Every finding on record at Harmony Park Ridge

Based on observation, interview, and record review, the facility failed to ensure residents were provided with and received adequate fluid intake. This failure applied to four (R1, R4, R6, and R10) of four residents reviewed for hydration. Findings Include: The facility census dated 6/1/2026 shows there are currently 84 residents residing on the second floor who receive fluids by mouth. R10 is a [AGE] year-old female admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to rheumatoid arthritis, Alzheimer's, Crohn's, hypothyroidism, hypertension, dementia, dysphagia, atrial fibrillation, and depression. On the (MDS) Minimal Data Set assessment of 3/3/2026, section C1000(Cognitive Skills for Daily Decision Making) indicates severe cognitive impairment. On MDS of 3/3/2026 on section GG, Eating Ability, the resident requires partial/moderate assistance. The helper does less than half the effort. Care plan intervention dated 12/14/2025 reads: Monitor intake from meals and provide assistance for meals if indicated. On 6/2/2026 at 12:20PM, observed V10 (Certified Nursing Assistant) on the second-floor finishing to assist R10 with lunch, and the residents ate 100 percent on her plate. No fluids offered or provided. The food ticket dated 6/2/2026 had milk selection and was circled to be provided, and residents had no coffee option per ticket, but V10 said that he did not look at the ticket and just assisted her with the food. V10 said that he was supposed to check and provide milk and tea, or juice, but he did not. V10 continued to assist another resident with her meal. The surveyor asked R10 if she wanted fluids, but the resident did not answer or communicate at all during the interaction. R1 is [AGE] years old Spanish-speaking female admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to dementia, hypertension, diabetes, and a right femur fracture. On the (MDS) Minimal Data Set assessment of 3/12/2026, section C1000 (Cognitive Skills for Daily Decision Making) indicates severe cognitive impairment. On MDS of 3/12/2026 on section GG, Eating Ability, Substantial/maximal assistance - Helper does MORE THAN HALF the effort. The helper lifts or holds trunk or limbs and provides more than half the effort.On 6/1/2026 and 6/2/2026, R1 only received coffee with her meals for lunch. R1 could not communicate if she wanted only coffee during meals in English or Spanish when questioned. R1 is alert to self. R4 is [AGE] years old female admitted to the facility on [DATE] with a medical diagnosis that includes, but is not limited to, heart failure, atrial fibrillation, anemia, hyperlipidemia, diabetes, fatigue, dementia, insomnia, mood disorder, hypertensive heart disease, repeated falls, cognitive communication deficit, and Hypertension. On the (MDS) Minimal Data Set assessment of 5/7/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 1/15 and indicates severe cognitive impairment. On MDS of 5/7/2026 on section GG, Eating Ability, supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittently. On 06/01/2026 12:20 PM, R4 was observed in the dining room, with their food tray in front of them. No water is present on the tray, only coffee. R6 is a 94yrs old female admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to Alzheimer's dementia, syncope, atrial fibrillation, essential hypertension, type 2 diabetes mellitus, metabolic encephalopathy, schizophrenia, bipolar disorder, anemia, hyperlipidemia, gastroesophageal reflux disease, and obesity.On the (MDS) Minimal Data Set assessment of 4/17/2026, section C 1000(Cognitive Skills for Daily Decision Making) indicates severe cognitive impairment. On MDS of 4/17/2026 on section GG, eating Ability, Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.On 06/01/2026 at 12:25 PM, R6 was observed in the dining room, with their food tray in front of them. No water, coffee, or tea on the tray. On 06/02/2026 at 9:25AM, R6 was observed in the dining room, being fed by V10 (Certified Nursing Assistant). No water, coffee, or tea on the tray. On 6/3/2026, Burim [NAME] (Dietary Manager) said that the kitchen will provide the food, and nursing is responsible for providing the fluids, such as water, coffee, and juice, to residents in the units. The dietitian will update the likes and dislikes. On 6/4/2026 at 10:45AM, V2 (Director of Nursing) said the second floor has 84 residents and approximately 50 residents eat in the dining room, and 19 residents require assistance with meals. V2 stated, I expect the staff to pass on fluids, and to check the food ticket and provide the required fluids on the ticket, and if there is no fluid selected, staff are expected to offer water or juice. When residents cannot express their needs and ask for fluids, staff members are expected to provide water and juice during meals. I expect the staff to provide fluids and follow the meal ticket and offer water during meals. On 6/4/2026 at 10:55AM, V21 (Licensed Dietitian) said that breakfast, lunch, and dinner residents are offered juice, coffee/tea, and milk, approximately 720ml per meal, in addition to water that is offered per day. That is more than 2000ml/day. I don't expect the staff to receive only solid food with no liquids with the meals. On 6/3/2026 at 3:51PM, V2 (Director of Nursing) provided facility policy titled, Hydration, revised date 6/30/2025, which reads in part (but not limited to),Policy:It is the facility's policy to ensure that residents are adequately hydrated.B- Ensure that during mealtime, residents have fluids with their food.C- Ensure that during meals, there is an available source of hydration (juice, water, coffee, etc.) when the resident asks for it.D-Ensure that residents who ask for fluids are provided with fluids.

Based on interview and record review, the facility failed to provide a properly sized mattress to meet the needs of a tall resident, resulting in the resident's foot extending beyond the mattress, affecting comfort and dignity. Findings Includes: R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. On the (MDS) Minimal Data Set assessment of 2/12/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 2/12/2026, GG section R1 is dependent for personal hygiene and toileting hygiene. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Section GG for Roll left and right, sit to lying and lying to sitting on the side of the bed: The ability to roll from lying on the back to the left and right side and return to lying on the back on the bed. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 04/27/2026 at 12:00PM R1 said, I have had an air mattress since admission on [DATE]. I want a longer bed with an air mattress that fits the bed without any bed extender because of my wounds. R1 stated that he is 6.6 feet, and the bed is not long enough for him to stretch his leg and be comfortable. R1's bed user manual specifications feature a sleeping surface with a fixed width of 35x80 inches. On record review, the resident's height is 78 inches long, not leaving enough space for the resident to move and reposition. R1 spends the majority of his time in bed. R1 stated not being comfortable and wants a bed appropriate for him. On 4/27/26 at 12:00PM, the surveyor observed R1's head of the bed elevated approximately to 40 degrees, and R1's foot was touching the footboard, and the resident had no room to move. R1 stated that he wanted to be able to stretch his leg without touching the footboard. On 4/28/2026 at 2:53PM, V2(Director of Nursing) said R1 would benefit from having a longer bed so he can move better. On 4/28/2026 2:24PM, R7(Wound nurse) said R1 should have a bigger bed because he is too tall and would benefit from having a longer bed so his foot will not touch the foot board. On 4/28/2026 at 3:40PM, V1 said she ordered a longer bed that is 48X102 inches and it will be delivered soon so R1 will have more space to move. On 4/29/2026, on V1(Administrator) provided facility, Illinois Long-Term Care Ombudsman Program, Residents' rights, date 11/2018, which reads in part (but not limited to),You have the right to dignity and respect.You have a right to make your own choices.Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.Your rights to safety. The facility provided Joerns User-Service Manual dated 2023. Which reads in part (but not limited to),Feature and SpecificationsStandard Features:Sleep Surface:Fixed width 35x80 inches

Based on interview and record review, the facility failed to meet the resident's need to have two staff members assist while being provided with incontinence care, as per the resident's assessed needs. This failure applied to one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while being provided incontinence care that resulted in a left knee skin tear and right shoulder pain.Findings Includes:R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. On the (MDS) Minimal Data Set assessment of 2/12/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 2/12/2026, GG section: R1 is dependent on personal hygiene and toileting hygiene. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Section GG for Roll left and right, sit to lying and lying to sitting on the side of the bed: The ability to roll from lying on the back to the left and right side and return to lying on the back on the bed. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 4/27/27 at 11:30AM, R1 said, I fell on [DATE], and (V4 - Certified Nursing Assistant) was helping me change because my colostomy was leaking and the linen was dirty. (V4) turned me toward the door, and I held the bar on my right side. (V4) cleaned my back, and I started to fall. I fell on my face, I hit my head on the refrigerator, and I hit my left knee and my right shoulder. I have an air mattress, and I think I was at the edge of the mattress and fell. V4 was by himself assisting me. My left knee was swollen, and I still have pain in my right shoulder, especially if I lift my arm up. I did not go to the hospital during the fall, but I went on Monday, 3/10/2026, because I was having a lot of pain. Hospital records notes of 3/10/2026 by V12 (ARRT) read: R1 states the certified nursing assistant moved him on his side, and then he rolled off the bed and fell on his face. R1 states he has pain in his bilateral shoulders, 9/10, pain in his chest just under his right pectoral muscle, 8/10, pain in his mid-back, 9/10, and it hurts to breathe in, and he has pain in his left leg that feels like it's on fire. There is a wound on his left shin that has blood on the bandage. The resident has a left lower ostomy site, and he has a Foley catheter. On 4/28/2026 at 11:30 AM, V11(Registered nurse) said, I heard a noise, and when I got to the room, (R1) was already on the floor, and I called 911, and when they came to the facility. (R1) refused to go to the hospital and said that he was okay. I cleansed his left knee skin tear. V11 said that V4 was in the room providing care to R1 when the fall happened, and for the surveyor to ask V4 for details of the fall. When the surveyor questioned V11 about how many nursing assistants R1 required for his incontinence care and repositioning care, V11 said R1 requires one assist, and for the resident with an air mattress, V11 said two assists. On 4/28/2026 2:33 PM, V4 said, (R1) called me to empty his colostomy bag and changed the dirty sheets. I turned (R1) towards the door and provided incontinence care because the colostomy was leaking. I removed the dirty linen, and I was next to the bed. I was picking up all the dirty linen when I noticed (R1) turning, and he slid out of bed. (R1) is on an air mattress, and I was not able to stop him from falling. I think (R1) wanted to grab something from the table. I was providing care by myself, like I always do. (R1) is one assist, and I do not know if I was supposed to have 2 assist to care for (R1). On 4/28/2026 at 2:53PM, V2(Director of Nursing) said, I expect the staff to follow the plan of care and provide care with two staff members to resident that are dependent for incontinence care, personal hygiene, and repositioning. I expected the staff to provide care to residents on an air mattress with two assists because the surface is not stable to prevent falls. On 4/29/2026, on V1(Administrator) provided facility Policy Titled, Falls, dated 08/2020. Which reads in part (but not limited to) Policy Statement:The Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated.Objectives1. To identify residents at risk in a timely manner.2. To gather accurate, objective, and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs.3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls.4. To evaluate outcomes.

