On 12/22/25 at 2:00 PM, V8 stated, I do remember that day, though I'm not sure of the exact date. By the time V9 and I got back to clean up R4, V11 had already done it. On 12/23/25 at 10:00 AM, R4 was lying in her bed looking out the window. R4 appeared clean and appropriately groomed. R4 stated, I don't want to get the staff in trouble or anything, but I do lay here sometimes all night in pee and poop. It is not their fault. I don't think they have enough help sometimes. It makes me feel uncomfortable, and it's kind of disgusting. R4 looked away and frowned. 2.) On 12/23/25 at 6:17 AM, 6:30 AM, 6:40 AM, and 6:45 AM, R12's call light was on. At 6:50 AM, R12's call light was no longer on. R12 was sitting on the side of her bed with her pants at her knees. R12 stated an unidentified housekeeper had answered her call light and told her she would get staff to help. R12 stated she had been waiting to use the bathroom, which was why her call light was on. R12 stated she has waited up to 45 minutes in the past, which has caused her to urinate in her pants due to waiting so long. At 7:00 AM, V21, Certified Nursing Assistant (CNA), entered R12's room. V21 stated she and the other CNA, V31, were in another resident's room performing a full mechanical lift transfer. R12 told V21 that her call light had been on for at least 20 minutes, which she stated was a long time to wait when needing to use the bathroom. V21 assisted R12 to the bathroom, and R12 was wearing an incontinence brief. At 7:10 AM, R12 stated she wears incontinence briefs so that when she is incontinent, her pants will not get wet. R12 stated she does not like waiting so long that it causes her to be incontinent, stating, It's awful. R12's Minimum Data Set (MDS), dated [DATE], documents R12 as cognitively intact, occasionally incontinent of bowel and bladder, and requiring partial/moderate staff assistance for toileting hygiene and supervision/touch assistance for transfers. R12's active Care Plan documents that R12 receives diuretic therapy and has diagnoses of morbid obesity and complex pain syndrome. On 12/23/25 at 7:07 AM, V21 stated that two CNAs are not enough for R12's hallway, describing it as a heavy hall. V21 stated mornings are busy completing showers, which can affect call light response times. V21 stated there are 12–13 residents on the hall who require mechanical lift transfers with two staff. V21 stated all staff are supposed to help answer call lights. On 12/23/25 at 10:38 AM, V1, Administrator, stated that call lights should be answered timely and that all staff are expected to answer call lights so assistance can be provided. V1 confirmed that a 30–45 minute response time would not be considered timely for a call light or toileting request.

Based on interview and record review the facility failed to ensure accurate documentation of medications that was administered for 2 of 3 residents (R1,R2) reviewed for medication administration.Findings include: 1.R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Fibromyalgia, Morbid Obesity, Complex Regional Pain Syndrome, Major Depressive Disorder, HTN, Hypothyroidism, GERD, Anxiety Disorder and Barrett's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R1's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 8 hours as needed for severe pain.R1's Controlled Drug Receipt Record/Disposition Form dated August 29, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R1's Medication Administration Record (MAR) dated August 29, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.2. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Primary Osteoarthritis Right Knee, Type 2 Diabetes, Cellulitis of Left Lower Limb, Non-Pressure Ulcer Right Lower Leg, Ataxia, Difficulty in Walking, Pulmonary Hypertension, Non-ST Elevation Myocardial Infarction, Heart Disease, Venous Insufficiency, Chronic Embolism and Thrombosis of Deep Veins of Lower Extremity. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R2's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 4 hours as needed for severe pain. R2's Controlled Drug Receipt Record/Disposition Form dated September 8, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R2's Medication Administration Record (MAR) dated September 8, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.The Facilities Medication Administration General Guidelines not dated documents: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the residents Medication Administration Record (MAR) directly after the medication was given. 3. When as needed (PRN) medications are administered the following documentation is provided: a) Date and time of administration, dose, route of administration and if applicable the injection site. d) signature or initials of person recording administration and signature or initials of person recording effect, if different from the person administering the medication. On 9/13/25 at 10:15 AM V4 Licensed Practical Nurse stated that when V4 administers a residents opioid, V4 will open the lock box, obtain the medication and sign out for the medication on the Controlled Drug Receipt Record/Disposition Form. V4 stated after administering the medication, V4 will then sign that the medication was administered in the residents Electronic Health Record (EHR). On 9/13/25 at V1 Administrator confirmed that R1's Controlled Drug Receipt Record/Disposition Form dated August 29th, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R1's Medication Administration Record (MAR) does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 also confirmed that R2's Controlled Drug Receipt Record/Disposition Form dated September 8th, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R2's Medication Administration Record (MAR) dated September 8th, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 stated that V3 should first sign out for the residents narcotic on the Controlled Drug Receipt Record/Disposition Form, and then after administering the medication to the resident, V3 should document that the medication was administered to the resident in the residents Electronic Health Record.

Based on interview and record review the facility failed to protect the residents right to be free from physical and verbal abuse by another resident. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. This failure resulted in R1 abusing R2 causing R2 to experience psychosocial harm as evidenced by crying. Findings include: The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. R1's Face Sheet dated 5/8/25 documents the following diagnoses: Dementia with agitation and behaviors and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan (current) documents R1 has a behavior problem and screams/curses at staff. This same record documents R1 is frequently verbally aggressive towards others and can have aggressive behaviors. A Progress Note dated 5/7/25 documents R1 still wearing the same clothing as the day before and R1 resistive to cares and very aggressive physically and verbally. R2's Face Sheet dated 5/8/25 documents the following diagnoses: Alzheimer's Disease. R2's MDS dated [DATE] documents R2 is severely cognitively impaired. A typed, undated incident narrative documents a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 Certified Nursing Assistant (CNA) hitting R2 in the back and yelling at R2 stating R2 needed a good smacking. On 5/7/25 at 12:38pm, V9 Registered Nurse stated R1 can be aggressive towards other residents. V9 stated R1 does not like other residents to be around R1. On 5/7/25 at 1:21pm, V4 CNA stated on 4/26/25, R1 was in the lobby sitting area near the table by the front window and R2 was near the front door yelling I want to go home. V4 stated this is not unusual for R2. V4 stated V4 was sitting at the nurses station charting when V4 heard R1 yelling at R2, 'I'm tired of listening to you. Why don't you shut up.' V4 stated V4 then heard what sounded like R1 smacking R2 in the back and R2 posturing like R2 had been hit in the back. On 5/8/25 at 10:45am, R8 stated R1 cusses residents out. On 5/8/25 at 12:21pm, V16 CNA stated the last weekend V16 worked, either Saturday or Sunday (4/26/25 or 4/27/25), V16 was told by V4 CNA that R1 hit R2. V16 stated V16 came upon R1 and R2 shortly after the incident. V16 stated R2 was crying and rubbing R2's arm and R2 said R1 hit R2.

Based on interview and record review the facility failed to ensure residents' right to be treated in a dignified manner for three (R8, R9, and R10) of 12 residents reviewed for abuse in the sample list of 13. Findings include: The facility's Resident Rights policy dated 8/23/17 documents 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 On 5/8/25 at 10:45 AM R8 stated V3 Certified Nursing Assistant (CNA) is a b**** (expletive), she's just mean. R8 stated about six months or so ago V3 hit R8 in the stomach while rolling R8 in bed. R8 felt this was done intentionally and described V3 as being mean about it. V3 stated V1 Administrator and V2 Director of Nursing were notified. R8 stated V3 also left R8's former room mate, R10, to take herself to the bathroom. R8 stated V3 knew R10 needed the bathroom, but left her on her own. R8 stated R10 waited an hour for V3 to return prior to taking herself to the bathroom. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. The facility's daily assignment sheets dated 4/30/25-5/7/25 documents V3 worked on R8's hallway five days during this time frame. V3's employee file was reviewed on 5/8/25. This file contained Employee Disciplinary Action Form dated 11/7/24, which documents a written warning and three day suspension was given to V3 regarding being unprofessional in language and actions with resident (identified as R9) and family (identified as V16 CNA) present. V3 was educated on Abuse and Neglect and Customer Service. This file contained Employee Disciplinary Action Form dated 2/27/25, which documents it was reported to V1 Administrator that V3 did not assist a resident (R10) with toileting assistance and walked out of the room. V3 was issued a written warning and three day suspension, and provided education on the facility's Customer Service Policy. The attached undated Customer Service policy documents the facility is dedicated in serving others to create a positive experience, and this includes responding promptly and in a positive/professional manner and being polite, interested, and respectful. This policy documents to smile, convey friendliness, avoid raising your voice in frustration or anger, have an open/friendly posture, be respectful and empathize and apologize where required. R9's Census documents R9 discharged from the facility on 2/10/25. R9's MDS dated [DATE] documents R9 has severe cognitive impairment. R10's Census documents R10 discharged from the facility on 3/17/25. R10's MDS dated [DATE] documents R10 as cognitively intact. R10's Care Plan initiated 2/12/25 documents R10 has Activities of Daily Living self care deficit with varying levels of assistance needed due to right distal femur fracture. On 5/8/25 between 10:35 AM and 1:13 PM the following staff were interviewed: V19 Licensed Practical Nurse stated V3 has a history of problems with R8, including R8 saying V3 was rough with R8. V19 stated V1 Administrator was aware and V3 was placed on suspension. V16 CNA stated V16 was R9's Power of Attorney and V3 has a history of not doing things. In regards to V3's 117/24 Disciplinary Action , V16 stated V16 entered R9's room and noted an odor. V3 entered R9's room to give V16 report and V16 told V3 that R9 needed to be checked/changed. V16 stated V3 huffed and said V3 did not have time for this while standing near R9. V16 stated V1 was notified and V16 was upset to find out that V3 continues to be employed by the facility despite having similar situations. V16 stated V3 had poked R8 in the chest causing R8 to cry. V18 Human Resources, in regards to the 11/7/24 Disciplinary Action, stated it was reported by V16 that while assisting V3 to change R9, V3 did not sound very professional, it was V3's tone of voice. V3 was placed on suspension and educated on customer service. On 5/8/25 at 11:54 AM V3 stated R8 does not like V3 and described R8 as being rude to V3, even though V3 is not rude to R8. V3 confirmed V3 still provides cares for R8. V3 confirmed receipt of abuse and resident rights training. In regards to V3's 11/7/24 Disciplinary Action, V3 stated V3 went in to provide care for R9 who was dirty/incontinent. V3 stated V3 told R9 that R9 was dirty and V3 needed to change her. V3 stated V16 was also in the room providing care for R9's unidentified room mate, and V16 told V3 that V3 shouldn't talk to R9 that way. V3 stated management talked to V3 about the situation, but didn't recall what was said or reviewed. In regards to the 2/27/25 Disciplinary Action, V3 stated R10 called to request the bathroom, V3 told R10 that V3 was in the middle of providing cares to another unidentified resident and would return. V3 stated V3 did not return to R10's room since R10's call light was no longer on. On 5/8/25 at 10:40 AM V2 Director of Nursing stated R10 was R8's room mate on 2/27/25. V1 and V2 confirmed V3's 2/27/25 Disciplinary Action form was for R10. V1 stated the concern was reported by R10 and this was addressed with V3. At 10:52 AM V1 stated R8 says a lot of people are rough with her and R8 likes to make up things. V1 stated R8 has said V3 was rough with her and we have talked to V3 about it. At 1:27 PM V1 confirmed that V3 has been allowed to continue to provide R8's cares, despite a history of abuse allegation between R8 and V3 in June 2024.

Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. Findings include: On 5/7/25 at 9:49am, V1 Administrator stated V1 was notified on 4/26/25 by V4 Certified Nursing Assistant (CNA) of R1 hitting and yelling at R2 but did not report the incident to the State Agency or do an investigation. On 5/7/25 at 10:59am, V6 R1's Representative stated V6 was not notified of the altercation between R1 and R2. On 5/7/25 at 1:21pm, V4 CNA stated V4 notified V1 Administrator on 4/26/25 of R1 yelling at R2 and hitting R2 in the back. There is no documentation in R1's medical record of the state survey agency or V6 being notified of the incident. There is no documentation in R2's medical record of the state survey agency or V10 R2's Representative being notified of the incident. The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on interview and record review, the facility failed to timely report an allegation of resident to resident physical and verbal abuse to the state survey agency. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. Findings include: R1's Face Sheet dated 5/8/25 documents the following diagnoses: Dementia with agitation and behaviors and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan (current) documents R1 has a behavior problem and screams/curses at staff. This same record documents R1 is frequently verbally aggressive towards others and can have aggressive behaviors. A Progress Note dated 5/7/25 documents R1 still wearing the same clothing as the day before and R1 resistive to cares and very aggressive physically and verbally. R2's Face Sheet dated 5/8/25 documents the following diagnoses: Alzheimer's Disease. R2's MDS dated [DATE] documents R2 is severely cognitively impaired. A typed, undated incident narrative documents a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 Certified Nursing Assistant (CNA) hitting R2 in the back and yelling at R2 stating R2 needed a good smacking. There was no abuse investigative file for the altercation between R1 and R2 and no documentation of the incident in R1 or R2's medical record. There is no documentation that the facility reported this altercation to the state survey agency. On 5/7/25 at 9:49am, V1 Administrator stated V1 was notified on 4/26/25 by V4 Certified Nursing Assistant (CNA) of R1 hitting and yelling at R2 but did not report the incident to the state survey agency or do an investigation. On 5/7/25 at 12:38pm, V9 Registered Nurse stated R1 can be aggressive towards other residents. V9 stated R1 does not like other residents to be around R1. On 5/7/25 at 1:21pm, V4 CNA stated on 4/26/25, R1 was in the lobby sitting area near the table by the front window and R2 was near the front door yelling I want to go home. V4 stated this is not unusual for R2. V4 stated V4 was sitting at the nurses station charting when V4 heard R1 yelling at R2, 'I'm tired of listening to you. Why don't you shut up.' V4 stated V4 then heard what sounded like R1 smacking R2 in the back and R2 posturing like R2 had been hit in the back. V4 stated V4 notified V1 Administrator on 4/26/25 of R1 yelling at R2 and hitting R2 in the back. On 5/8/25 at 10:45am, R8 stated R1 cusses residents out. On 5/8/25 at 12:21pm, V16 CNA stated the last weekend V16 worked, either Saturday or Sunday (4/26/25 or 4/27/25), V16 was told by V4 CNA that R1 hit R2. V16 stated V16 came upon R1 and R2 shortly after the incident. V16 stated R2 was crying and rubbing R2's arm and R2 said R1 hit R2. The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample of 13. Findings include: The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents the following: when suspicion of abuse or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members and visitors in the area. Obtain witness statements. Document the entire investigation chronologically. Notify the attending physician and the resident's family/legal representative. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions. A typed, undated incident narrative documents V1 Administrator notified by V4 Certified Nursing Assistant (CNA) of a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 hitting R2 in the back and yelling at R2 stating R2 needed a good smacking. Further documents R1 and R2 separated by nursing staff and R2 assessed for injury by V5 Licensed Practical Nurse. On 5/7/25, the above incident narrative failed to document the time of the incident between R1 and R2, failed to document the date and time of required notifications, failed to document what staff and residents were interviewed, the results of those interviews, and the date/time of those interviews. The same record failed to document the investigation chronologically and failed to document any subsequent monitoring or assessment of potential resident psychosocial outcomes following R1 and R2's incident on 4/26/25. On 5/7/25 at 9:49am, V1 stated the typed, undated incident narrative was the complete investigation for the incident between R1 and R2. The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R206) of nine residents reviewed for call light response times in the sample list of 27. Findings include: On 3/25/25 at 9:00 am, R206 stated that R206 needed assistance from staff, and R206 was unsure why they took so long to come to R206's room. R206 stated sometimes R45 (R206's roommate) has to wait 45 minutes or more for staff to come and put R45 into bed. R206 stated that sometimes R206 will wheel down the hall to get staff to come and help R45. Facility Census documents R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture, and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score of 8, moderate cognitive impairment, and needs moderate assistance with showers/bathing. On 3/25/25 at 9:15 am, R45 stated that sometimes R45 has to wait 45 minutes or more for staff to come and help R45 into bed. R45 stated that R206, R45's roommate, will get staff to help R45. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing. On 3/25/25 at 11:24am R38 stated that it takes staff to long to answer call lights sometimes. R38 stated that R38 needed assistance from staff to get transferred to the toilet. R38 stated that in more than one instance R38 has had an incontinent episode, due to waiting on staff to come toilet R38. R38 stated, R38 sometimes has to wait 30-40 minutes for staffs' assistance. Facility Census documents R38 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder. R38's Minimum Data Set (MDS) dated [DATE] documents R38's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs substantial/maximum assistance with showers/bathe. On 3/26/25 at 9:00am, a resident council meeting was held. During the meeting R206 stated it takes a long time for call lights to be answered, R206's roommate (R45) calls out, so R206 turns the call light on for R45. R206 stated R206 has had to go looking for staff because no one responds to the call light. R206 stated R206's/R45's room gets overlooked because it is at the end of the hallway. R17 stated R17 has waited for over an hour for R17's call light to be answered, especially during the afternoon and midnight shifts. R17 stated R17 waits a long time for the call light to be answered and often ends up getting out of bed by herself, but R17 is supposed to have assistance from staff. These residents stated that call light wait times have been an ongoing issue brought up in the resident council meetings that haven't been resolved. On 3/26/25 at 9:15am R17 stated that staff take a long time to answer call lights and R17 needs help to get to the toilet. R17 stated we have been bringing it up at the monthly resident council meeting and nothing seems to get done, it's not getting any better. Facility Census documents R17 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder. R17's Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs Partial/moderate assistance with showers/bathe. On 3/26/25 at 9:20am V5 Activity Director confirmed call lights have been an ongoing concern brought up in the resident council meetings. V5 stated that for the past two monthly Resident Council meetings residents have been complaining on waiting a long time for call lights to be answered. On 3/26/25 at 10:30 a.m., the V1 Administrator stated that V1 is aware of the delay in answering residents' call lights. V1 stated that the facility has been educating staff on answering call lights in a timely manner, but residents are still complaining that the staff is taking too long to answer them. V1 stated that some residents are taking themselves to the toilet due to staff not responding in a timely manner. The Resident Council Minutes dated 1/27/25 and 2/24/25 document concerns with call light response times taking too long. Facility Call Light Policy dated 2/2/18 documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Residents' call lights will be answered in a timely manner. 1. All residents who can use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to a room to respond to call system and promptly cancel the call light when the room is entered. 5. Hand bells will be provided for alert dependent resident's when positioned out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to Maintenance Department for servicing. Check room frequently until system is repaired.

Based on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of three residents who were reviewed for showers in the sample list of 27. Findings include: 1. On 3/25/25 at 9:00am R206 was sitting in the wheelchair in R206's room, nails not trimmed and face not shaven. On 3/25/25 at 9:00 am R206 stated that R206 was admitted a couple of weeks ago and has only gotten one shower last week. R206 stated that staff do not cut R206's nails on that day or any other day; they are very long and need trimming. The Facility Census documents that R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment and needs moderate assistance with showers/bathe. The Facility's East Evening Showers schedule documents R206 is scheduled to receive showers on Tuesdays and Fridays. R206's Shower Day Skin Inspection report documents R206 received showers on 3/21/25 and has no documented refusals or bed baths. The same report documents R206's nails were never cut or trimmed. 2. On 2/25/25 at 9:15am R45 was sitting in the wheelchair in R45's room, nails not trimmed. On 2/25/25 at 9:15am R45 stated that R45 never gets two showers a week. R45 stated that staff never cut or trim R45's nails, and they are long and need trimming. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing. The Facility's East Evening Showers schedule documents R45 is scheduled to receive showers on Tuesdays and Fridays. R45's Shower Day Skin Inspection report documents R45 received showers on 2/11/25, 2/18/25, 2/28/25 and 3/21/25, refused showers on 2/25/25, 3/11/25 and 3/14/25 and was not offered a bed bath. The same report documents that R45's nails were never cut or trimmed. On 2/26/25 at 1:30 p.m., V2, the Director of Nursing, stated that all residents are scheduled two showers a week and should be getting them. V2 stated that after a resident receives a shower, bed bath, or refuses a shower, the Certified Nursing Assistant is required to complete a Shower Day Skin Inspection Form. V2 confirmed that R45 and R206 are not receiving two showers a week and will have staff cut their nails today. The Facility's Shower Documentation documents showers should always include washing hair, oral care, fingernails, toenails (except diabetic residents), shaving, stripping and remaking the bed, cleaning the shower room. Please make sure you're performing each of these when giving a shower. Shower reminders: refusals or N/A's require a shower sheet be completed with reason (showered on AM shift, showered yesterday by hospice, res states does not feel like it).

Based on observation, interview, and record review the facility failed to provide supervision to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in R1 falling and sustaining a laceration to R1's head requiring sutures. Finding Include: R1's Care Plan reviewed 9/25/24 includes the following diagnoses: Urinary Incontinence, Anxiety, Right Sided Hemiplegia, Osteoarthritis, Parkinson's Disease, and Dysphagia. This Care Plan also documents R1 is at risk for falls related to Gait and Balance Deficit, Incontinence, Poor Communication and Comprehension, Diagnosis of Parkinson's and History of Cerebral Vascular Accident with Right Sided Hemiparesis. This care plan also documents R1 has a physician's order for a Regular, Pureed Diet with Nectar Thick liquids. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired, has decreased range of motion for lower and upper extremities of one side, and requires supervision or touching assistance for eating. R1's After Visit Summary from the emergency room dated 9/24/24 documents (R1) came to the emergency room after (R1) had a fall and hit (R1's) forehead and had a laceration that was bleeding. (hospital staff) repaired the the laceration with sutures. These sutures need to come out in one week. This can be done through your primary care provider, at a convenient care location or at the emergency room . On 10/25/24 at 12:14 PM, R1 was observed sitting in the dining room at the table for lunch. R1 had a divided plate with pureed foods and nectar thickened liquids. R1 was receiving hands on assistance with feeding. R1 was not talking and was weak to the right side. R1 did not respond meaningfully to verbal stimuli. On 10/22/24 at 2:00 PM, V3 (Certified Nurse's Aide) CNA stated I was passing trays on the hall (on 9/24/24), and I heard another resident scream out (R1) was 'on the floor.' (R1) had her tray. I think probably someone from dietary gave it to her. (R1) was on the floor and her head was bleeding. It looked like R1 was reaching either for the call light or to turn on the light. The light wasn't on. I immediately called the nurse and (R1) was sent to the hospital (R1) should not have been left in her room alone with her tray. On 10/23/24 at 9:30 AM, V5 (Certified Nurse's Aide) CNA stated I would not have left (R1) alone for a meal in her room. (R1) is on thickened liquids and is very confused and often tries to get up unassisted. (R1) is pretty much total care. I regularly care for (R1) and she needs supervision and some help during meals. On 10/24/24 at 11:00 AM, V1 Administrator and V2 Director of Nursing verified that (R1) should not have been left in her room alone with her food tray and that the fall and sutures might have been prevented if (R1) had been taken to the dining room for her meal.