Based on interview and record review, the facility failed to ensure necessary services and treatment were provided to prevent the development and/or worsening of pressure injuries for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2 developing a Stage 3 pressure ulcer to the left buttock and a Stage 4 pressure ulcer to the right buttock while residing in the facility.Findings:R2 was a [AGE] year-old resident. admission nursing note dated 02/05/2025 documented incontinence and slight redness to the sacral area. A skin assessment completed the same date indicated pressure ulcers to the right and left buttocks.On 04/20/2025 at 1:45 PM, V4 (R2's family member) stated R2 had two black holes on their buttocks while they lived in this facility. V4 stated R2 did not come to this facility with wounds but got them while they lived in the facility. V4 stated they visited daily and R2 was typically saturated in urine and sometimes feces. V4 stated the incontinence briefs being used on R2 were too large and leaked urine on the bed, therefore, R2 usually lay in wet briefs and sheets when they arrived at the facility; V4 began providing incontinence briefs from home at this time to try to assist the situation. V4 stated V16 (Registered Nurse) and V4 (Certified Nursing Assistant) told them R2 had two large wounds on their buttocks. V4 stated that shortly after this time, R2 was sent to the hospital and did not have them return to this facility; V4 stated R2 was admitted to an alternative facility following their stay at the hospital. Review of R2's clinical record lacked documentation of daily interventions to address ongoing incontinence or prevent prolonged exposure to moisture.On 04/20/2026 at 4:30 PM, record review revealed an admission nursing note dated 02/05/2025 at 9:56 PM, states in part but not limited to incontinent of urine, sacral slight redness noted.ETAR (electronic treatment administration record) dated February 2025 has an order dated 02/05/2025 for Remedy Z-Guard to sacral, buttocks, and peri area, as needed, and weekly skin assessment (fill out the skin inspection in wound assessment manager).Skin assessment dated [DATE], created by V16 (RN), includes (visual body map and Braden Risk Assessment Report, indicates a skin tear present on right shin and two pressure ulcers present (right and left buttock). Braden Risk Assessment Score (assessment for risk for skin impairment) was 14, moderate risk.Skin assessment dated [DATE], created by V16 (RN), includes a skin assessment (visual body map and Braden Risk Assessment Report), which indicates a skin tear present on the right shin and two pressure ulcers present (right and left buttock). Braden score was an 18 with a risk level of mild. No additional documentation on wound care or consulting with wound care team found for this date.R2's MDS (minimum data set), Section M, dated 02/11/2025, does not indicate sacral/buttock area redness.Review of R2's initial care plan dated 02/14/2025 includes: R2 is at risk for impaired skin integrity/skin breakdown, referencing the Braden Scale score of 14 (slight redness on sacrum). Interventions include (but not limited to): Daily skin inspection, report any changes in skin or signs of possible skin breakdown or redness, turn and reposition frequently as tolerated and as patient allows, use absorbent pads or incontinent products that wick and hold moisture, use moisture barrier per protocol.The clinical record did not reflect completion of the daily skin inspections identified in the care plan. Facility staff were asked for any documentation pertaining to daily skin assessments and they were unable to provide any requested documentation.Physician order dated 02/17/2025 written by V17 (Medical Doctor/Facility Medical Director) was placed in the ETAR (electronic treatment administration record) to reposition R2 every 2 hours, for sacral wound cleanse with normal saline pat dry, then apply Medi honey over with foam dressing daily.Nursing note created by V14 (Registered Nurse), entered on 02/20/2025 at 3:32 AM includes: wound care to the back scheduled with Medi honey and dry dressing.Nursing note created by V15 (Licensed Practical Nurse) 02/20/2025 at 2:24 PM states in part but not limited to pressure ulcer//right buttock//wound to right buttocks, treatment put in place, calcium alginate with honey, cover with dry dressing daily.Facility wound care documents dated 2/20/25 include Stage 3 wound is present on the left buttock that measures 3.0 cm x 3.0 cm and a Stage 3 wound is present on the right buttock that measures 3.0 cm x 2.0 cm.Care plan created date 02/21/2025 for impaired skin integrity includes: AEB pressure ulcer, at risk for further skin breakdown. Skin tear on right lateral shin, Stage 4 right buttock, Stage 3 left buttock. Interventions in care plan include but are not limited to: Refer to POS/ETAR for any modification or treatment plan and care, low air loss mattress, assess and document wound with measurements, notify physician if no progress per PUSH (pressure ulcer scale for healing) tool after two weeks, pressure ulcer dressing per protocol, turn and reposition resident frequently as tolerated and as patient allows.Physician's order was placed in the ETAR dated 02/22/2025 for sacral wound, cleanse with normal saline, pat dry, then apply Medi honey and cover with foam dressing daily and for right buttocks, to cleanse with normal saline, pat dry, then apply Medi honey, then calcium alginate, cover with dry dressing daily.On 02/24/2025, identical orders from 02/22/2025 for the sacrum, were ordered for the right buttock and left buttock.Review of the ETAR showed on 02/26/2025, an order for a low air loss mattress was placed, an order for right buttock to cleanse with wound cleanser, pat dry, apply Santyl (ointment that assists in removing dead cells from wounds), hydro fiber (woven fibers that transform into a gel upon contact with wound exudate) and cover with dry dressing daily, an order was placed for the left buttock to cleanse with wound cleanser, pat dry, apply Santyl, hydro fiber and cover with dry dressing daily.Record review indicated that on 02/26/2025, the facility contracted wound care company performed an initial wound evaluation and management summary for R2. The evaluation lists a Stage 4 wound to the right buttock with measurements of 7.9 cm x 4.5 cm x 0.3 cm and a Stage 3 wound to the left buttock with measurements of 6.7 cm x 8.6 cm x 0.3 cm.On 04/21/2026 at 12:21 PM, this surveyor interviewed V18 (Certified Nursing Assistant). V18 stated the expectation is for CNAs to look at the skin of residents while performing peri care, bathing/showering and to update nursing if any changes are noted. V18 stated they would have filled out a paper with findings from bathing/showering or peri care and placed it in a tray for the nurses to assess. V18 stated they told V16 (Registered Nurse), directly, of any changes to residents' skin, etc. V18 stated showers are given twice weekly to residents.On 04/21/2026 at 2:30 PM, this surveyor interviewed V2 (Director of Nursing). V2 stated it is the facility protocol, unwritten, for all new admissions to be seen by the in-house wound care team within 24-48 hours of admission, regardless of skin condition at time of admission. V2 also stated all new admission residents are assessed by their admitting nursing team, upon admission and documentation is to be created.On 04/22/2026 at 9:05 AM, this surveyor spoke to V21 (Wound Care Physician). V21 confirmed being the rounding wound care physician during the period when R2 resided in the facility. V21 stated their protocol for wound care rounding is to see their residents weekly. V21 stated when a new resident is added to their service, they will see them within the same week to assess, establish a baseline, and possibly begin treatment; V21 stated it is their priority, within their role, to see residents on a weekly basis and to see new residents within the week of being added to service. The clinical record indicated the initial wound care evaluation occurred on 02/26/2025.Facility Policy labeled Skin Care Regimen and Treatment Formulary, dated 07/03/2025 states in part but not limited to:2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician.a. Pressure Injuries/Vascular Wounds (Stasis/Arterial/Diabetic)b. Surgical Woundsc. Other Skin Conditions5. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.6. Residents who cannot turn and reposition themselves will be turned and repositioned at least every two hours unless otherwise specified by the physician.8. Residents with Stage III and IV pressure injuries will be placed in specialized air mattresses like low air loss mattresses with an incontinence brief if they are incontinent only; incontinence pad which will also act as repositioning aid, and a flat/fitted sheet which are all necessary to prevent infection control issues.

Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions for one (R1) of three sampled residents reviewed for accidents and supervision who had severe cognitive impairment and was assessed as high risk for elopement. This failure resulted in R1 being sent to an outside medical appointment without an escort, leaving the medical building unsupervised, and being found confused and wandering in the street. Findings include:R1 is a [AGE] year-old, male, originally admitted in the facility on 11/11/25 with the following diagnoses: Encephalopathy, Unspecified; and Dementia in other Diseases Classified Elsewhere Moderate, with Agitation.MDS (Minimum Data Set) dated 02/10/26 documented R1's BIMS (Brief Interview for Mental Status) score of 5, which means severe cognitive impairment. MDS indicated R1 has no impairments on the upper and lower extremities. R1 is ambulatory with no assistive devices.On 04/20/26 at 10:43 AM, R1 was observed walking in the unit, alert, oriented with confusion. R1 went to his room, was asked regarding recent doctor's appointment outside facility. R1 stated, It was a tattoo appointment. I did the tattoo appointment, see, look, come here, you see that house, you go inside, that's where the appointment was. It was not raining. I did it alone. R1 went to the window while pointing to a house across the street. R1 was asked again regarding medical appointments. R1 verbalized, I never went out for an appointment.On 04/20/26 at 2:30 PM, R1 was observed standing by the nurses' station on the first floor in the facility. He was roaming around the unit and when about to go near the reception area, the alarm went off. R1 was redirected.On 04/21/26 at 9:40 AM, R1 was observed sitting on the couch on the first floor.R1 is a resident on the third floor in the facility.POS (Physician Order Sheet) dated 02/19/26 recorded R1 has a dermatology appointment on March 31, 2026 at 8:30 AM in the city.Incident Report dated 03/31/26 recorded: On 03/31/26, at approximately 10:30 AM, Transportation Coordinator (V3) received a phone call from the dermatology office that transportation company came to pick up R1 and they were unable to locate him (R1) in the lobby. V1 (Administrator) was notified and advised staff to inform family and law enforcement. V1 located R1 outside of the clinic by private transportation. R1 stated he wanted to go see his mother and old house. R1 was immediately assessed with no injuries.On 04/20/26 at 12:39 PM, V3 was asked regarding R1's medical appointment. V3 replied, Last 03/31/26, he went out for an appointment. On that day, when I called the transportation to make sure he was picked up, they said that he went out, and he could not be found. I called the doctor's office and asked about what happened, was told he was there and seen. The office said he was in the waiting area. I called transportation again but said he was not there. I called the medical office again and called police. (V1) was notified and came looking for him, and she (V1) found him. He went to an appointment alone; no staff went with him. That was the second time he had been to an appointment by himself. He was familiar with the office clinic and the environment. I do send an escort with residents if they need one. For him (R1), the nurses said he was okay to go alone. On 04/20/26 at 1:22 PM, V1 was interviewed regarding R1's incident on 03/31/26. V1 stated, Last 03/31/26, I was actually off and got a call late morning reporting that he (R1) left for his appointment. At that point, I directed staff that family be notified and police and was reassured that they were notified. From there, two employees from facility and myself from my house drove separately to appointment location to get more information and support. What was the situation? Because he (R1) was waiting at the lobby for transportation and had left. Luckily, I was able to locate him (R1) safely. I saw him within the proximity of the clinic office. He was walking, ambulatory, pleasant, said he was going to see his mom's house and checked his old house which was within the neighborhood. It was drizzling, he was not wet or cold. I pulled over, parked and he had a big smile and told him to go back to the clinic building. He said he was fine. He got into my vehicle. I brought him back to the clinic building, at that point police were notified and updated. He was transported back into the facility. Not that I am aware that he had an escort. I was told that he always go there for an appointment without escort arrangement and he is familiar with the clinic. After evaluating the situation, we discussed that he would require an escort moving forward. There were no injuries, he is oriented, in good spirits. V1 further stated, I found him walking on the street around 11:30 AM. The appointment was in the city, and he was walking in a residential side street stating he was going to his old home address.Per R1's face sheet, his previous address was two miles from the appointment clinic, but he needs to cross busy streets and intersections. Progress notes dated 03/31/26 documented R1 came back around 12:45 PM, alert and a little confused, skin, intact, ate lunch and he was good.On 04/20/26 at 2:13 PM, V9 (Registered Nurse, RN) was asked regarding R1. V9 verbalized, He is alert, oriented to self; confused a lot of times. He knows people but not to where he is. He is ambulatory, he wanders from floor to floor. On 03/31/26, he came late from his doctor's appointment. I came to work at 7 AM and night nurse endorsed to me that ambulance to pick him up at 7:30 AM for his appointment. He was already dressed up and ready to go. I handed him the envelope and ambulance crew took him. My shift ended around 3:40 PM. He came back late around 1:40 PM, almost 2:00 PM. I was told that the driver was looking for him at the clinic and he was not there and was later found. When he came back, he was alert but mostly confused. He was not sweating. I asked him to remove his clothes so I could assess him, there was nothing. I dressed him up and gave him foods to eat. V9 was asked if R1 is an elopement risk. V9 replied, I was not aware that he was an elopement risk at the time. There was no endorsement.R1's elopement risk evaluation dated 11/12/25 documented in part but not limited to the following:Score 9, which means high risk for elopement6. The resident roams or wanders throughout the facility and does not respond favorably to staff redirection - yes7. Resident attempts to leave the facility unsupervised and does not respond favorably to staff redirection - yes8. The resident is confused to time and place and has the physical ability to leave the building - yesCheck all interventions that apply:a. personal safety alarm deviceb. exit and stairwell alarmsd. frequent monitoringf. identification braceletso. photo on potential elopement listp. staff aware of residents on wander/elopement riskV10 (Director of Social Services) was interviewed on 04/20/26 at 2:34 PM regarding R1 and elopement risk. V10 stated, He is alert, oriented, familiar with staff, familiar with room, with a bit of confusion, ambulatory. I don't believe he was an elopement risk at the time. He can be redirected and had no history of elopement while in the facility. V10 was asked if R1 needs supervision during medical appointments. V10 stated, I don't think he required an escort at the time because he was responsive, pleasant, very agreeable. He is redirected, can follow directions. He was admitted with dementia. In his case, he did not need an escort at that appointment.On 04/21/26 at 12:24 PM, V18 (Certified Nurse Assistant, CNA) mentioned during interview that R1 is pretty much independent, alert, forgetful, roams around the unit and wears a device which triggers alarms to prevent elopement. He maybe is considered elopement risk. He always sits in the sofa by the nurses' station, walks around the first floor.On 04/21/26 at 1:41 PM, V2 (Director of Nursing) was asked regarding R1 and supervision when out for medical appointments. V2 replied, He is alert with confusion, he converse with staff, with residents, moves around; walks around. There was no episode that he attempted to elope while in the facility. He was assessed upon admission as high risk; staff should have awareness for elopement risk and residents should be monitored. At the time of the appointment, he (R1) was alert with confusion, with awareness of the clinic and appointment, he does not need an escort for medical appointments. R1's care plans documented the following:Date initiated 11/12/25, canceled date 04/14/26:1. I have impaired cognitive function/dementia or impaired thought processes related to or as evidenced by: diagnosis: major neurocognitive disorder; dementia with agitation, adjustment disorder with disturbance of mood/anxietyInterventions:Cue, reorient and supervise me as needed.2. I demonstrate(s) movement behavior that may be interpreted as wandering, pacing or roaming, on wander guard to left leg.Interventions:Staff to provide my photo for potential for elopement list; staff to educate other staff, to be aware of my wander/elopement risk.Date initiated 11/11/25, canceled date 04/14/26:I am at risk for altered thought process Dementia, Disease process with diagnosis of Encephalopathy, UTI (urinary tract infections), altered mental statusInterventions:Offer cues, direction and redirection as needed.Incident report dated 03/29/26 recorded that R1 was involved in an incident of pulling another resident's shirt to get off the chair because he (R1) believes he (R1) works at the facility in that post area. The incident showed R1 is confused and requires staff monitoring.Care plan dated 03/29/26, canceled dated 04/14/26 documented: R1 believes he works at the facility as he stations at the front door greeting others - Interventions: Staff to monitor.On 04/21/26 at 1:25 PM, V17 (Medical Director) was asked regarding R1. V17 verbalized, I am the primary physician of this resident (R1). He is confused, he has Dementia, as far as I know. I was notified that he went out for an appointment and got lost. If he was assessed as high risk for elopement risk, and was documented as elopement risk, it would be preferrable that he needs to be escorted during medical appointments. Facility's policy titled, Appointment and Transportation Policy dated 6/26/25 stated in part but not limited to the following:Policy: When a resident requires an appointment outside the facility, the appointment will be scheduled in a timely manner as outlined below.Procedure: 4. Depending on the resident's medical, physical and cognitive needs and condition, the resident may require an escort while out of the facility for an appointment. If the resident has no representative, family member, friend, etc to escort him/her during the appointment, the facility will provide one. Facility's policy titled, Elopement dated 6/30/25 documented in part but not limited to the following:Policy Statement:It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care.

Based on observation, interview and record review the facility failed to follow physician order in using oxygen for resident who has respiratory disorder. This deficiency affects two (R2 and R3) of three residents reviewed for Respiratory/oxygen management.Findings include:1. On 12/26/25 at 10:34AM, Observed R2 sitting in wheelchair in his room with nasal cannula oxygen tubing in his mouth. R2 said he got tired of putting oxygen in his nose, so he put it in his mouth. R2 added that he still received the same oxygen. R2 is alert, oriented and response appropriately. R2 can verbalize his needs to staff. R2 had a long oxygen tubing from the oxygen concentrator at 3LPM (liters per minute) with no label or date of changed. R2 said they seldom changed his oxygen tubing. His oxygen concentrator was set at 3LPM, while his oxygen tank at the back of his wheelchair was set at 5LPM. V3 Nursing supervisor said R2's oxygen tank is almost empty but still okay. V3 added r2 usually asked the staff if his oxygen tank needs to be changed. R2 uses his portable oxygen tank when he goes out of his room. R2 said his full tank of oxygen runs for 2 and 1/2 hours or less. R2 said it takes a while for them to change his portable tank. Observed nebulizer mask exposed on top of bedside drawer connected to portable nebulizer machine placed on the floor. V6 said nebulizer machine should not be place on the floor and nebulizer mask should be in plastic bag after each use for infection control.R2 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic obstructive pulmonary disease (COPD) with exacerbation. Acute respiratory failure unspecified whether with hypoxia or hypercapnia, Chronic respiratory failure with hypoxia, Dependence on supplemental oxygen, Personal history of other malignant neoplasm of bronchus and lung, bipolar disorder. Active physician order sheet indicated: Oxygen 3-5 LPM via nasal cannula to maintain oxygen saturation level equal or above 92%, may titrate if needed. Comprehensive care plan indicated he has altered respiratory status/difficulty breathing related to COPD, respiratory failure, shortness of breath with exertion and at rest. Interventions: Ensure oxygen levels for portable oxygen tank has adequate supply. Give oxygen as ordered by the physician. R2's MAR (Medication Administration Record) did not reflect oxygen administration as ordered.On 12/26/25 at 1:00PM, Reviewed R2's medical records with V2 DON. Informed DON that oxygen order was not reflected accurately in MAR or TAR (Treatment administration record). There is no documentation of R2's amount of oxygen received to maintained 92% oxygen saturation. V2 said oxygen ordered by the physician should reflect accurately in MAR or TAR (Treatment Administration Record) as indicated in their policy. V2 presented R2's record of oxygen saturation daily monitoring without indication of amount of oxygen usage. V2 said they change oxygen tubing weekly and as needed. V2 said nebulizer machine should not be place on the floor and nebulizer mask should be in plastic bag after each use for infection control.2. On 12/26/25 at 1:57PM, Rounds made with V6 RN. Observed R3 up in wheelchair in her room with oxygen via nasal cannula (NC) at 1LPM with oxygen label dated 12/7/25. Nebulizer masks were exposed on top of the bedside drawer. V6 RN said R3 supposed to be on 2LPM and usually night shift changes the oxygen tubing every 72 hours.R3 was re-admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure with hypoxia, Emphysema, Fracture right pubis, General anxiety disorder. Active physician order sheet indicated: Apply oxygen at 2-3 LPM via NC to keep oxygen saturation greater than or equal to 90% as needed (PRN) related to chronic respiratory failure with hypoxia. Change oxygen tubing/bubblers weekly and PRN. Check and record oxygen saturation every shift related to chronic respiratory failure with hypoxia. Comprehensive care plan indicated: She is at risk for alteration in respiratory functioning related to chronic respiratory failure with hypoxia, emphysema. Intervention: Administer oxygen and other medication and respiratory treatments as ordered. R3's MAR for December 2025 indicated apply oxygen at 2-3 LPM via NC to keep O2 saturation greater than or equal to 90% as needed. No documentation of oxygen was given on 12/26/25 during survey investigation.On 12/26/25 at 2:00PM, Reviewed R3's medical records with V6 RN. Informed V6 that R3's oxygen ordered is 2-3 LPM but she is only receiving 1 LPM. The tubing was changed last 12/7/25 instead of weekly as ordered. V6 said they should be following physician order.On 12/26/25 at 3:30PM, Informed V1 Administrator and V2 DON of above concerns.Facility's policy on Oxygen Therapy and Administration revised 7/2/25 indicated: Oxygen therapy shall be administered to patients as indicated upon a physician's order. Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients. Procedure: Confirm order from physicianNote: c. Oxygen setups should be changed every seven days and as needed if heavy soiling is present.Facility's policy on Physician orders revised 7/3/25 indicated: Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (physician order sheet). Procedures: 7. Medication orders entered in POS shall be reflected accurately in the MAR (Medication Administration Record). In addition, wound treatment orders entered in the POS shall be in the TAR (Treatment Administration Record).

Based on observation, interview, and record review, the facility failed to ensure that residents were served meals at a safe, appetizing temperature by not checking the food temperature before serving. This applies to all 121 residents consuming food through the dietary service.The Findings include:On 12/09/2025 at 11:05 AM, during kitchen tray line observation, observed V20 (Dietary Aide) and V13 (Dietary Cook) started serving lunch from the kitchen steam table without checking the food temperature.On 12/09/25 at 11:20 AM, V13 stated, The old management never did that, and that's why I didn't check the food temp.12/09/25 at 11:25 AM, V14 (Dietary Manager) stated, I thought my cook (V13) checked the food temperature. We are supposed to check the food temperature before starting to serve.12/10/2025 11:00 AM V14 added, We took over this place in October. We don't have any documentation available to prove that we were checking the food temps.The facility presented the Policy and Procedure Manual, chapter 3, page 35, document: Record food temperature prior to service and again after half of the meal has been served.On 12/11/2025 at 9:07 AM, V2 (Director of Nursing) stated that 121 residents are consuming food from the dietary service.

Based on observation, interview, and record review, the facility failed to follow their Medication Storage, Labeling, and Disposal Policy. The facility failed to ensure medications will be stored in locked storage area. This failure has the capacity to affect 19 residents (reviewed for medications) in a total sample of 29. On 12/09/2025 at 12:08 PM, during rounds on the unit, observed medication cart in unit A, first floor, to be unlocked, third drawer opened halfway, with no authorized staff in the hallway. The medication cart was facing in the opposite direction that V7 (Registered Nurse/RN) was in.On 12/09/2025 at 12:12 PM, V7 (Registered Nurse) walked out of a resident's room, noticed the cart was left unlocked and third drawer open, proceeded to turn the cart the opposite direction. V7 (RN) stated the medication cart should have been fully closed and locked, for safety. On12/10/2025 at 10:23 AM, V8 (Assistant Director of Nursing/ADON) stated it is important for nurses to make sure the medication carts are closed and locked when a nurse walks away from the medication cart to ensure the medications are secured.On 12/11/2025 at 1:36 PM V2 (Director of Nursing) stated the medication cart is considered a storage area and medications should always be locked in the medication cart when nursing staff are away from the cart.Facilities Medication Storage, Labeling, and Disposal with a revision date of 7/2/2025 documents: The facilities policy to comply with federal regulations and storage labeling and disposal of medications will be secured in lock storage area.

Based on observation, interview and record review, the facility failed to follow their Call Light Policy. The facility failed to ensure call lights are placed within reach of residents who are able to use it at all times. This deficient practice affects 2 residents (R68 and R52) of 4 residents reviewed for accommodation of needs in a total sample of 29 residents.On 12/09/2025 at 8:13AM Observed R68 and R52 in the same room, each asleep in their assigned beds. The privacy curtain was fully extended out in between R68 and R52. Observed R68's call light attached and clipped high, in the middle of the curtain that was extended all the way to R68's foot bed frame, not within reach of R68. R52's call light was observed under R52's bed, on the floor close to the foot of the bed, not visible to R52. Both R68 and R52's call light string was attached and connected to the call light system. R68s Minimum Data Set (MDS) has a Brief Interview for Mental Status (BIMS) of 15/15, Cognitive intact.R52s Minimum Data Set (MDS) has a Brief Interview for Mental Status (BIMS) of 10/15, cognitive moderately impaired.On 12/09/2025 at 8:41AM, state agency and V9 (Registered Nurse/RN) observed R68 and R52 asleep in their beds, observed R68's call light attached/ clipped high, in the middle of the curtain that was extended all the way to R68's foot bed frame, not within reach of R68. Also observed R52's call light was observed under R52's bed, on the floor close to the foot of the bed, not visible to R52.V9 (RN) stated the call light should have been clipped, placed with the reach of R68 and R52.On 12/10/2025 at 10:23 AM V8 (Assistant Director of Nursing) stated the call light should have been placed within reach of both residents.Facilities Call Light Policy with a revision date of 6/30/25 documents procedures: Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observation, interview and record review, the facility failed to follow their Hand Hygiene Policy. The facility failed to perform hand hygiene after direct resident contact. This deficient practice affects one resident (R 127) of three residents reviewed for hand hygiene in a total sample of 29 residents.On 12/09/2025 at 7:23am observed V12 (housekeeper) walking in the hall, second floor towards unit B wearing gloves pushing the janitor cart. V12 proceeded to open the door to unit Bs shower room, with gloves on, change out the garbage and place a new garbage bag, adjust the shower curtain, leave the shower room wearing the same gloves and proceed to walk pushing the janitor cart walking to wing A. On 12/09/2025 at 8:55AM observed V21 (Activity Aide) not wearing gloves to reposition R127 and not performing hand hygiene afterwards when walking out of R127s room. V21 confirmed she was just assisting to reposition R127 and did not have gloves on and did not perform hand hygiene afterwards. On 12/10/2025 V8 (Assistant Director of Nursing) stated hand hygiene should be completed after direct care resident contact and after cleaning a room. V8 stated hand hygiene is important to prevent the spread of infection and control infection. Facilities Hand Hygiene Policy with a revised date of 6/30/2025 documents: procedures: Hygiene using alcohol-based hand rub is recommended during the following situations before and after direct resident contact.

Based on interview and record review, the facility failed to follow MD order for daily weights for a dialysis resident. This failure has the capacity to affect 1 of 1 resident (R111) reviewed for dialysis in a total sample of 29.Findings include: R111's December Vital Signs Flowsheet (weights) documents missing weights on December 10th, 7th, 5th, and 3rd. Flowsheet documents missing weights on November 28th, 26th, 25th, 24th, 21st, 20th, 19th, 18th, 17th, 16th, and 15th. On 12-11-25 at 9:43 AM, V7 (Registered Nurse) said the daily weights are taken to observe for fluid overload especially for dialysis residents. V7 verified missing daily weights on the flow sheet.On 12-11-25 at 9:52 AM, V2 (Director of Nursing) said daily weights for dialysis resident monitors for fluid overload status. V2 said R111 has daily weight order and weights should be done every morning. V2 verified R111's flow sheet documents missing daily weights. On 12-11-25 at 12:23 PM, V18 (Nurse Practitioner) said daily weight is monitored to determine the fluid balance. V18 said if there is a significant weight gain this will determine how much fluid may be removed. V18 verified Physician Order Summary for daily weights. V18 said the facility is expected to obtain daily weight per MD order. Physician Order Summary documents: Monitor daily weight before breakfast. Notify MD of a 2 lb. weight gain in one day or a 5 lb. weight gain in one week.Dialysis Care Plan reviewed and documents: Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately.

Based on observation, interview and record review, the facility failed to ensure specialty mattress devices were on the correct weight setting for residents who are high risk in developing pressure injuries. This failure has the potential to affect two resident (R27 and R69)) out of three residents reviewed for pressure injury prevention and treatment in a final sample of 29 residents.Findings Include:R69:On 12/9/25 at 8:00AM, observed R69 in bed, asleep using specialized mattress. Low Air loss mattress is set to 4 (250 lbs.)On 12/9/25 ay 8:07AM, confirmed with V3 (Registered Nurse) R69's Low Air loss mattress is set to 4 (250 lbs.). V3 stated the Low Air loss mattress has a sticker on it to let V3 know which number setting the resident needs. V3 stated that the supervisor is the one that updates the sticker. The mattress setting should be within the resident weights.R69 is [AGE] year-old female with diagnosis of but not limited to type 2 diabetes, vascular dementia, osteoarthritis, peripheral vascular disease, hemiplegia and hemiparesis affecting left dominant side.R69's Braden Scale and Clinical Evaluation Form dated 11/24/25, R69 scored 9 (High Risk).R69's Physician Order Sheet reviewed with order for low air loss mattress with start date of 7/20/25. R69's weight is 148.1 lbs., dated 12/8/25.R69's care plan reviewed and dated 7/3/25, reads in part: R69 at risk for further pressure ulcer development and or potential skin breakdown related to frail asking associated with aging process, R69 require substantial to max assistance with most of ADL task. R69 have multiple chronic co-morbidities and on multiple meds to include usage of antiplatelet. R69 is incontinent with both bowel and bladder, diagnosis of Peripheral Vascular Disease.R27:On 12/09/25 at 8:40AM, observed R27 in bed, asleep using specialized mattress. Low Air loss mattress is set to 9 (400 lbs.)On 12/9/25 at 8:45AM, confirmed with V4 (Registered Nurse) that the low air loss mattress is set to 9 (500 lbs.) Confirmed with V4 R27's weight and stated it is 136.1 lbs. V4 stated the low air loss mattress should be set to resident's weight.R27 is [AGE] year-old male resident with diagnosis but not limited to metabolic encephalopathy and hemiplegia and hemiparesis affecting the right side.R27's Braden Scale and Clinical Evaluation Form dated 11/30/25, R27 scored 12 (High Risk).R27's Physician order sheet reviewed with order for low air loss mattress with start date of 10/10/25.R27's weight is 136.1 lbs., dated 12/8/25.R27's care plan reviewed with created date of 12/11/25, reads in part: R27 have alteration in skin integrity and potential for pressure ulcer and or skin breakdown development related to Disease process, Immobility, clinical complexities, presence of g-tube. Intervention: Check air mattress if functioning properly every shift and prn.On 12/11/25 at 11AM, V19 (Wound Treatment Nurse) stated R69 is currently does not have any active pressure ulcer injury. Only has wound on right toe and it is an arterial wound. R69 is assessed to be high risk for Pressure ulcer injury due to history of pressure injury. V19 also stated R27 is currently does not have any active pressure ulcer wound. R27 is assessed to be high risk for pressure ulcer injury. R27 has a history of sacral wound pressure ulcer injury.V19 also stated that both R27 and R69 are using low air loss mattress as a preventative measure. The low airless mattress should be set on based on resident's weight. Nurses can change the setting at any time and to make sure that they check the resident's weight to know the right setting for the mattress.Policies Reviewed:Skin Care Regimen and Treatment Formulary Policy with a revised date of 7/23/25, reads in part: It is the Policy of the facility to ensure prompt identification, documentation and obtained appropriate treatment for residents with skin breakdown. Prevention use of pressure redistribution mattress.Braden scale policy with revised date of 6/30/25, reads in part: It is the policy of this facility to complete the Braden risk assessment for all its residents for the following objective: To be able to assess the resident's potential or risk factor to develop pressure ulcers.To be able to identify each risk factors unique to the resident that can potentially cause for the development of pressure ulcer and properly address them in the resident's care plan interventions. Licensed nurse shall complete the Braden scale assessment on admission, after admission, readmission, quarterly, annually and with significant change in condition MDS. Interpret and calculate score to determine risk potential either low risk or high risk.Each risk factor and potential caused should be reviewed individually and addressed in the residence care plan. Implement intervention per the residents Braden Scale and/or individual risk factors identified as reflected in the care plan. If the resident was assessed as low risk using the Braden scale but the facility feels that the resident is at high risk, the facility may put in place intervention to prevent development of pressure ulcers, put them in the care plan, and indicate that the resident is high risk for pressure sore development.