Based on interview and record review, the facility failed to safely transfer a resident (R1) by mechanical lift from a geriatric chair to bed. This failure resulted in R1 being hit in the shoulder by the mechanical lift equipment causing a hematoma to R1's shoulder and R1's foot becoming caught in R1's geriatric chair causing a fracture. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: The facility Transfers-Manual Gait Belt and Mechanical Lift Policy (revised 1/19/18) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility will use mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. The transfer needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H-Mechanical Lift with two caregivers. R1's Face Sheet dated 10/1/24 documents R1 is on Hospice and R1's diagnoses include: Alzheimer's Disease, Dementia, Hypothyroidism, Hypertension, and Pulmonary Fibrosis. R1's Medical Record does not document R1 as having any underlying bone diseases. R1's Comprehensive assessment dated [DATE] documents R1 is severely cognitively impaired with no upper or lower limb impairments, uses a wheelchair (geriatric chair) for mobility, and is dependent on staff for all activities of daily living (ADL) including transfers. R1's Care Plan (current) documents R1 has ADL self-care deficit related to impaired balance, Alzheimer's/Dementia, uses a mechanical lift for transfers and a geriatric chair for mobility. This same record documents for chair to bed/bed to chair transfers, R1 requires two staff with a mechanical lift. The facility investigation report dated 9/15/24 documents R1 was observed by the nurse (V4) exhibiting signs and symptoms of pain and decreased range of motion (ROM) to the left lower extremity. This same report documents R1 was assessed by the nurse and bruise to left shoulder was observed and V17 R1's Representative refused x-rays until 9/17/24. Further documents R1 diagnosed with a left distal femoral fracture on 9/18/24 and knee immobilizer in place. The same report documents V3 Certified Nurses Assistant (CNA) found to have improperly transferred R1 with a mechanical lift without assistance. R1's Hospice Note dated 9/15/24 at 9:40am, documents R1 has new bruise/swelling/abrasion noted to left shoulder. R1 also has new onset of severe pain to left hip/leg when being changed in bed. R1 screaming in pain and PRN (as needed) Morphine (Opioid pain medication used to treat severe pain) administered. R1's Medication Administration Record (September 2024) documents R1 had been prescribed Morphine 100 milligrams/5 milliliters (ml), give 0.25 ml by mouth every two hours as needed for pain/air hunger. This same record documents R1 was administered Morphine on 9/15/24 at 9:27am, 12:05pm, and 4:39pm for pain. There are no other administrations of Morphine to R1 during the month of September prior to 9/15/24. R1's Left Knee x-ray dated 9/18/24 documents the following: left knee pain. Impression: Distal femoral fracture. On 10/1/24 at 11:42am, V1 Administrator stated based on the facility investigation, the facility concluded R1's injuries are due to an improper transfer with one person. V1 stated R1 is a mechanical lift transfer and none of the staff stated they assisted V3 CNA during the transfer of R1. V1 stated the investigation revealed V3 transferred R1 from bed to geriatric chair and from geriatric chair back to bed by self on the evening of 9/15/24. V1 stated during one of these transfers of R1, the lift arm came down and hit R1 on the left shoulder causing the bruise and R1's foot became caught in the gap between seat of R1's geriatric chair and footrest. V1 stated V3 did admit to transferring R1 out of bed to R1's geriatric chair by self. V1 stated V3 was suspended pending investigation and subsequently quit. On 10/1/24 at 1:31pm, V4 Licensed Practical Nurse stated V4 worked 9/15/24 and noticed the bruise to R1's shoulder and had not noticed it prior to 9/15/24. V4 stated the CNA's also reported it to V4 and also stated they had not seen it before. V4 stated, us nurses are big on telling our support staff to ask for help and to transfer appropriately. We are always available to help. On 10/1/24 at 1:58pm, V7 CNA stated V7 came in on 9/14/24 and worked 5:00pm to 9:00pm. V7 stated V7 worked the hall with V3 CNA that evening. V7 stated V7 did not assist V3 in getting R1 up for dinner as V7 was not in the facility at that time. V7 stated R1 was already in the dining room when V7 arrived. V7 stated V3 went on break around 6:15pm and V7 did not put any of the mechanical lift residents down by V7's self. V7 stated R1 was in R1's room at this time but resting in R1's geriatric chair. V7 stated when V3 returned from break, V7 went on break. V7 stated when V7 returned from break R1 was in bed. V7 stated V7 did not assist V3 with transferring R1 back into bed with V3. On 10/1/24 at 2:35pm, V2 Director of Nursing stated all nursing staff have been educated on safe mechanical lift transfers. V2 stated the facility has plenty of staff and even nurse managers help on the floor.

Based on interview and record review the facility failed to follow physician orders for a resident's anticoagulant medication (Warfarin/Coumadin) resulting in the resident receiving an increased anticoagulant dosage for 24 days. The facility also failed to monitor the resident's anticoagulant medication as recommended by the drug manufacturer guidelines. These failures affect one (R1) resident reviewed for anticoagulation therapy on a sample list of three residents. These failures resulted in R1 experiencing internal bleeding and dying. Findings include: The Immediate Jeopardy began on [DATE] when the facility failed to follow the physician orders to decrease R1's Warfarin dosage from 3mg to 2.5mg and failed to obtain a PT/INR (Prothrombin Time/International Normalized Ratio (measures blood clotting time)). Twenty four days later, R1's PT/INR were at critical levels, R1 was bleeding internally and was sent to the hospital for Warfarin toxicity where he subsequently died . V1 Administrator was notified of the immediate jeopardy on [DATE] at 3:37PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The undated Warfarin package insert documents, The dosage and administration of warfarin sodium tables must be individualize for each patient according to the patient's (International Normalized Ratio) INR response to the drug. Adjust the dose based on the patient INR and the condition being treated. Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determination every ,d+[DATE] weeks. The National Institute of Health (NIH) report on Warfarin (Coumadin) anticoagulant dated [DATE] documents, Close monitoring of a patient's INR is a strong recommendation when initiating Warfarin. The INR requires more frequent monitoring when starting Warfarin. More frequent monitoring is necessary for patients with supratherapeutic or subtherapeutic INR to evaluate safety and efficacy. Also, the INR requires assessment when initiating, discontinuing, or changing doses of medications known to interact with Warfarin. Patients also require close monitoring for signs and symptoms of active bleeding throughout their treatment. Close monitoring for signs and symptoms of bleeding, such as dark tarry stools, nosebleeds, and hematomas, is necessary. R1's census report dated [DATE] documents admission to the facility. R1's undated diagnoses sheet includes the following diagnoses: Transient Cerebral Ischemic Attack, Non-Rheumatic Aortic Valve Stenosis, Hypothyroidism, Hypertension, Chronic Respiratory Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Aneurysm of the Ascending Aorta Without Rupture, Depression, Dementia, Anxiety, and the Presence of a Prosthetic Heart Valve. R1's January, February and [DATE] physician order sheet documents Plavix (antiplatelet) 75 milligrams (mg) to be given daily. R1's [DATE] medication administration record documents R1's Plavix was discontinued and Warfarin (anticoagulant), 4mg daily was started. R1's Anticoagulant Monitoring Flow Sheets do not document target INRs. R1's Prothrombin Time (PT) and International normalized ratio (INR) results sheet dated [DATE] documents a target range PT of 9XXX,d+[DATE].7 and a target range INR of 2XXX,d+[DATE].0. R1's first documented PT/INR in the medical record is dated [DATE] with PT results of 16.4 and INR results of 1.7 (Both out of range). R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 14.3 and INR results of 1.5 (Both out of range). R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 15 and INR results of 1.5 (Both out of range). R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 19.4 and INR results of 2.0 (PT results out of range). R1's [DATE] physician orders document to administer Warfarin 2mg from [DATE]-[DATE] and to administer Warfarin 3mg from [DATE]-[DATE]. R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 24.8 and INR results of 2.6 (PT results out of range). R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 51.3 and INR results of 5.4 (Both out of range). R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 35.8 and INR results of 3.7 (Both out of range). R1's [DATE] physician orders document Warfarin 3mg to administer from [DATE]-[DATE], [DATE]-[DATE] and from [DATE]-[DATE]. R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 116 and an INR greater than 10 (Both critically out of range high results). R1's physician orders dated [DATE] document to hold the Warfarin for three days, obtain two PT and INRs, the first on [DATE] and the second on [DATE] and to restart Warfarin at 2.5mg on [DATE]. R1's June and [DATE] medication administration records document that the facility continued to administer 3mg of Warfarin from [DATE] until discharge on [DATE] (24 days) and that a PT/INR was not completed until [DATE], rather than as ordered on [DATE] and [DATE]. After the critical PT/INR value on [DATE] and the recheck on [DATE]; the facility, the physician, nor the pharmacy requested another PT/INR until [DATE] when the results are documented as a PT of 120 and an INR of greater than 10 (critically high results). At this time R1 was sent to the local hospital. R1's local hospital notes dated [DATE] document that R1 was sent to the local hospital with Warfarin toxicity and was admitted with lethal bleeding requiring frozen fresh plasma to reverse his INR and then R1 was sent to a tertiary care center for critical care. R1's tertiary care center notes dated [DATE] document a left hemothorax, right lung with alveolar hemorrhage, increased size of the ascending aortic aneurysm, and a subcutaneous right gluteal hematoma measuring 7.8 centimeters (cm) x 5.7cm x 7.9cm. R1's death certificate dated [DATE] documents R1's cause of death as cardiopulmonary arrest with acute respiratory failure and a left hemothorax. On [DATE] at 10:30AM, V2 Director of Nursing (DON) said that the facility was not administering the Warfarin as ordered and not monitoring R1's labs as they should have done. On [DATE] at 9:10AM, V13 Medical Director said that the facility should have followed the correct Warfarin order and that R1 was at risk for increased bleeding and that R1 clearly died from the hemothorax. On [DATE] at 10:30AM, V12 Consultant Pharmacist said that she was unaware that R1 had out of target range or critical Prothrombin (PT) and International normalized ratio (INR) times. On [DATE] at 1:15PM, V3 Pharmacist stated that collaboration with the pharmacy when PT/INRs are inconsistent is the standard of care and that given R1's inconsistent results, closer laboratory monitoring should have been done. Failure to do so could result in increased bleeding and possibly death. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. All licensed and direct care staff was educated on Administration Procedures for All Medications including but not limited to: medications are administered in accordance with physician order, and physician notification including monitoring and adverse reactions by the Director of Nursing (DON) and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator. 2. All licensed and direct care staff was educated on referencing and following drug manufacturing guidelines for monitoring of drug side effects, labs, and possible adverse reactions by the Director of Nursing and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator. 3. All licensed staff was educated on utilizing the Coumadin Tracking Log to ensure medication dosage, order, and follow-up PT/INR are reviewed and to ensure physician's orders are carried out by the Director of Nursing and the Administrator on [DATE]. Licensed staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator. 4. All licensed and direct care staff was educated on anticoagulant administration, effects, precautions, and monitoring by the Director of Nursing and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator. 5. All licensed staff was educated on the facility process to monitor/review/follow-up/coordinate and administer safe use of anticoagulant medications by the Director of Nursing and the Administrator on [DATE]. Licensed staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator. 6. An impromptu QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director and staff IDT (Interdisciplinary Team) to discuss deficiency and facility action plan. 7. The facility will audit the Coumadin Tracking Log and review resident charts to ensure anticoagulant medication orders were followed, monitoring for anticoagulant side effects, the physician was notified of changes in condition(s) of residents, and that abnormal lab results were reported to the physician within a timely manner. A QA (Quality Assurance) tool -will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC (Registered Nurse Certified). 8. The facility will audit all residents currently receiving an anticoagulant to ensure physician orders are being followed, and monitoring is in place including monitoring side effects, labs, and adverse reactions. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC. 9. Nursing Management will audit all newly admitted and readmitted residents within 24 hours of admission to ensure residents receiving anticoagulant medication are being monitored for side effects and adverse reactions, laboratory orders are in place, and the physician is notified of any change in condition. A QA tool -will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC. 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] for revisions. The facility presented a revised abatement plan on [DATE] and the survey team accepted the abatement plan on [DATE].