Based on observation, interview, and record review, the facility failed to follow their abuse policy by not protecting a resident from employee-to-resident abuse. This failure resulted in R85 sustaining redness, mild swelling, and facial bruising. This affected 1 resident of 3 reviewed for (Employee-to-Resident) Abuse in a total sample of 29.Findings include:On 12-9-25 at 8:26 AM R85 was observed with a resolving facial bruise below his right eye. R85 said 2 weeks ago, V16 (unnamed Agency Certified Nurse Aide) punched R85 in the face. R85 said the V16 did not knock on the door and announce she is coming in the room. R85 said he does not remember V16's name nor did she announce herself. V16 told R85 she did not read the door signs or use the doorbell because R85's front door is too cluttered. R85 said V16 was tending to R85's roommate. R85 said he spilled his coffee and V16 was coming at R85 in an aggressive manner. R85 said he threw his coffee at V16. R85 said V16 punched R85 in the face with her left hand. R85 said he had blood from his face and refused to let the nurses tend to him. R85 said his facial bruise is resolving. R85 said he had some defensive scratches on his arm which have healed.On 12-9-25 at 12:01 PM, V15 (Registered Nurse) said R85 is alert, oriented, and able to make simple needs known. V15 said she heard agency V16 shouting for help in front of R85's door. V15 said she came running with Nursing Supervisor. V15 said she saw V16 with coffee stain on V16's upper trunk. V16 told V15 R85 poured his coffee on V16. V15 went inside room and asked R85 what happened. V15 said R85 was shouting and refused body assessment. V15 said she saw (new) redness on the bridge of R85's nose and (new) redness to R85's lateral eye. V15 said she did not see any blood at this time. V15 said this redness was not seen during V15's prior shift.On 12-11-25 at 11:11 AM, V2 (Director of Nursing) said V16 was providing care to the R85's roommate and was upset at V16 thus R85 threw his coffee at V16. V2 said V16 asked for help from V15 (Registered Nurse). V2 said V15 went to room. V2 said V16 had a coffee stain on her side. V2 said R85 sustained redness to right lower eye. V2 said V15 attempted to assess R85 however R85 refused.BIMS Score (ARD 10-23-25) documents: 15.Nursing Progress note dated 11-25-25 documents: Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Patient observed with skin tear around his eye and face while trying to pour hot coffee to staff. MD notified. Patient refuse body assessment. Patient was sent to ER for further evaluation. Appropriate parties notified.Police Report dated 11-25-25 documents: Upon arrival, I spoke with the complainant, R85. R85 related that he became very upset when a CNA, later identified as V16, entered his bedroom (217) without knocking, retrieved his urinal jug from his bathroom, and allowed his roommate to use it. R85 stated that this upset him greatly, and he acknowledged that he became aggressive and began calling V16 names. R85 stated this escalated to him throwing his cup of coffee at V16. V16 reported that after R85 threw the coffee, V16 became upset and began throwing various items in R85's room at him and approached R85. R85 stated he went into defense mode and that during the altercation, V16 struck R85 in the face with a closed fist, knocking R85's glasses off. R85 stated the incident continued for a few minutes until V16 ran out of the room and notified staff. R85 related that the coffee was not hot that it had been sitting for 30 minutes prior to being thrown. R85 related he sustained scratches under his right eye as a result and a scratch on his left arm near his wrist. R85 then related staff had come into his room and tried to clean the blood under his eye. Local Fire Department was called on scene as requested by R85 due to R85 wanting to get his injuries checked out. R85 was transported by local Fire Department to local hospital. Prior to R85 being transported I observed 3 small red scratches under R85's right eye. I observed a purple bruise on R85's right eye. Hospital Record dated 11-25-25 documents: Triage Notes: Pt to ED from NH after altercation with staff member. According to EMS, pt threw coffee on and hit NH staff member then staff member punched pt's R eye. According to pt, pt asked staff member to leave and threw coffee on the staff member then was hit. Pt denies hitting staff member. R eye mildly swollen and bruised.

Based on observation, interview, and record review the facility failed to implement its abuse prevention policy by failure to report injury of unknown origin. This deficiency affects one (R3) of three residents reviewed for abuse prevention policy. Findings include: On 6/18/25 at 4:15PM, R3 was assessed by V4 (Restorative Nurse) and V2 (Director of Nursing) and surveyor present. R3 was observed with discoloration to bilateral side of breasts. On 6/18/25 at 4:30PM, V2 (Director of Nursing) said staff is aware to report any injuries of unknown origin to Administrator to complete an investigation and report to IDPH in a timely manner. V2 said it was not reported to IDPH. On 6/18/25 at 4:30PM, V4 (Restorative Nurse) said any unknown injury is reported immediately for follow up. On 6/21/25 at 10:44AM, V1 said she did not send the initial report to IDPH in a timely manner for an unknown injury incident. V1 said staff is aware to report immediately to V1 for follow up and investigation. V1 said she did not think it was an abuse case, however per facility policy failed to follow protocol. R3 was admitted on [DATE] with diagnosis in part but limited to cerebral infarction, other coronavirus, anemia, type 2 diabetes mellitus, hyperlipidemia, heart failure, essential hypertension. Progress note dated 6/13/25 indicates observation of bruising. Initial report of incident dated 6/18/25 reported to IDPH. Abuse Investigation and Reporting Policy Revised 11/2023. Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the Ascension Living Abuse Prevention policy. Reporting: A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community; 2. Other officials in accordance with State Law, including to Adult Protective Services where state law provides for jurisdiction in long term care facilities; 3. The Resident's Representative (Sponsor) of Record; 4. The resident's Attending Physician; and 5. The community Medical Director. B. Alleged violations involving abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or Serious Bodily Harm - Immediately but not later than 2 hours. * If the alleged violation involves abuse or results in serious bodily injury. 2. No Serious Bodily Injury - As soon as practical, but not later than 24 hours*. If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.

Based on interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when transferring resident using a mechanical lift. This affected one resident (R1) of three residents reviewed for falls. This failure resulted in resident (R1) falling from mechanical lift and sustaining a left displaced femoral neck fracture. Findings include: R1 was admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur, unspecified osteoarthritis, encounter for other specified surgical aftercare, hypothyroidism, hemiplegia, unspecified affecting left nondominant side, unspecified dementia, unspecified severity without behavioral disturbance, difficulty in walking, unspecified fall, subsequent encounter. Admission/Baseline care plan dated 2/14/23 indicated at risk for falls with interventions monitor residents' position when changing in bed, falling star program. ADL care plan dated 2/17/22 indicates requires assistance partial to substantial assist with Activities of Daily Living due to decreased strength and endurance, decrease balance, decrease mobility, unsteady gait, h/o Left sided weakness, CVA's, Dementia interventions include transfer with mechanical lift and 2 persons assist. admission functional mobility assessment dated [DATE] indicated that he needs Dependent assistance with chair/bed-to-chair transfer, sit to stand, toilet transfer. On 6/11/25 at 12:35 PM, R1 observed in dining room, in wheelchair, proper footwear in place, R1 said he does not recall what happened when he fell on 5/23/25. On 6/11/25 at 12:42PM, V8 (Certified Nurse Aide) said she was the certified nurse aide assigned to R1 and was transferring him to bed using the mechanical lift. V8 said she noticed that R1's left foot was not on the base of mechanical lift, and she bent over to place it on the base when R1 let go from the grab bar with his right hand and slid off to the floor. V8 said she assisted R1 back to the bed. V8 said she was the only certified nurse aide in the room with R1. V8 said she is aware that R1 is a two person assist and that when using any mechanical lift two-person assist is also required. V8 said that the other staff were busy and could not get any help. On 6/11/25 at 1:09PM, V9 (Registered Nurse) said he saw call light on and went to R1's room and saw R1 in bed already. V9 asked V8 if she needed any help because the call light was on and V8 said that R1 was a little restless and had assisted R1 to bed. V9 said he assessed R1, and no injuries noted. R1 denied any pain. V9 said V8 was the only certified nurse aide in the room. On 6/11/25 at 1:49PM, V10 (Restorative Nurse) said she is familiar with R1 and R1 is a two person assist with activities of daily living and transfers. When using any Mechanical lift machine for transfers staff should be a two person assist. V10 said it is the facility policy when using a mechanical lift that two-person assist is implemented. V10 said all staff gets training prior to working the floor with residents upon hire and agency staff is trained as well. On 6/11/25 at 3:07PM, V11 (Evening Registered Nurse Supervisor) said V9 had called him to assess R1 after R1 falling. V11 said, When I entered the room, R1 was already in bed and no injuries were observed. R1 denied pain. R1 is somewhat confused. V11 said V8 told him R1 had slid off the mechanical lift and had assisted him back to bed, V8 was the only one transferring R1. V11 said when transferring with a mechanical lift the staff are supposed to have a two person assist. On 6/11/25 at 3:15PM, V2 (Director of Nursing) said her expectations of staff are to follow the residents care plan for fall interventions. V2 said that when using a mechanical lift, the standard of care should be a two person assist. The staff is trained during orientation prior to start of working the floor. The interventions are in the resident's profile the CNAs and nurses can access them. They also have the Kardex at the nurse's station for the transfer status. On 6/11/25 at 3:20PM, V1 (Administrator) said her expectations when staff is using a mechanical lift should always be a two person assist per facility policy. V1 said she was unaware that only one certified nurse aide was transferring R1, V1 said she knew about the fall incident. R1's fall incident documented by V11 (Evening Registered Nurse Supervisor) on 5/23/25 at 9:30PM indicated: V8 (Agency Certified Nurse Aide) reported to the nurse that the resident was assisted to bed and at that time V8 instructed the resident to use the grab bar to help him ease himself down to the bed. V8 observed the residents' left foot was on the floor. V8 was unable to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored resident post-fall for any injuries. No signs of injury and no complaints of any pain until 5/24/25, when resident complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. Resident was transferred to the hospital for further evaluation. His vital signs at the time of discharge were observed as follows: BP 160/78 mmHg, pulse 72 bpm, temp 97.5 F, RR 18 breaths/min, and O2 sat rate at 94% on room air. R1 fall incident initial report was sent to IDPH on 5/25/25 at 5:19PM. Final report was submitted to IDPH on 5/30/25 at 3:33PM indicated: On 5/23/2025 a CNA reported to the nurse that R1 was put to bed, and at that time the CNA instructed the resident to use the grab bar to help him ease himself down to the bed. The CNA observed R1's right hand had let go of the grab bar, which caused the resident to slide off of the bed. The CNA observed his left foot was on the floor. CNA was able to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored the resident post-fall for any signs of injuries. No signs of injury and no complaint of any pain until 05/24-/2025, when R1 complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. R1 was transferred to the hospital for further evaluation. His vital signs at the time of discharge were as follows: BP 160/78 mmHG, pulse 72bpm, temperature 97.5F. respiratory rate 18 breaths/min, and oxygen saturation rate 94% on room air. R1's hospital emergency department records dated 5/25/25 to 5/30/25 discharge summary indicated: Left femoral neck fracture, surgical intervention on 5/27/25, no weight bearing to lower left extremity. Patient had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain. Due to dementia, he is a poor historian. Per wife patient has been non ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed. Patient was discharged to nursing home facility on 5/30/25 for skilled therapy. Facility Policy on Mechanical Lifts revised 1/2024. Policy Statement- It is the policy of Ascension Living to use mechanical lift(s) according to current standards of practice and keeping with manufacturer's guidelines. B. The use of the mechanical equipment is considered either as a full body lift or sit to stand lift that aids the resident and associate in transfer and/or care procedures. G. Education shall be provided on the proper use of the assistive mechanical lifting equipment prior to the use. Facility Policy on Falls revised 1/2024. Purpose-To prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with Communities managing fall risk through the process of assessment, planning, implementation, and evaluation (APIE). B. Residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. Facility Policy on Fall Prevention revised 7/2023. Policy Statement- The intent of this policy is to provide an environment that is free from accidents hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents.