Based on interview and record review the facility failed to ensure the residents' right to be free from mental and physical abuse by staff. R2 experienced physical pain and psychosocial harm including fear, feeling unsafe, crying and mental stress/worrying. R3 experienced mental abuse through crying, being upset and scared. These failures affect two (R2, R3) residents out of four residents reviewed for abuse in a sample list of eleven residents. Findings include: The facility undated policy titled 'Abuse, Neglect and Misappropriation of Resident Property' documents Physical/mental-the facilities policy is that the resident has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment and misappropriation of resident property in accordance with all state and federal regulations. Residents must not be subject to abuse by anyone including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends or other individuals. Abuse definition is documented as the willful infliction of injury, unreasonable confinement, intimidations or punishment with resulting physical pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Examples of verbal abuse include but are not limited to threats of harm and saying things to frighten a resident. Physical abuse is defined as hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse is defined as humiliation, harassment, and/or threats of punishment or deprivation. Involuntary seclusion is defined as the separation of a resident from other residents, from his or her room, or confinement to his or her room with or without roommates against the residents will or the will of the resident representative. 1.) R3's Initial Report to the State Agency dated 7/1/24 documents R3 had complained that V13 and V14 Agency Certified Nurse Aides (CNA) were rude to her and not listening to her when she told them how to take care of her. R3's undated Abuse Investigation Form documents V1 Administrator was notified on 6/29/24 at 10:20 AM that R3 had complained that V13 and V14 Agency Certified Nurse Aides (CNA) were rude to her and not listening to her when she told them how to take care of her. This report documents (R3) stated that the agency staff (V13, V14) had argued with her about how to do her care, did not get her up with a sit to stand to the bedside commode, but attempted to roll her over and clean her. This caused her pain in her leg and she wet which caused the agency staff to raise their voices, throw things on the floor and leave the room leaving her in the bed uncovered. On 6/30/24 at 9:45 AM, R3 stated Yesterday (6/29/24) two agency Certified Nurse Aides (CNA) (V13, V14) came into my room a little after 5:00 AM Saturday (6/29/24) morning to get me up for breakfast. I had asked to use the lift (partial mechanical body lift) to get me up to the commode. They (V13, V14) said they weren't going to get me up to the commode and were just going to change me in my bed. They (V13, V14) were rolling me around in bed so hard. I told (V13, V14) that my left leg hurt. I have been in the hospital twice this month for the awful pain in my left leg. They (V13, V14) grabbed my left leg and twisted my left leg and so I let out a yell. I told (V13, V14) several times to quit twisting my left leg but they just kept on. Then they (V13, V14) just left me there laying in a wet bed half dressed. I told (V16) how awful those two (V13, V14) were. I am afraid that they (V13, V14) will come back and hurt me worse. On 6/30/24 at 12:50 PM, V16 Registered Nurse (RN) stated V16 talked with R3 about 5:30 AM. V16 RN stated (R3) was crying so hard she had trouble even talking. I tried to console (R3) but she was crying so hard she was inconsolable. (R3) told me that (V13, V14) CNA's were 'very rough' with her that morning. (R3) had asked to use the bathroom and she was told no. (R3) stated (V13, V14) rolled her around so hard and rough that she had urinated in her bed because she was scared of them. On 6/30/24 at 12:30 PM, V15 Social Service Director (SSD) stated R7 (R3's roommate) reported to V15 SSD Those two Certified Nurse Aides (CNA's) (V13, V14) were mean to my roommate (R3) this morning. I heard them yelling and carrying on. They (V13, V14) just threw her blankets on the floor and walked out. V15 SSD stated R3 was still upset and crying throughout the entire conversation. On 6/30/24 at 1:40 PM, V7 Restorative Certified Nurse Aide (CNA) stated When I entered (R3's) room, she was crying. (R3) had her pants around her knees, her shirt was tucked up under her breasts, her bed was wet and she didn't have any covers on. This would have been about 5:40 AM or so. (R3) said her left leg hurt. I had to help (R3) move her left leg because it was hurting her so bad. Normally (R3) can move her own legs, slowly, but she can do it on her own. Yesterday (6/29/24) (R3) couldn't even move her left leg on her own due to the pain. On 7/1/24 at 10:05 AM, V17 Licensed Practical Nurse (LPN) stated the morning of 6/29/24 was very chaotic. V17 LPN stated R3 had reported to V16 Registered Nurse (RN) that they (V13, V14) scared her and hurt her leg. V17 LPN stated R3 has been hospitalized twice in June for left leg pain but the Physicians are not able to find a cause of the pain. V17 LPN stated It ended up that (R3) alleged physical abuse and (R2) alleged mental abuse both by (V13 and V14) CNA's. V17 LPN stated I went to (R2's) room first about 6:30 AM. (R3) told me that 'those two (V13, V14) were awful, mean to her and hurt her leg'. V17 stated R3 said 'They (V13, V14) scared me so bad I peed as they were wiping me and (V13) Agency CNA yelled out. V17 stated R3 reported that V13 and V14 Agency CNA's left her in the wet bed half dressed and crying. V17 LPN stated When I saw (R3), she was crying hysterically. It took her a long time to be able to calm down enough to talk to me and tell me what happened. 2.) R2's Initial Report to the State Agency dated 7/1/24 documents R2 had complained that V13 and V14 Agency Certified Nurse Aides (CNA) were rude to her and not listening to her when she told them how to take care of her. R2's undated Abuse Investigation Form documents V1 Administrator was notified on 6/29/24 at 10:20 AM that R2 had complained that V13 and V14 Agency Certified Nurse Aides (CNA) were rude to her and not listening to her when she told them how to take care of her. On 6/30/24 at 10:10 AM, R2 stated There were two agency CNA's (V13, V14) that were here (facility) yesterday (6/29/24). (V13) Agency CNA pushed a washcloth in my hand and told me to wash my face. I can't do that because of my Arthritis. (R2's hands appear deformed at knuckles. R2 was unable to open both hands completely.) R2 stated (V13) kept pushing the washcloth into my hand. It hurt a bit. I told them (V13 and V14) multiple times that I just can't physically do it. I showed (V13, V14) my hands so they could see how bad they are. I pushed the washcloth back at (V13). I don't deserve that. They (V13, V14) just rolled their eyes and looked at me so mean. I have to say I was scared that morning. R2 stated later that morning after breakfast V13 and V14 agency CNA's assisted R2 from her wheelchair to her bed. R2 stated They (V13, V14) threw me into bed. (V14) CNA grabbed my hand (R2 holding onto her own Right hand) and squeezed so hard it really hurt. It didn't bruise but it sure hurt. I yelled out several times and they (V13, V14) left me laying there in my bed. On 7/1/24 at 10:08 AM, V17 LPN stated I could hear (R2) yelling from her room with her door closed four doors down in the dayroom on [NAME] hall. (V16) and I went to investigate. I didn't see (V13, V14) actually do anything to (R2) but I do know they had just been in there laying (R2) down after breakfast. (R2) told me that they (V13, V14) were just in her room and laid her down. (R2) told me 'I'm just so scared of them (V13, V14). Please don't let them back in my room'. On 7/1/24 at 11:15 AM, V13 Agency Certified Nurse Aide (CNA) stated (R2) is rude to the staff. We (staff) don't have to tolerate that. I am not helping anyone that treats me like that. (R2) was all kinds of frustrated at me and (V14) Agency CNA. (R3) was the same way. (R3) wanted to get up but she had already been incontinent so there is no reason to get somebody up after they have already been incontinent. (R3) just kept crying and wouldn't be quiet about it. There is no reason for (R3) to be crying like that. We (V13, V14) just walked out of (R3's) room. On 7/1/24 at 2:00 PM, V1 Administrator stated Our facility has a lot of great staff who are caring and knowledgeable to care for our residents. Unfortunately, these two Agency CNA's (V13, V14) did upset our residents R2 and R3 a great deal. V1 stated R2 reported physical and mental abuse to our staff and R3 reported an allegation of what could be mental abuse by (V13, V14). V1 confirmed R2 and R3 were both physically and mentally abused by V13, V14 Agency CNA's. V1 Administrator stated We (facility) take this very seriously. My staff has already been educated. Our residents have been interviewed and say they feel safe here now. You can be sure those two Agency CNA's will not return to our facility.