Based on interview and record review, the facility failed to provide adequate supervision on a resident who has significant risk for falls for one of three residents (R3) reviewed for accidents. Findings include: During record review, R3's incident report dated 05/04/2025 with time of incident at 6:15PM indicated that a resident from another wing alerted V7 (Licensed Practical Nurse) that R3 was sitting on the floor. It indicated a CNA (Certified Nursing Assistant) was in the dining room with R3 sitting by the window and watching on her phone. V7 asked V15 (CNA) what happened when V15 started yelling and screaming at V7 for no reason. On 05/15/2025 at 1:12PM V2 (Director of Nursing) stated staff members should not be on their phones when they are on the unit and when supervising residents in the common area to ensure adequate supervision is provided to the residents. Review of R3's CNA Post Fall Report dated 05/04/2025 indicated R3 was last visually seen at 5:30PM, last toileted at 4:25PM, and given food and fluids at 5:30PM. Review of R3's Fall Risk assessment dated [DATE] indicated R3 had a total score of 43 which indicates significant risk for falls. Review of R3's Fall Care Plan with problem onset date of 05/29/2022 indicated R3 a had a recent fall due to decreased safety awareness most likely attributed to her dementia, impaired standing balance and activity tolerance resulting in unsteadiness, hx (history) of multiple falls, presents with co-morbidities to include DM (Diabetes Mellitus, TIA (Transient Ischemic Attack, dementia, hx of angioplasty with graft, anemia, usage of psychotropic med (medication), BP meds, hypoglycemic agent, (+) with impulsivity, gets up and walks abruptly without assistance, inconsistent with call lights, and approaches including to anticipate toileting needs and offer toileting after dinner, offer to toilet after dinner with date 09/07/2023, and offer to toilet after dinner with date 01/20/2023. Review of V8's Compliments, Suggestions, and Concerns Form dated 05/05/2025 written by V4 (Director of Social Services) indicated V8's concern on the care provided to R3 in the dining area on 05/04/2025. V15 was attending to her cellphone, and V15 was unaware of R3 sliding off the wheelchair. Review of facility's policy entitled Fall Prevention last revised 07/2023 indicated the following: Policy Statement: The intent of this policy is to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. I. Fall Risk Evaluation - Residents shall be evaluated by the licensed nurse during the admission process, routinely and as indicated; to identify potential risk for fall. If the resident scores a higher risk for falls, the resident shall be placed on the Falling Star Program. II. Fall Risk Intervention - The Interdisciplinary Team shall identify individualized interventions to reduce risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the associates may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).

Based on interview and record review, the facility failed to protect a resident from allegedly being roughly handled, threatened, punched, and intimidated by an agency staff person; failed to assess resident of any injuries; and failed to train staff on screening, abuse prevention and investigation. This failure affected 1 (R1) of 3 residents reviewed for abuse from the sample of 3 and resulted in R1 abruptly ending her rehabilitation to discharge home due to the resident feeling unsafe and distressed for fear of agency staff's return. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. On 4/4/25 at 11:25 AM, R1 stated upon interview, It was about 4 AM and I had to go to the bathroom, so I did it myself because it seemed there was no one around. No one was at the nursing station when I peeked outside my door plus the hallway was dark and a lot of the lights were turned off. I couldn't get my diaper back on so I put a clean diaper on the bed to lay it down. I went to sit on it but couldn't put it on. I put my call light on so I could get help and a woman (with a winter hat and coat on) came barging in without a word, and just takes my diaper that I was sitting on and angrily rips it into shreds and then walks out of the room and then came back in with another diaper. She pushed me and took her fist and punched me twice in my back. I told her to stop, and I tried to grab the rail because I almost fell . I screamed because I was afraid of what this person was going to do to me. She said to me scream all I want but that that nobody was around. I tried to get her name, but she would not tell me, and I said please don't do that again and she told me to turn around and kept punching me while she tried to get my diaper on me. I said stop punching me or I'm going to call somebody. She said go ahead nobody is here. I was scared to death, and I didn't yell again because I did not see anyone anyway and I was afraid if I did scream again, she may have punched me harder again or even pull out a knife. When this nurse V4 (RN) finally came in it was around 6 in the morning, I was crying, my back hurt where she punched me, and I told him what happened. He said he'd take care of it, and he called in another nurse V5 (LPN supervisor) because he was in charge of the building, and he said that the woman isn't coming back. I didn't understand what that meant and was frustrated that they weren't around all night and now they tell me that woman is gone now, so their words were not assuring to me. That was the reason I left because I was scared and didn't know if she would retaliate against me for telling on her. A written statement by R1 provided to V1 (Administrator) dated 3/7/25 at 3:45 AM, reads in part, I got myself up and went to the bathroom and had bowel movement and took off my pull-ups as it was soiled and I cleaned myself up and came out and got a new diaper to put on, but I could not, so I laid it on the bed and sat on it. I pressed call button at 4:15 (AM) and a woman came in with her winter coat on and was yawning and I told her about my diaper and told me to sit on it again. She started pulling and ripped it to shreds. She left and came back with another one and said turn over and she put her fist and pushed me so hard I said stop you're going to push me on the floor. Then she turned me to the other side and pushed me again and I said stop and take blanket off me and then she left. I asked her name 3 times, and she would not tell me. So, 10 minutes later I put call button and said I want someone else here. She says no and I said I want to tell them you're about to push me off the bed. She says you're still on the bed, I said, oh you're now getting smart with me and she leaves and on her way out she says Do not put call button on, so I did anyway because I thought maybe someone else was on duty but she did not come back for 1/2 hours . On 4/4/25 at 11:00 AM, V10 (family member) stated that she never received a call pertaining to the incident involving the CNA V8 but rather was only informed to come in to the facility to sign papers about her mom receiving continued therapy and to obtain payer information. V10 stated when she came in to the facility around 1:30 PM on 3/7/25 her mom started crying to her and informed her that some staff person pushed her while in bed, punched her in the back, and then threatened her to not use the call light. V10 said she immediately went to tell the nurse to call the police and that was when V1 administrator came in to talk to her about the incident. V10 said she was upset that no one told her about what had happened to her mother until she came in to visit and that V1 appeared very nonchalant and indicated she would handle the situation after she had her lunch. V10 said, My mom said she wanted to go home because she didn't feel safe and that no one was around all night to protect her, so I took her home. On 4/4/25 at 12:30 PM, V4 (RN) stated upon telephone interview, What happened was I was drawing blood for the whole house when I received (R1) she was in her chair next to her bed. She looked very distraught and was crying. It was about 5 or 6 in the morning because I was drawing every body's blood and I started around that time. The resident was trying to explain to me what happened, and she looked very guarded, almost as if she was in shock. She explained that V8 CNA on duty told her she should not ring the bell until the end of her shift or until she left. The resident is very alert, so she came across very credible, so I let the charge nurse V5 know when I saw him walk by and told him that we have a situation here and told him to come into the room. I told him because he was the supervisor at night. I have never seen this agency CNA before as there's been so much Agency staff lately. (R1) identified the CNA and I saw her just sitting by the couch near the nurses station. She had her stuff with her already like bags, notebooks and she had her winter coat on. We actually asked her to leave about 20 minutes to 7 AM after we called the administrator. Initially (V1-Administrator) didn't pick up but then she eventually called the facility back and said to write a statement later and so I did that and left. Surveyor asked if V4 did anything else with the resident to determine if she had any visible injuries or felt safe. V4 said, I don't recall and I'm not familiar with the policy in that facility because I'm mostly PRN (as needed) and I don't get involved in the whole thing like this. Surveyor asked if V4 called the police. V4 said, No I didn't call the police because I'm not familiar with their policies here. I just called the nurse in charge, and he called the administrator. Surveyor asked if V4 assessed the resident for any injuries. V4 stated, I don't know, everything went so fast, and I probably should have but no I didn't. A written statement signed by V4 dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she (R1) was in tears and when I asked her why, she stated that she was scared. I asked her why she was scared. She (R1) responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like, and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) There was no written statement taken by V1 (Administrator and abuse prohibition coordinator) for V5 (LPN night supervisor) who was directly involved during R1's initial reporting of allegation of abuse. Surveyor however was able to interview V5. On 4/4/25 at 12:40 PM, telephone interview with V5 (LPN night supervisor) said, There was an incident where an agency CNA was assisting a patient (R1). The nurse on duty (V4) called my attention to R1's room about a concern that the patient was scared about an Agency CNA. R1 described the CNA as African American, tall, wearing coat. I asked V4 what happened, and he described what the patient told him. What I can get from the nurse was that when the patient was being changed, she had a feeling she was going to fall from the bed during a diaper change. I guess she was being pushed too far at end of the bed and she was scared of the CNA and while being changed was pushed or hit by the CNA. When this all happened, I guess I was basically on 2nd floor doing rounds. I've been here since 2005 and this is the first time this has ever happened. The patient is very alert and is not confused at all. She was here for rehab. When I saw R1, she appeared very frightened and shaken up by the whole thing I could tell. Surveyor asked V5 if there was any assessment conducted. V5 said, No I don't recall doing that. We got so busy getting information from her and we called the administrator and left a message for her and by the time she called back, it was may have been about a quarter to 7 and the CNA (V8) was going home soon anyway but yes, I should have made sure V4 assessed her to see she was uninjured. Surveyor clarified if there was any nursing assessment conducted as V1's abuse incident report indicated that there was one done. V5 stated, No I don't recall that. Surveyor asked if the physician or family was notified of the incident. V5 said, No I didn't call the family or doctor, we just called the administrator. I'm just supposed to call the administrator and I haven't encountered this situation before, so I didn't know what to do. On 4/4/25 at 10:40 AM, V9 (Human resource director) said, I don't handle agency staff paper work or trainings, just our own. We don't screen agency staff; they do the screening for us. Surveyor asked if agency staff screenings were reviewed by her, V9 said, No I don't review any of their staff that they send, I didn't know I had to. Surveyor requested to have V8's hire records and trainings provided to her by her agency, but no records were provided during the investigation. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (Doctor) could not be reached for interviews during this investigation after several attempts were made. Facility interdisciplinary notes showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or psychosocial assessment, if needed.