Based on observation, interview, and record review the facility failed to accurately complete fall risk assessments, thoroughly investigate a fall, and implement fall interventions for three (R1, R2, R6) of three residents reviewed for falls in the sample list of six. The facility also failed to safely transfer R1, resulting in R1 falling and sustaining a right ear laceration requiring sutures to close. Findings include: 1.) R1's undated Diagnoses List documents R1's diagnoses include Cerebral Infarction (stroke), hemiplegia and hemiparesis following Cerebral Infarction affecting right dominant side, aphasia (difficulty communicating), epilepsy (seizures) and lack of coordination. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of two staff for transfers. This MDS documents R1 has impaired balance requiring staff assistance to stabilize when moving from sitting to standing, walking, turning, transferring on/off of the toilet, and during surface to surface transfers. from R1's Care Plan dated as revised 10/2/23 documents R1 fell and includes an intervention dated 10/2/23 that staff was educated to use a gait belt with R1's transfers. R1's Care Plan dated 10/1/23 documents R1 has an Activities of Daily Living self care deficit related to impaired mobility and includes interventions that R1 is usually provided substantial assistance of one staff person for chair/bed transfers and when moving from sitting to standing. R1's September 2023 Medication Administration Record (MAR) documents R1 received the following medications from 9/15/23 through 9/30/23: Furosemide (diuretic) 40 milligrams (mg), Losartan Potassium (antihypertensive) 25 mg, Carvedilol (antihypertensive) 6.25 mg, and Levetiracetam (antiseizure) 500 mg, R1's Fall Risk assessment dated [DATE] documents a score of 11, indicating R1 is at risk for falls. This assessment is inaccurate. The section for gait/balance does not document R1's impaired balance with standing and walking. This assessment documents R1 takes 1-2 of the types of medications listed (Anesthetics, Antihistamines,Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics,Psychotropics, Sedative/Hypnotics). This assessment documents R1 does not have any predisposing diseases, and CVA (Cerebrovascular Accident) and seizures are listed as examples of predisposing diseases. R1's Physical Therapy Progress Report dated 9/29/23 and signed by V14 Physical Therapist/Director of Rehab documents as of 9/28/23 R1 requires partial/moderate assistance with chair/bed transfers and R1 has right sided hemiparesis. R1's Fall Report dated 10/1/23 at 6:00 AM documents: Resident (R1) had witnessed fall this AM during transfer at approximately 0600 (6:00 AM). Staff states they were attempting to transfer resident and resident got weak and lost balance and fell . Staff states resident hit his head on the night stand as he fell . Laceration noted to his R (right) ear. MD (Medical Doctor) notified and stated to monitor bleeding and if needed, can be glued. VS WNL (vital signs within normal limits). Resident had no visible s/s of fx (signs/symptoms of fracture). Called POA (Power of Attorney) at approximately 0900 (9:00 AM) to inform her of fall. POA states she would like resident to be seen in hospital to rule out any bleeding or fractures just to be safe. Called 911 and EMTs (Emergency Medical Technicians) arrived at 0940 (9:40 AM) to take resident to (emergency room ). R1's Hospital Oral & Maxillofacial Surgery Consult Note dated 10/1/23 documents R1 presented to the emergency room for a witnessed fall during a staff assisted transfer from the bed to the wheelchair. R1 fell and hit R1's right ear on the night stand and has a 2 centimeter partial thickness laceration to the right ear. This note documents R1's laceration required sutures to close the wound. R1's Fall Interdisciplinary Team Note dated 10/2/2023 at 10:43 AM documents a summary of R1's fall (10/1/23) and the root cause was that R1 lost R1's balance. The post fall intervention is documented as staff education provided on use of gait belt. The facility's fall investigation for R1's 10/1/23 fall, provided by V2 Director of Nursing (DON), included V4 Certified Nursing Assistant (CNA) interview dated 10/1/23 that documents V4 was transferring R1, R1 lost balance and fell forward hitting R1's ear on the nightstand. V4's Employee Disciplinary Action Form dated 10/5/23 documents V4 was given a 3rd and Final Written Warning for failing to follow safe transfer instructions resulting in a resident injury after a fall. On 10/17/23 at 3:08 PM, V4 CNA stated on 10/1/23 V4 assisted R1 with transferring out of bed and into the wheelchair. V4 stated R1 was using a quad cane,V4 was standing behind R1's wheelchair with the wheelchair positioned between R1 and V4, and R1 was transferring towards R1's bad side (right side). V4 stated R1 had right sided weakness, and R1's prior room was set up to where R1 would transfer out of bed towards R1's left side. V4 stated V4 did not use a gait belt during the transfer. V4 stated R1 lost R1's balance and fell to the floor, hitting R1's right ear on the corner of the night stand. V4 stated V4 received a written warning for not using a gait belt during R1's transfer, and gait belts should be used for any transfers that are not mechanical lifts. V4 stated using a gait belt may have lessened R1's impact. On 10/17/23 at 2:45 PM, V2 Director of Nursing (DON) stated fall risk assessments are completed by the nursing staff. V2 reviewed R1's fall risk assessment dated [DATE] and confirmed the assessment does not accurately document R1's impaired balance, diagnoses, and medication use which affects the fall risk score. V2 stated V4 CNA was assisting R1 with transferring out of bed on 10/1/23, R1 lost balance and fell , and R1 had a laceration to the right ear from hitting the night stand. V2 stated the root cause of R1's fall was that R1 lost R1's balance and V2 stated V4 was not using a gait belt during R1's transfer. V2 stated after R1's fall, V4 was educated to use a gait belt and was given disciplinary action. V2 stated a gait belt should be used for all resident transfers that is not a mechanical lift transfer. On 10/17/23 at 3:48 PM, V16 Physician confirmed R1's right ear laceration would be consistent with R1 falling and hitting R1's head on the night stand. V16 stated V16 would defer to physical therapy in regards to whether a gait belt should have been used for R1's transfer. V16 stated if therapy recommends a gait belt be used, then one should have been used for R1's transfer. On 10/18/23 at 8:45 AM, V15 Certified Occupational Therapy Assistant stated R1 was evaluated for therapy services on 9/14/23 and was receiving physical and occupational therapy until R1's discharge on 10/1/23. V15 stated R1 transferred with assistance of two staff, hemiwalker, and gait belt. V14 Physical Therapist/Director of Rehab stated R1 had fair balance and confirmed R1 required hands on assistance with gait belt during transfers to maintain balance. 2.) R2's MDS dated [DATE] documents R2 requires extensive assistance with transfers and ambulation, has impaired range of motion to one upper and lower extremity, and has impaired balance during transfers/walking and requires staff assistance to stabilize. R2's Care Plan dated 10/5/21 documents R2 has impaired physical mobility and includes an intervention dated 7/14/23 to transfer with two assist and use of gait belt. R2's October 2023 MAR documents R2 receives the following medications: Atenolol (antihypertensive) 50 mg, Bupropion Hydrochloride (antidepressant) Extended Release 100 mg, Enalapril Maleate (antihypertensive) 2.5 mg, Furosemide (diuretic) 10 mg, Norvasc (antihypertensive) 2.5 mg, Sertraline Hydrochloride (antidepressant) 100 mg, Lantus insulin (hypoglycemic) 44 units, and Insulin Aspart (hypoglycemic) 10 units. R2's Fall Risk assessment dated [DATE] documents a score of 9 and indicates R2 is not at risk for falls. This assessment is inaccurate. The section for gait/balance does not document R2's impaired balance with standing and walking. This assessment incorrectly documents R2 takes 1-2 of the types of medications listed (Anesthetics, Antihistamines,Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics,Psychotropics, Sedative/Hypnotics). On 10/18/23 at 11:17 AM, V2 DON reviewed R2's Fall Risk assessment dated [DATE] and confirmed this assessment was not completed accurately to reflect medication use and impaired balance, which would create a higher score and higher risk for falls. 3.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment, is dependent on two staff for transfers, is dependent on one staff for toileting assistance, and is frequently incontinent of bowel and bladder. This MDS documents R6 has impaired balance during surface to surface transfers and requires staff assistance to stabilize. R6's Care Plan with revised date 9/28/21 documents R6 is at risk for falls related to spinal stenosis, osteoporosis, osteoarthritis and weakness, and includes interventions for a low bed, use of floor mat beside R6's bed (initiated 8/30/23), and staff were educated to ensure the floor mat is in place (9/15/23). R6's October 2023 MAR documents R6 receives the following medications: Furosemide 20 mg, Loratadine (antihistamine) 10 mg, Spironolactone (diuretic) 12.5 mg, Metoprolol Tartrate (antihypertensive) 12.5 mg, and Norco (narcotic) 5-325 mg R6's Fall Risk assessment dated [DATE] documents a score of 15 indicating R6 is at risk for falls. This assessment is inaccurate and documents R6 takes 1-2 of the types of medications listed. R6's Nursing Note dated 10/8/2023 at 11:11 PM documents nurse (V8 Registered Nurse (RN)) heard R6 yelling, upon entering R6's room there were two nurses (V18 RN and V19 Licensed Practical Nurse) assisting R6 who was lying on the floor. This note documents R6 was found holding onto R6's bedrail yelling, with R6's lower body on the floor. The nurses assisted R6 to the floor and R6 had no injuries. This note documents R6's floor mat was not in place when R6 was assisted into bed. R6's 10/8/23 Fall Investigation, provided by V2, includes staff witness statements but there is no documentation as to what time R6 was last checked on or toileted prior to R8's fall. The documented root cause of R6's fall was that R6 was trying to get out of bed without assistance. On 10/17/23 at 12:49 PM, R6 was sitting in a wheelchair in R6's room and there was a full mechanical lift sling positioned underneath of R6. At 1:48 PM and 1:53 PM R6 was lying in a bed that was low to the floor. There was no fall mat positioned besides R6's bed. R6's fall mat was standing up next to the closet. On 10/17/23 at 2:13 PM, V9 CNA stated R6 uses a fall mat when R6 is in bed. V9 stated hospice staff laid R6 down earlier and did not put the floor mat down. On 10/17/23 at 3:35 PM, V8 RN stated on the evening of 10/8/23 V8 heard R6 yelling and other nurses were already in R6's room when V8 entered. V8 stated R6 was lying on the floor and had no injuries. V8 stated there were two nurses (V18 and V19) in R6's room assisting R6. V8 stated R6's fall mat was not beside R6's bed when R6 fell . V8 stated the CNA forgot to put the fall mat down when R6 was assisted to bed. V8 stated It is a large mat and obvious to see in (R6's) room. On 10/17/23 at 2:45 PM, V2 DON referenced R6's 10/8/23 fall investigation and stated R6 tried to crawl out of R6's bed which was in low position. V2 stated R6's fall mat was not placed beside R6's bed. V2 stated following R6's fall we obtained a concave mattress from hospice and increased frequent checks on R6 to ensure R6's fall mat is down and check R6 for positioning needs. On 10/18/23 at 11:17 AM, V2 reviewed R6's Fall Risk assessment dated [DATE] and confirmed this assessment was not completed accurately to reflect medication use which affects the total score. V2 confirmed all of the documentation for R6's fall investigation was provided, and confirmed there is no documentation to indicate when R6 was last checked on or toileted prior to R6's fall. The facility's Fall Prevention Program dated as revised 11/21/17 documents: The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Transfer conveyances shall be used to transfer residents in accordance with the plan of care. The fall risk interventions will be identified on the plan of care. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. The facility's Transfers-Manual Gait Belt and Mechanical Lifts policy revised 1/19/18 documents a gait belt will be used for one and two person assisted transfers.