Based on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. An initial and final report dated 3/7/25 written by V1 (administrator/abuse prohibition coordinator) reads in part, Allegation of abuse and internal investigation: At 6:00 AM when the night nurse went into the resident's room, she informed the nurse she was upset because she felt the CNA assigned to her was inappropriate with her verbally, and treated her roughly when helping her to turn in bed during incontinence care. When she put her call light on at around 4:00 AM, the CNA entered the room and said What do you want? Then, while providing incontinence care, the resident felt the CNA was pushing her over too hard and this made her concerned she was going to roll off the bed onto the floor when she was turned. After the incontinence care, the CNA then told the resident to not press the call light again, and left the room. The resident asked the CNA three times if she could have her name, but the CNA refused to answer that question. This was the only time she had interaction with the CNA. Immediately after the resident reported the incident to the nurse, the nurse notified the Executive director (V1) The executive director directed the nurse to have the CNA leave the facility immediately. A Body check was done, and there was no redness or bruising noted. The resident's physician was notified. The resident is alert and oriented and declined the executive director notifying her family, because she stated she wanted to inform them herself. A comprehensive internal review, including resident reviews, yielded no evidence of abuse. The local police were notified of the allegation, and came to the facility at approximately 3:30 PM to interview the executive director, the resident and her daughter who was present during their visit to the facility. Surveyor's interviews of staff and and nursing records provided are not consistent with V1's initial and final report of abuse allegation: On 4/4/25 at 1:40 PM , V1 (administrator and abuse prohibition coordinator) stated, I didn't interview or get statements from V5 night supervisor but I did speak to both (V5) and (V4) the nurse on duty because they both called me together on the phone, but I guess I should have gotten a statement/interview from V5 himself. I didn't interview any other staff because they were on different assignments but you're correct, I could have done that to see if they heard anything. Surveyor asked if she tried to interview V8 who was involved in the incident, V1 stated, No I did not interview the agency CNA. On 4/4/25 at 11:15, V7 (Staffing Agency manager) said, I was only reported by the facility to not send (V8) to go back to the same place is what I do. We DNR (Do Not Return) the staff person and report that there was an allegation of abuse and ensure to block them from picking up at any of V1's other facilities. We did not interview the CNA in question, we just remove them from picking up shifts. We do not investigate situations like this nor report it to the CNA registry. We leave that to the facility reporting the allegation. On 4/4/25 at 11:25 AM, V3 (facility staffing scheduler) provided surveyor with list of residents on each unit where V8 worked the night of the incident and on previous shifts and units that V8 had worked on. A review of the V1's internal investigation showed 5 other residents interviewed but were not within the same unit as R1 where V8 had worked. There were no other staff members interviewed who were working during V8's shift. On 4/4/25 at 11:55 AM,.V2 (DON Director of Nursing) said, I am the interim DON and have been here since last December and what should happen is usually I would be informed of incidents like this and especially pertaining to allegations of abuse, however I was not and I should have been. I had no involvement in the investigation whatsoever, but yes these nurses do fall under my direction and I should be kept informed however unfortunately I was not. A written statement signed by V4 (RN nurse on duty) dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she was in tears and when I asked her why she stated that she was scared. I asked her why was she scared. She responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) Facility interdisciplinary notes provided to surveyor during this investigation showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (doctor) could not be reached for interviews during this investigation after several attempts were made. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or psychosocial assessment, if needed.

Based on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. An initial and final report dated 3/7/25 written by V1 (administrator/abuse prohibition coordinator) reads in part, Allegation of abuse and internal investigation: At 6:00 AM when the night nurse went into the resident's room, she informed the nurse she was upset because she felt the CNA assigned to her was inappropriate with her verbally and treated her roughly when helping her to turn in bed during incontinence care. When she put her call light on at around 4:00 AM, the CNA entered the room and said, What do you want? Then, while providing incontinence care, the resident felt the CNA was pushing her over too hard and this made her concerned she was going to roll off the bed onto the floor when she was turned. After the incontinence care, the CNA then told the resident to not press the call light again and left the room. The resident asked the CNA three times if she could have her name, but the CNA refused to answer that question. This was the only time she interacted with the CNA. Immediately after the resident reported the incident to the nurse, the nurse notified the Executive director (V1) The executive director directed the nurse to have the CNA leave the facility immediately. A Body check was done, and there was no redness or bruising noted. The resident's physician was notified. The resident is alert and oriented and declined the executive director notifying her family, because she stated she wanted to inform them herself. A comprehensive internal review, including resident reviews, yielded no evidence of abuse. The local police were notified of the allegation and came to the facility at approximately 3:30 PM to interview the executive director, the resident and her daughter who was present during their visit to the facility. Surveyor's interviews of staff and nursing records provided are not consistent with V1's initial and final report of abuse allegation: On 4/4/25 at 1:40 PM, V1 (Administrator and abuse prohibition coordinator) stated, I didn't interview or get statements from V5 night supervisor, but I did speak to both (V5) and (V4) the nurse on duty because they both called me together on the phone, but I guess I should have gotten a statement/interview from V5 himself. I didn't interview any other staff because they were on different assignments but you're correct, I could have done that to see if they heard anything. Surveyor asked if she tried to interview V8 who was involved in the incident, V1 stated, No I did not interview the agency CNA. On 4/4/25 at 11:15, V7 (Staffing Agency manager) said, I was only reported by the facility to not send (V8) to go back to the same place is what I do. We DNR (Do Not Return) the staff person and report that there was an allegation of abuse and ensure to block them from picking up at any of V1's other facilities. We did not interview the CNA in question, we just remove them from picking up shifts. We do not investigate situations like this nor report it to the CNA registry. We leave that to the facility reporting the allegation. On 4/4/25 at 11:25 AM, V3 (Facility staffing scheduler) provided surveyor with list of residents on each unit where V8 worked the night of the incident and on previous shifts and units that V8 had worked on. A review of the V1's internal investigation showed 5 other residents interviewed but were not within the same unit as R1 where V8 had worked. There were no other staff members interviewed who were working during V8's shift. On 4/4/25 at 11:55 AM, V2 (DON Director of Nursing) said, I am the interim DON and have been here since last December and what should happen is usually, I would be informed of incidents like this and especially pertaining to allegations of abuse. However, I was not, and I should have been. I had no involvement in the investigation whatsoever, but yes these nurses do fall under my direction, and I should be kept informed however unfortunately I was not. A written statement signed by V4 (RN nurse on duty) dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she was in tears and when I asked her why she stated that she was scared. I asked her why she was scared. She responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like, and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) Facility interdisciplinary notes provided to surveyor during this investigation showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (Doctor) could not be reached for interviews during this investigation after several attempts were made. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or psychosocial assessment, if needed.