Based on observation, interview and record review, the facility failed to monitor the positioning of a resident leg during a mechanical lift transfer and during positioning, and complete a thorough investigation for two of three residents (R1, R2) reviewed for accidents on the sample list of four. This failure resulted in R1's left leg bumping into an unknown object when being transferred via mechanical lift into a wheelchair causing a laceration to the lower inner left leg, which required 18 sutures to approximate the laceration. Findings Include: 1) The Facility's Report to IDPH (Illinois Department of Public Health) Office dated 8/4/23 documents on 8/1/23, R1 was transferring via a mechanical lift with assistance of two staff from the bed to the wheelchair when R1's leg was bumped on the wheelchair. First Aide was administered and V4 Physician was notified with orders received to send R1 to the hospital. R1 returned back to the facility the same day with sutures to the left lower extremity. This investigation folder contained witness statements from V5 and V6 CNA's (Certified Nursing Assistant's) who transferred R1 and V8 RN (Registered Nurse) assigned to R1. R1's Hospital History and Physical dated 8/1/23 by V9 Hospital Physician documents R1 presented to the hospital for evaluation of an injury to the left lower extremity. R1 states that R1 was being transferred with a mechanical lift and somehow got R1's left lower extremity caught. R1 sustained a 7 cm (centimeter) laceration requiring repair with 18 sutures. There is also some bruising to the left lower extremity as well. R1's MDS (Minimum Data Set) dated 8/3/23 documents R1 is alert and oriented and requires extensive assistance of two staff for transfers. On 8/15/23 at 1:00 pm, V5 CNA stated V5 and V7 CNA had transferred R1 into R1's wheelchair around 9:00 am on 8/1/23. V7 CNA left the room and V5 was going to get R1 situated in the chair better when V5 noticed blood coming from under R1's pant leg. V5 stated R1's leg was not bumped as far as V5 was aware explaining R1 never called out or anything or said it hurt. On 8/15/23 at 1:10 pm, V8 RN stated V8 was alerted by a CNA that R1 was bleeding, that was around 9 am on 8/1/23. V8 explained, as soon as I (V8) seen it {leg laceration}, I (V8) knew (R1) was going to need sutures. The laceration was on the lower inner leg area. V8 stated V8 applied a dressing over the laceration and sent R1 to the hospital. On 8/15/23 at 2:10 pm, R1 stated R1 sustained a leg laceration a couple of weeks ago but it is really unclear how I (R1) got the laceration. R1 explained staff were transferring R1 into a wheelchair with the mechanical lift and R1 was already sitting in the chair when all of a sudden, R1 felt a little pinch. R1 explained it was at the same time of the pinch that the CNA reported R1 was bleeding. R1 stated R4, roommate at the time, said R4 thought my leg was bumped with the foot rest. R1 stated, that makes sense because it's a 3 inch V-shape laceration and the shape of the corner of the foot pedal. On 8/15/23 at 3:35 pm, V2 DON (Director of Nursing) with V1 Administrator present stated V2 feels like R1 might have bumped R1's leg inside of the wheelchair and with R1 being so edematous with the lyphedemna, R1's leg just split when bumped. V2 stated V2 thinks V2 interviewed R4 as a witness to the situation but doesn't have anything in writing and cannot remember what R4 said about the incident. On 8/16/23 at 9:07 am, V5 again stated, V5 isn't sure how R1 sustained the leg laceration and explained, all I (V5) know is (R1) made it to the chair safely. Foot pedals were on the chair and I (V5) was holding up (R1's) foot, trying to flip the pedal in place to be able to place (R1's) foot {on the pedal} and that is when I (V5) noticed (R1) bleeding from the other leg. V5 stated, it is very possible that when doing that, the pedal hit R1's leg because it was all at the same time. On 8/16/23 at 10:16 am, V2 confirmed R1's incident investigation was not thorough as all potential witnesses were not interviewed and that V2 didn't really dig down for the root cause explaining, I (V2) know (R1) hit it {leg} on something., just don't know what exactly or how. 2.) On 8/15/23 at 11:02 am, V5 and V6 CNA's (Certified Nursing Assistant's) entered R2's room to provide cares. V5 and V6 placed the mechanical lift swing under R2 and V6 lifted R2 with the lift into the air and was pushing R2, while suspended in the air and swaying back and forth, toward the wheelchair, which V5 was positioned behind. R2 was facing the wheelchair and slightly bumped R2's left leg on the arm of the wheelchair. At that time, V5 pushed R2's leg, which caused R2 to swing around and was now facing the mechanical lift instead of the wheelchair and guided R2 into a sitting position in the chair. On 8/16/23 at 8:50 am, V2 DON (Director of Nursing) stated residents are being transferred via a mechanical lift, one staff should be operating the machine while the other staff is behind the resident, with hands on them guiding them where they are going.

Based on observation, record review and interview the facility failed to monitor R17's skin condition with daily skin checks per facility policy. This resulted in staff not identifying the development of R17's pressure ulcer and initiating treatment until it progressed to a Stage four pressure ulcer. R17 is one of four residents reviewed for pressure ulcers in the sample of 15. Findings include: On 02/13/13 at 9:15 A.M. E3, Licensed Practical Nurse (LPN) indicated R17 had a Stage 4 pressure ulcer to his left heel that he acquired while in the facility. R17's February 2013 physician's orders [REDACTED]. R17's Nursing Admission Assessment Form dated 1/05/13 shows R17 was readmitted to the facility on [DATE]. R17's Admission Nursing Assessment completed on that date indicates "heels assessed, no open areas." R17 had a physician's orders [REDACTED]. R17's Braden Scale Ulcer Risk assessment dated [DATE] documents R17 as being "at high risk" for pressure ulcer development. R17's current Plan of Care dated 11/06/12 includes an intervention for ..."daily skin checks..." On 02/13/13 at 2:45 P.M. E3 stated,"...(R17) has a care plan intervention for daily skin checks. I don't think it got carried over to his current physician's orders [REDACTED]." R17's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no indication that daily skin checks were performed by a licensed nurse from January 3, 2013 through January 31, 2013. On 02/13/13 at 4:00 P.M. E2( Director of Nursing) stated, "(R17) had an order for [REDACTED]." Facility policy titled "Ulcer Policy & Procedure" directs licensed nursing staff to ..."complete daily skin checks and ...address changes as needed... for residents that are assessed as high risk for skin breakdown..." On 01/15/13 R17's Nurses Notes states, " Necrotic area observed on posterior top of left heel. Measurement of 1 X 1 centimeters with sub-cutaneous (sub-q) damaged tissue/unstageable. No odor with inflamed tissue surrounding area..." On 02/14/13 at 2:25 P.M. Z7 (Contracted Wound Nurse) stated,"(R17) was seen for the first time (in the Wound Clinic) on 01/25/13. At that time the area measured 3 cm x 3.2 cm with an unknown depth. The area was surgically debrided on 01/25/13 and has been debrided weekly since. The last wound measurements on 02/18/13 were 2.6 cm x 2.8 cm x 0.4 cm..." On 02/14/13 at 2:40 P.M. Z8, Wound Care Physician stated, "... the resident (R17) has chronic spasms of his lower legs. He probably rubbed the area on the brace and over time the skin eroded. Eventually, without proper treatment, a deep tissue wound appeared..."

Based on record review and interview, the facility failed to thoroughly investigate, evaluate root cause, make recommendations, and implement interventions and safety precautions to prevent falls for three of ten residents (R1, R2, R10) sampled for falls, out of a sample of 14. These failures contributed to falls with hip fractures for R1 and R2. Findings include: 1. According to admission records and the current physician's orders [REDACTED]. The Minimum Data Sets (MDS) of 7/20/11 and 10/20/11 assess R1 with cognitive impairment, requiring supervision only for transfers and ambulation, and history of falls. Fall risk assessments dated 4/28, 7/22 and 10/20/11 all score R1 as a moderate fall risk. The printed careplan dated 8/2/11 states under Safety Notes that R1 fell and fractured her hip at home, and is "forgetful and don't (sic) remember it is not safe to get up and walk in...sock feet." This careplan states that R1 had six falls from admission to 4/20/11, when R1 fractured her left ulna and radius. According to the Occurrence report and corresponding nurses notes, on 4/20/11 at 6:00pm, R1 complained of pain and swelling in the left wrist. R1 reported she had fallen, unwitnessed, but later denied she fell . When reported to Z1 (family member), Z1 stated that she thought she had seen swelling and bruising on 4/17/11, but did not report it. The Physician was not notified until 4/21/11, when R1 had other behavioral symptoms and R1's pain/swelling continued. Upon evaluation, R1 was found to have fractures of the left distal radius and ulna, along with a UTI. The fractures were treated with a sling and antibiotics were given for the urinary tract infection. The incident Follow up Report dated 5/2/11 completed by E2 (Director of Nursing) stated as Root Cause, "Other, unwitnessed. Resident stated that she fell , but 5 minutes later stated that she didn't." Under the section for Recommendations is "None Noted." Nurses notes state that R1 had increased confusion, agitation and elopement attempts on 5/8/11 and 5/13/11, alleviated by intramuscular (IM) Ativan (anxiolytic). R1 continued to ambulate throughout facility on 5/14/11, and was continuously redirected and reminded to use her walker. On 5/15/11 at 8:00am, R1 ambulated into the dining room, lost balance and fell . The Occurrence Report did not include a follow-up with any root cause, and Recommendations stated "None Noted." Nurses notes continue that R1 had intermittent episodes of agitation, refusing care, and elopement attempts, including 8/10, 8/12, 9/6, 9/7, and 9/24/11. On 10/21/11, there was a nurses notes and telephone order, "written order to d/c (discontinue) lap buddy" due to R1 being independent with the walker. There were no other notes or assessments addressing any use of a lap buddy. On 10/24/11 at 5:00pm nurses notes state that R1 was very agitated and was walked outside with staff before being redirected inside. When E6 (nurse) went to give IM Ativan, dark purple bruising was found on R1's left hip and elbow. Notes state, ". . .spoke with 2 CNAs (Certified Nurse Aides). . .pt (patient) is independent of toileting and dressing so staff would not have seen bruise unless pt was getting shower. . . .on Thursday day shift. Pt is confused and she'll fall and get herself up and not report. . . .DON (Director of Nursing) and Admin (Administrator) notified at home. . .Pt up and ambulatory - gait steady. . . very agitated. . ." On 10/25/11 at 12:20am, bruising was also noted on the left outer orbital area. This bruising of unknown origin was not listed on the Occurrence Report log provided by the facility. However, the Occurrence Report states that R1 "fell a few days back". The Follow up Report was not completed, had no Root Cause and no Recommendations. Notes of 10/25 and 10/28/11 state that R1 continued to wander about the facility and attempt to go outside, with IM Ativan given. The Occurrence report dated 10/29/11 at 10:00pm states that R1 was found lying supine on the floor in her room, after previously seeing her in her armchair. R1 stated that she hit her head, she did not bear weight when getting up from the floor, and her wrist was swelling. There were no nurses notes for this 10/29/11 incident, until a late entry after 10/31/11. This late entry stated that R1 was found near the door, and the walker was near the bed. The late entry also said R1 had a "ping pong ball sized bump on the left forehead. . ." R1 was sent to the hospital. The Emergency Report notes R1 as "quite demented." The report states that a CT scan of the head was done and R1 had full range of motion without pain of both hips. R1 returned to the facility at 12:30am on 10/30/11 R1 was sent out again on 10/30/11, as x-rays were not done the first time. According to the Preliminary Radiology Report dated 10/30/11, X-rays were noted to be negative for hip fracture, and what was later determined to be an old fracture of the left wrist. However, there is another Radiology Report dated 10/30/11 that noted "most likely impacted, subcapital fracture of the neck of the femur" which has the fax date of 11/2/11. Nurses notes of 11/2/11 state that the x-rays were not new findings. Z3 (Physician) signed this 10/30/11 x-ray report on 11/2/11 and ordered "{treatment and follow-up} by {Z4 (Orthopedist)}." However, the appointment with Z4 was cancelled by the family. An investigation was conducted for the 10/29/11 fall and Follow up Report completed. The bruise of 10/24/11 was listed as a Recent Occurrence. The Follow up Report listed no Root Cause and no Recommendations. An Ad Hoc meeting list signed by E1 (Administrator), E2 (DON), E3 (MDS/Careplan Coordinator), and E5 (Social Service), states that R1's room was rearranged "to allow more room without obstacles. Fridge was removed and the dresser was taken out. . ." Another timeline list in the investigation stated that "bed alarm applied" on 10/30/11 at 3:00pm. This ad hoc meeting addressed both x-rays for the wrist reviewed per Z4, but did not address hip x-rays. Nurses notes dated 10/30/11 at 9:00pm state that R1 "stayed in bed since coming back from x-rays. . . Bed alarm placed on bed. Reinforced need to call for help if needing anything. {Left} wrist splint applied. . . taken it off several times and reminded several times of need to keep it on." Bruising was again noted on 10/31/11 on the hip and forehead. Nurses notes continue that R1 was ambulatory, occasionally agitated/combative, and attempting to exit on 10/31, 11/2, 11/3, 11/5, 11/7, 11/11 (times three), and 11/18/11 throughout the morning. There was no mention throughout these notes regarding a bed or chair alarm or any other monitoring device. Nurses notes state on 11/18/11 at 1:45pm R1 was "found laying on floor beside bed. Her walker placed outside door. . . laying on L' (left) side. Denies falling. . . does not want to get up. Assisted to bed. Res {ambulates} without difficulty. . . " This incident was not listed on the facility Occurrence Log. The next Nurses Note is 11/19/11 at 9:30pm, stating "heard a yell. . . observe {R1} sitting on floor {with} the appearance of having scooted herself out of room . Stated she had fallen while getting out of bed and had landed on her buttocks. . . no apparent injury. . . bed alarm not sounding. Noted alarm disconnected in a placement and manner consistent with resident's statement of having landed on buttocks from bed; it appears that resident was scooting herself to edge of bed. . . disconnecting alarm in the process. When reconnected, alarm found to be in good working order. . . " The Occurrence Report dated 11/19/11 states under "Preventative measures at time of fall" that the alarm was not sounding, the call light was off, the low bed was in place but no mattress on the floor, and R1 was wearing socks only - not slipper socks. The Follow up Report for the incident was not completed, having "N/A" (not applicable) in all the blanks. There was no Root Cause and no Recommendations. Nurses notes of 11/24 and 12/1/11 state that R1 ambulated to the dining room with the walker. On 12/4/11 at 12:30am, notes state that R1 was "{up and down}" most of the night, and "continually requiring reminders to use walker for ambulation. . . complains of hip pain. . . Refused to lie in bed, as she does {not} like the sound of the bed alarm. . . Agitation escalated. . . IM Ativan given. . . .Continues to require 1:1 monitoring. . . ." Nurses notes for 7, 8 and 11:00am on 12/4/11 state R1 was sleepy and did not get up for meals. Notes state that R1 would refuse offers of pain medication. On 12/5/11 at 7:00am, Nurses Notes state that R1 "lost balance while using walker and fell to floor. . . .it is possible this (hip pain) was a factor in the fall as resident often c/o (complains of) hip pain but declines PRN (as needed) analgesics . . ." At 9:00am, the Physician was notified of the fall, and of "bruise on R' (right) hip that staff states was present prior to fall. . . ." R1 ambulated with the walker the remainder of the day. The Occurrence Report noted that the incident was observed with walker and shoes in place. The Follow up Report was not completed, with no Root Cause and no Recommendations. Nurses notes on 12/6/11 state that R1 was "up ad lib with walker but needed several reminders to use it even in her room." Also noted on 12/8/11 was R1's dark and foul smelling urine. Staff were unable to obtain a urine specimen as ordered from 12/8 to 12/14/11. There is no evidence that the Physician was notified that they were unable to obtain the specimen, or if symptoms of UTI persisted. A late entry note for 12/9/11 written 12/12/11 states that R1's "bed alarm is making her not sleep at night as it sounds when she moves in bed and makes her agitated and upset. . . The night nurse removed her bed alarm and she sleeps much better and she is not upset or agitated." Nurses notes on 12/15/11 at 4:10am state that R1 was "found sitting on floor in room. . . attempted to move left leg pt in severe pain. . . " R1 was sent to the hospital where she was found to have a fractured hip. The Occurrence Report stated that the alarm was not in use at the time of the fall. The Follow up Report was not complete; there was no Root Cause nor Recommendations. Investigation and interviews conducted by E1 noted that R1 was found next to her roommate's bed. Statements by multiple staff members indicate they were unaware if R1 was to have a personal alarm on. Some were aware R1 did have a bed alarm, but thought it had been discontinued. The careplans dated 8/2/11 in the chart and in the CNA book were marked as revised on 10/20 and 10/27/11 respectively. The printed entries under Safety Notes ends with the 4/22/11 fracture of the ulna and radius. The undated goal is that R1 "will demonstrate safe use of my walker." A hand-written entry dated 10/24/11 notes the bruises on L' hip , elbow and orbit, but includes no interventions or further observations. Another hand-written entry states R1 "fell [DATE] fx L' wrist splint to L' arm/wrist she removes 10/30/11 applied bed alarm {??} skid material put in chair use of w/c (wheelchair) due to splint L' arm 11/1/11 res removes splint form her L' arm herself." There are no interventions as to monitoring or confirming placement and functioning of bed alarm, nor are there interventions addressing R1 removing splint or alarm. These were all the additional written interventions on the careplan in the CNA book. These entries are written in such a way as to be illegible. Additional hand-written entries in the careplan in the chart include "11/1/11 rearranged room to make more space; 11/18/11 1345 (1:45pm) fell " - crossed out as error; "11/19/ 11 on the floor when she tried to get out of bed; 11/21/11 non skid socks at HS (bedtime); fell [DATE] - MD (medical doctor) notified to review for pain control; 12/9/11 removed bed alarm from bed; tabs alarm in bed at noc (night) 12/12/11." Again there is no evidence as to how these interventions were to be implemented and how to ensure that interventions were in place. These entries were also added and written in such a way as to be virtually illegible. Nurses notes dated 12/15/11 by E2 documented a conversation with Z2 (family) regarding the x-ray report of 10/30/11 - "in the course of investigating fall from 12/15/11, an x-ray report was found stating there was a probable fracture of the hip on 10/30/11." Z2 stated at that time that she thought Z4 was "looking at old x-ray" that that the left hip had fused after a fracture in 2010. The next nurses note on 12/16/11 stated that E1 had talked to Z2 to clarify that there was in fact a fracture on the 10/30/11 x-ray, from the fall of 10/29/11, which was "contrary to previous report." The hospital History and Physical of 12/15/11 describe R1 as "very senile. . . .extremely confused/demented. . . yells and screams with palpation of left hip. . .X-ray of left hip and pelvis showed a fragmented intertrochanteric fracture of the left hip." Consultation report by Z4 dated 12/16/11 lists [DIAGNOSES REDACTED]. R1 had a left hip replacement on 12/16/11. The Operative Report states, "1. August 8, 2011: Subcapital fracture left proximal femur (Garden III classification). 2. History of falling at her nursing home now with increasing pain to suggest acute-on-chronic fracture/necrosis left proximal femur. . ." Z4's reports on three occasions refers to prior x-ray with fracture on August 8, 2011. Z5 (Z4's office nurse) stated on 1/9/12 at 9:45am that the previous x-rays referred to were indeed from 2010, not 2011 as noted. Z5 also clarified that while Z4 was aware of the wrist x-rays from 10/30/11 and comparing them to previous x-rays, Z4 was never made aware of the 10/30/11 hip x-ray showing fracture. Z5 stated that the consultation which the family cancelled on 11/3/11 was for the wrist and not the hip. Z1 and Z2 (both family) stated on 1/4/11 at 9:30am that the facility did not really do anything about R1's falls "until after about the fourth fall." Family stated that R1 is "feisty" and "has a mind of her own." Family stated that R1 would not be able to use the call light to call for help. Z1 and Z2 stated they were aware of x-rays but thought that the physician may have been looking at old x-rays. All of the above information was reviewed with E2 on 1/4/12 at 2:00pm, including the lack of root cause and recommendations. E2 stated that recommendations are placed on the careplan. E2 also confirmed that R1 was to have a personal alarm on at the time of the 12/15/11 fall. E2 stated she thought the references to the 8/8/11 hip fracture was an error in dates by the hospital. E2 was asked but was not able to point out interventions on the careplan to address the falls. E2 was asked again on 1/5/12 at 2:30pm if there was any additional information regarding R1's falls. E2 provided no additional information. The Ad Hoc investigation by the facility confirmed that staff did not apply the personal alarm as planned. The investigation also states that Z4 "said that there is severe demineralization at the site of injury and that area would continue to fracture due to the condition of the bone." This was confirmed by Z5 on 1/9/12 at 9:45am. E1 also confirmed on 1/9/12 at 10:00am that Z3 was aware of the fracture on the 10/30/11 x-ray, but did not know if Z3 knew that the consult with Z4 had been cancelled by the family. E1 stated that R1 was again ambulating with the walker and Z3 gave no new orders. 2. The Physician order [REDACTED]. The facility fall assessment dated [DATE] states that R2 is high risk for falls. The Care Plan dated 10/7/11 states, "I will repeatedly try to get out of my bed or chair without help.....I use a (reclining geriatric chair) to get around....I get anxious and try to get out of my chair at times....I need supervision and reminders to not get up out of my chair by myself. I need you to reposition me when I do this....Sometimes when I get anxious and restless I need to go to the bathroom....Please keep me in a public area and observe me when I am in the chair as much as possible.....Drop the seat to my chair and that will help position me better in the chair....Toilet me on bed checks at night....I take off my clothes at times and also remove my (personal) alarm....Reapply my clothes and alarm........." The facility Incident/Accident Log documents the following falls for R2: 7/6, 7/16, 8/9, 8/17, 9/17, 10/20, 10/25, 11/5 times 2, 11/6, 11/17, 11/21, 12/5, 12/19 times 2. The Occurrence Report dated 7/6/11 at 7:55pm states that R2 attempted to self transfer from the wheelchair and fell to the floor with the alarm sounding. The Conclusion documents that R2 is having difficulty with ambulation/transfers and "staff will offer to transfer with assist." The Root Cause states, "Due to resident action or internal risk factors." The Occurrence Report dated 7/16/11 at 11:00am states that R2 "tripped on her shoe laces...." The Conclusion documents that R2 is having "difficulty with ambulation/transfers" and, medication has been adjusted , a psychiatric evaluation has been requested and a clip on personal alarm will be used. The Root Cause states, "Due to resident action or internal risk factors." The Occurrence Report dated 8/9/11 at 2:30am states that R2 "was crawling out of bed onto the floor....." The alarm was not sounding. The Conclusion documents that staff will wake and toilet R2 during bedcheck. The Occurrence Report dated 8/17/11 at 7:15pm states that R2 was sitting on the floor in her room by the bathroom. The alarm was not sounding. The report states R2 was last seen at 2:30pm but does not document when R2 was last toileted or repositioned. The Conclusion documents that R2 stated she was trying to go to the bathroom and "does not understand that she should ask for help." Under Conclusion it states the personal alarm was not sounding and the battery was replaced. There are no recommendations documented. The Occurrence Report dated 9/17/11 at 4:30pm states that R2 was walking down the hall, had removed the alarm from the wheelchair, so the alarm was not sounding. The Conclusion documents that staff will wake and toilet R2 during bedcheck. The Conclusion states R2 is not aware of safety issues with ambulation. Staff were instructed to place the "alarm in a position that (R2) could not reach it, and to walk (R2) ...when she appears anxious". The Occurrence Report dated 10/1/11 at 11:15am states that R2 was found "sitting on her bottom on the foot rest of the (geriatric) chair on the floor. Chair was tilted forward." The alarm was not sounding. The Conclusion documents that R2 was in the activity room with other residents when she "slid from the seat of her chair onto the footrest." The Conclusion states R2 will be "kept in a public area and observe when she is in the chair." The Root Cause states, "No fault." The Occurrence Report dated 10/25/11 at 3:15pm states that R2 was sitting in the (geriatric) chair in the common area and "seen sliding herself out of the chair....landed on her buttocks.." The Conclusion documents the "non skid material was in the chair (R2) lifted her buttocks across it..." The Conclusion states, "Maintenance lowered seat in the (geriatric) chair for easier positioning of (R2)." The Root Cause states, "No fault." E7, Maintenance Director, stated on 1/5/12 at 9:00am that he did not lower the seat of R2's chair. E1, Administrator, stated on 1/5/12 at 10:00am that "the bottom of the (geriatric) chair was not dropped(lowered), the chair would only recline." The Physician's Progress Note dated 10/25/11 states, ".......(R2) continues to try to get out of chair...." The Occurrence Report dated 11/5/11 at 4:15am states that R2 was found sitting on the mat on the floor next to the bed. The alarm was not sounding. The Conclusion documents that staff had been toileting R2 on rounds, but were in with other residents when R2 was found. The Conclusion states that R2 removed her gown, with the alarm attached, so it was not sounding. The Conclusion states R2 will be toileted first on rounds. The Nurse's Notes dated 11/6/11 at 1:10pm state R2 was sitting on the floor mat next to the bed. The Occurrence Report dated 11/6/11 at 1:10pm states that neither the personal alarm clipped to R2's clothing or the pressure pad alarm was sounding. The Conclusion documents that string for the personal alarm was "too long", so it was shortened and the pressure pad alarm was replaced. The Root Cause states, "Equipment Failure." The Occurrence Report dated 11/17/11 at 1:00am states, "(R2) was sitting in the day room in front of the nurse's station. I heard a noise and looked over to see (R2) tipping her chair over and (R2) landed on the foot rest of her (geriatric) chair.." The alarm was not sounding. The Conclusion states "staff will keep the back of the (geriatric) chair in the lower position to prevent tipping." The Root Cause states, "No fault." The Occurrence Report dated 11/21/11 at 1:30pm states, "(R2) was sitting in the (geriatric) chair in the lobby. (Personal) alarm was clipped to the back of blouse. (R2) was witnessed slipping off right side of foot rest onto the floor...alarm stayed on upper back of ...chair and alarm did not sound....." The Conclusion states "(R2) has been restless in her chair.....Staff will keep (R2) in eyeshot..." The Root Cause states, "Due to resident action or internal risk factors." The Physician's Progress Note dated 11/22/11 states, "...(R2) continuously tries to wriggle out of chair..." The Occurrence Report dated 12/5/11 at 11:45pm states R2 was sitting on the floor in her room with the alarm sounding. The report states that R2 was toileted at 9:30pm and last seen at 11:00pm. The Conclusion states R2 had been in bed sleeping on staff rounds........a body pillow will be placed in front of (R2) when she is in bed....." The Root Cause states, "Due to resident action or internal risk factors." The Occurrence Report dated 12/19/11 at 5:00am states R2 was on the floor in the hall outside of the dayroom, "crawling on hands and knees......CNA(Certified Nurse Aide) stated that prior to (apparent) fall, she had been bringing (R2) with her as she performed tasks...CNA took (R2) to dayroom with another resident and television in an attempt to offer ....alternative stimuli....." The report documents R2 was last seen at 4:45am, but does not document when R2 was toileted last. The Conclusion states, "....(R2's) personal alarm was in the unit, but was not clipped to her clothing....Female peer in room stated that (R2) unclipped it herself. Staff will clip lower so that (R2) cannot reach it..." The Root Cause states, "Due to resident action or internal risk factors." The Occurrence Report dated 12/19/11 at 6:45pm states, "(R2) napping in (geriatric) chair after supper in west day room. (R2) ...sleeping at (6:30pm). At (6:45pm).....(R2) lying on the floor." The report states the personal alarm was on but not sounding. The report states R2 was last observed at 6:30pm but does not document when R2 was last toileted. The Root Cause states, "Due to resident action or internal risk factors." The Nurse's Notes dated 12/19/11 at 6:50pm state R2 was sent to the hospital following the fall. The Radiology Report dated 12/19/11 states R2 has an "Acute right hip fracture, probably basicervical location with varus deformity and Osteoporosis." The statement dated 12/19/11 written by E12, CNA, states R2 was taken to the west day room from the dining room at 5:45pm. R2 was left sleeping in the day room in the geriatric chair with the personal alarm in place. E12 then left to provide care to other residents. At 6:45pm while walking down the hall, E12 saw R2 lying on the floor. The statement dated 12/19/11 written by E13, CNA states at 6:30pm she observed R2 sleeping in the chair in the west day room with the alarm in place. E2, Director of Nursing, stated on 1/5/12 at 9:30am stated that R2 would remove her clothing and the alarm which was clipped to her clothing. E2 stated R2's family brought clothing which was harder for R2 to remove and then R2 would unclip the alarm and remove it. E2 stated they then tried clipping the alarm where R2 could not reach it. When asked about R2's falls on 12/19/11(5:00am and 6:45pm) while in the dayroom unsupervised, E2 stated, "I agree. Can't put (R2) in the day room and I've told staff that." E2 was asked about the root cause analysis of R2's falls, as to why R2 was getting up continuously and stated staff will walk R2 when she gets anxious. E2 was asked for any further documentation detailing the root cause analysis of R2's falls. As of 1/9/12 at 11:40am E2 had not provided any further information. 3. The January 2012 Physician order [REDACTED]. The Nurse's Notes dated 12/14/11 at 9:15pm state R10 was found on the floor in the bathroom and has a 4 cm (centimeter) bump on the back of the head. The Occurrence Report dated 12/16/11 at 8:30am states that R10 is complaining of pain to his right buttocks and has a bruise on the right buttock measuring 5cm by 5cm from a fall on 12/14/11. E2, Director of Nursing, stated on 1/5/12 at 2:30pm that she could not find an Occurrence Report or Investigation for R10's fall on 12/14/11.

Based on record review and interview, the facility failed to provide adequate supervision to prevent falls for 1 of 7 residents reviewed for falls (R16), in a sample of 15. Staff left the room, leaving R16 unsupervised, failed to ensure that the personal fall alarm was functional, and failed to ensure that bedrails were in place as planned. These failures resulted in a fall from the bed, causing a hip fracture. Findings include: According to the physician's orders [REDACTED]. The POS has an order dated 8/3/10 for "upper siderails for positioning and to promote independence." The Minimum Data Set (MDS) of 8/27/10 assesses R16 as moderately cognitively impaired and requiring extensive to total assistance for bed mobility, transfers and locomotion. R16 did not ambulate, had a history of [REDACTED]. The MDS also stated R16 used bedrails for mobility and transfers. On 7/29/10 R16 was assessed as a high fall risk. On 8/18/10, R16 was changed from a sit-to-stand lift to full mechanical lift. A Siderail Assessment and Consent was completed and signed 8/17/10, but the type of siderails is not identified. The Care Plan dated 8/6/10 states that R16 was to have a motion alarm on the bed and wheelchair "to alert you to my attempts to get up without staff assistance." Additional interventions dated 9/27 and 9/30/10 respectively direct staff to use a non-skid material in the wheelchair, a mat next to the bed, and to put the bed next to the wall. According to Nurses Notes and the Occurrence Report, on 9/30/10 at 10:25pm, R16 was found on the floor next to the bed. The Occurrence Report states that the alarm was "not sounding" and that bedrails were "not in use." The General Follow up Procedures on this report stated that, "Base set of {personal motion} alarm was secured tightly to positioning rail in order to give notice more quickly with a shortened string." According to Nurses Notes and the Occurrence Report, on 10/9/10 at 6:25am, R16 was again found on the floor next to the bed. Nurses Notes state that possible right hip deviation was noted. R16 was sent to the hospital where a "subcapital angulated and displaced fracture of the neck of the femur" was identified. Also, marked demineralization and degenerative changes were noted on the x-ray. The family chose to return R16 to the facility without surgical treatment. The Occurrence Report of 10/9/10 states, "CNA (Certified Nurses Aide) reports that she had placed sling under resident preparing to transfer him from bed to chair. Left the room to get the lift and found resident on the floor upon her return." This report also stated that the alarm was not sounding and that bedrails were not in use. The General Follow up for this incident states the following: "{R16} is oriented to name only. He in non-ambulatory and transfers with the {mechanical} lift. Staff member noted resident on the floor. . . .X-ray showed fracture of right hip. . . .Staff member was counseled regarding taking all equipment needed into the room with you." Root cause is identified as "Human Error." E8 (CNA) stated on 12/22/10 at 11:10am. that she was getting R16 ready to get up from bed to the wheelchair on 10/9/10. E8 stated she stepped out of the room to get another staff person from the nurses station, and when she came back in, R16 had "rolled over and fell off the bed." E8 stated that R16 still had the personal alarm attached to him, but it was not sounding. E8 did not recall if R16's siderails were up. E2 (Director of Nursing) stated on 12/22/10 at 11:30am that at the time of R16's fall on 9/30/10 he was able to move around "quite a bit" and did need the alarm. R16 declined rapidly after that and did not move around as much. E2 stated that at the 9/30/10 fall the alarm string was too long, so they put the base unit on the siderail and made the string shorter. E2 confirmed that R16 did have partial siderails and that he was able to help reposition himself. E2 confirmed regarding the 10/9/10 fall that E8 did leave R16 unattended to go get the mechanical lift, and that E8 received a reprimand. However, E2 was not aware that R16 had the personal alarm on that was not sounding. Also, E2 did not know if the siderails were up or down. In addition, the computerized Occurrence Report stated, "No recent occurrences found," not recognizing the occurrence of 9/30/10. E2 stated at 1:00pm that they check the alarms once a week.