Based on observation, interviews, and a review of records, the facility failed to follow its weight monitoring policy to prevent or reduce the risk of residents experiencing unplanned significant weight loss. This failure affected three of ten residents (R17, R28, and R61) who were reviewed for weight monitoring and weight loss as part of a sample of 40 residents. As a result, R17 experienced an unplanned weight loss of 6.15% over a 30-day period, R28 experienced a 15.3% weight loss over six months, and R61 experienced an 11.2% weight loss during a six-month period. Findings include: 1) On 3/11/25 at 10:15 AM, R17 was observed to be on a pureed diet with nectar thick liquids. R17 was observed attempting to self-feed breakfast. R17 was observed to have only consumed 20% of breakfast. Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 12:27 PM, Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 at 10:45 AM, V8 RD (registered dietitian) reviewed R17's documented weights. R17 had an 8.8-pound weight loss in one month. V8 stated residents on a pureed diet should be eating in the dining room so staff can monitor them. V8 stated there is no re-weight documented. V8 stated that residents with a weight change of 5 pounds or more in one month should be re-weighed to verify the accuracy of the weight. V8 stated R17 will be re-weighed today. V8 stated V8 was not made aware of R17's weight loss. On 3/12/25 at 11:30 AM, V8 RD stated that V8 spoke with R17 and discussed food preferences. V8 stated V8 also spoke with staff to ensure R17 is in dining room for all meals so R17 can be monitored for amount eaten. As of 3/12/25 at 4:00 PM, R17 had not been re-weighed. R17's medical record notes on 3/6/25, R17's weight was 134.2 pounds. On 2/5/25, R17's weight was 143 pounds. R17 had a 6.15% weight loss in one month. There is no documentation found in R17's medical record noting R17's physician was notified of R17's weight loss. This facility's weight monitoring policy, revised 01/2023, notes residents with a weight change of five pounds or greater shall be re-weighed to determine an accurate weight. The registered dietitian should make recommendations for nutritional interventions. A nursing or nutrition associate should notify the health care provider of any significant weight change. This facility's weighing and measuring the resident policy, revised 09/2022, notes report significant weight loss to the nurse supervisor. The threshold for significant unplanned and undesired weight loss will be based on 1 month - 5% weight loss is significant; greater than 5% is severe. 39340 2) R61 was admitted to the facility on [DATE] with a diagnosis of muscle weakness, transient cerebral accident, dementia, hypertension, type II diabetes and heart disease. R61's weight documented on hospital transfer form dated 2/27/25 documents 59 kilograms which equals 124 pounds upon readmission. On 3/14/25 at 11:34Am, V21 (certified nursing aide, CNA) assisted R61 in her wheelchair that measured 38.8 pounds to the wheelchair scale. Scale was balanced to zero prior to weight taken and measured at 151.2 pounds. R61 weight was 112.4 pounds. R61's physician order dated 2/27/25 documents to weigh daily x3 days and weigh weekly x 4 weeks. Review of R61's medical record does not document any weights for R61. V19 (nursing supervisor) on 3/13/24 said there were no other weights recorded for R61 except for a written weight taken on 3/12/25 that documented 110 pounds that was just documented into the electronic record. R61's facility weight documents weight in October: 131. Pounds and November 124.4 pounds. There were no other weights presented for R61 for this survey. On 3/13/25 at 3;38PM, V8 (dietician) said she was made aware of R61 change in appetite on 3/5/24. There were no weights documented since November 2024. R61 had a significant weight loss of 11.2 % based on weights documented. V8 said weekly weights help to ensure weight is remaining stable, to monitor if any additional weight loss and if interventions are effective. R61's nutrition risk assessment dated [DATE] documents under type of assessment: significant change. Under anthropometric data documents: height 60 inches, current weight 110 pounds, usually body weight 124 pounds, body mass index (BMI) 21.5 which indicates underweight. Under comments: Resident had significant weight loss over the past 6 months 11.2%. R61 plan of care dated 3/4/25 documents poor PO intake with the following interventions: monitor weekly and monthly weights; monitor and record meal intakes, obtain food preferences, instruct family about dietary modifications for resident; praise resident attempts to follow diet, feed resident slowly. Weight Monitoring Policy dated 12/2016 documents: appropriate nutritional care shall be provided to resident who have a significate weight change. Each resident should be weighed daily for the first three days of admission, weekly for the first four week and monthly thereafter. Weighing and measuring the resident dated 12/2016 documents: The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. 1 month -5% weight loss is significantly greater than 5% is severe ;3 months -7.5% weight loss is significantly greater than 7.5% is severe;6 months 10% weight loss is significantly greater than 10% is severe. 41758 3) R28 was diagnosis with malignant neoplasm of endometrium. R28's care plan dated 1/11/25 documents: R28 has compromised nutritional status related to the diagnosis of sepsis, malignant neoplasm of endometrium, type one diabetes, hyperlipidemia and major depression; (2/27/25) significate weight change. Dietician note dated 2/27/25 documents: unintentional weight loss related to variable by mouth intakes as evidenced by resident with 17.3% weight loss times six months. Dietician note dated 11/29/24 documents: Unintentional weight loss related to variable by mouth intake as evidence by resident (R28) with 23 pound (lbs.) 15% weight loss in three months and 15lbs (10.3%) weight loss in one month. R28's significant weight change notification dated 11/29/24 documents: R28 had a significant weight loss of 15.3 % in three months. Plan of care: One carton of nutritional supplement once a day. Dietary recommendation/communication form dated 11/29/24 documents: reason for recommendation: significant weight loss. On 3/12/25 at 3:41PM, R28 who was alert and orient to person, place, said she was a picky eater. R28 said, she eats very little. On 3/13/25 at 12:36PM, R28 did not eat lunch. R28's family was at the bedside. R28's family put R28's uneaten tray on the dirty cart. R28's family said he brought food from home. V25 (CNA) said R28's family brings in food every day and feeds R28. On 3/13/25 at 2:48pm, V25 (CNA) said R28 only likes Polish food. R28 does not drink a nutritional supplement every day. On 3/13/25 at 4:02pm, V8 (dietitian) said, R28 had a 15.5% significant weight loss in six months. On 3/13/25 at 5:00pm, V3 (unit manager) said R28's nutritional supplement should be signed out on the medication administration record (MAR). V3 said R28's dietitian recommendation was not on the MAR. R28's family does not come every day to feed R28. On 3/14/25 at 10:17am, V2 (DON) said R28's recommendation for a nutritional supplement once daily was not implemented on 11/29/24 and it is not on the current MAR. V2 said the nutritional supplement should have been placed on the medication administration record. It was recommended to promote weight gain. On 3/14/25 at 11:34am, V20 (restorative nurse) said R28's nutritional supplement was added today. On 3/14/25 at 11:39am, V28 (nurse practitioner) said she was aware R28 was losing weight. R28 does not like the facility food. R28 has a history of malignant neoplasm of endometrium. R28 had surgery a few years ago and everything was removed. A nutritional supplement is a high calorie protein supplement that will aid in weight gain. V28 said she expected the dietitian recommendations to be implemented. R28's weight report documents: 3/13/25 - 122.2 pounds 2/5/25 - 124.8 pounds 1/8/25 - 126.8 pounds 11/7/24- 130.0 pounds 10/9/24- 145.0 pounds Weight Monitoring Policy dated 12/2016 documents: appropriate nutritional care shall be provided to resident who have a significate weight change. Weighing and measuring the resident dated 12/2016 documents: The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. 1 month -5% weight loss is significantly greater than 5% is severe. 3 months -7.5% weight loss is significantly greater than 7.5% is severe. 6 months 10% weight loss is significantly greater than 10% is severe.

Based on interview and record review, facility staff V3 (Certified nursing assistant, CNA) failed to report a fall to the nurse for one resident (R2). This failure resulted in R2 being transferred back into bed with no nurse assessment for over 10 hours. R2 was transferred to the hospital for a left ear laceration requiring eleven sutures and broken ribs for one of three residents reviewed for falls. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Covid 19, urinary tract infection, Parkinson's and overactive bladder. R2 Minimum Data Set, dated dated dated [DATE] documents R2 required substantial/maximal assistance (helper does more than half the effort) with sit to stand, chair to bed transfer, and toilet transfers. R2's fall risk assessment dated [DATE] documents: R2 is moderate risk for falls. On 12/26/24 at 3:37PM, V21(former unit manager) said R2 was alert and oriented with periods of confusion. V21 said she went to R2's room around 4:00pm per family's request and daughter showed her R2's ear which had a cut. V21 said she asked R2 what happened and R2 reported the same story 3 different times, that she fell in the middle of night around 1-2 AM. R2 said she was trying to get water and fell . R2 said she hit her head hard on something but unsure what. R2 said a male staff member picked her up and put her back in bed. R2 reported that same male staff told her she did not need a nurse. On 12/26/24 4:26PM, V2 (Director of nursing, DON) said family wanted to speak to V2 about a cut on R2's ear around 4:00PM on 12/11/24. R2 reported she was thirsty and wanted water that was on the bedside table around 1-2AM. R2 said she spilled the water, got up from bed and fell . R2 was unsure what she hit her head on, but R2 said a male staff picked her up and put her back to bed. R2 did not report fall to anyone. R2 may have been fearful. V2 said they found a towel on the floor in the bathroom with dried blood. V2 said staff must have used the towel because R2 needs assistance to get to bathroom and would not be able to get towel herself. V2 is unsure why no other staff observed the towel. V2 said staff should stay with a resident if they fall and get the nurse to assess the resident before moving the resident. On 12/26/24 at 5:02PM, V1 (Administrator) said through his investigation it was determined V3 did not follow facility protocol by not reporting a fall or change in condition to the nurse. V1 said V3's interview did not add up based on other interviews conducted and injuries observed. V1 said staff did not feel like R2 could get up unassisted and if a resident is found on the floor, staff should stay with resident and call for nurse. R2's hospital record dated 12/11/24 at 5:30PM: Under Emergency department physician note: R2 alert and oriented x3. R2 who presents with laceration on the back of the left ear. R2 reports that she fell last night around 2AM when she was attempting to pick up a fallen tray. She slipped and fell , an event that went unnoticed by staff. R2 denied any neck or back pain but reports pain in left clavicle, shoulder, and forearm, under physical exam. Ear left with transverse laceration through the superior third auricle through the lateral edge there is exposed cartilage but its intact. Lateral edge of wound is macerated. Laceration repair: length 6 centimeter (CM), depth 8 Millimeters (MM). eleven sutures placed. Under chest x-ray documents: possible six and seven posterior rib fractures. Correlate with point of tenderness. V3's employee file record documents: V3 terminated due to violation of code of conducts. Facility fall policy revised 7/23 documents if a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aide treatment as indicated. A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall and document findings in clinical record.

Based on interview and record review, the facility failed to adequately supervise one (R2) resident at risk for falls, a total assist resident and dependent on staff supervision/assistance with all ADL's (Activities of Daily Living); failed to provide assistive device of foot rests on a geriatric wheelchair to prevent sliding/falling; and failed to maintain functionality of bed in order to lower close to the ground. This failure affected one resident (R2) of 9 residents reviewed for accidents/hazards/supervision and resulted in R2 being transferred to the emergency department after a fall from a geriatric wheelchair and diagnosed with a right tibial fracture; and transferred again 11 days later to the emergency department after another fall from a malfunctioning bed. Findings include: R2 is a [AGE] year-old-male with diagnoses including but not limited to hemiplegia, diabetes, neoplasm of prostate, and epilepsy. On 6/11/24 at 10:30 AM, V2 (director of nursing) stated that on 5/23/24 at 2:00 PM, R2 was in the dining area attending an activity program when R2 slid down from his high-back geriatric chair and bent/twisted his right leg in the process. According to interview on 6/11/24 at 10:50 AM with V3 (activity aide), V3 did not see R2 slide down because V25 (CNA) in charge of monitoring R2, left the dining area at the time of the incident. V3 called for help and two CNAs (V4, V6) came to lift the resident back up from the geriatric chair. Per V4 (CNA) and V6 (CNA) R2 was supposed to have leg rests on his wheelchair which would have prevented the resident from sliding down, however there were no leg rests that were attached as they should have been. The nurse on duty at the time (V8-RN), assessed R2 but did not report the incident of a fall because at the time, V8 did not consider the incident a fall. The following day, V7 (CNA) reported to the nurse on duty that R2 had pain and swelling on the right knee so the resident was sent to the emergency department for evaluation where he was diagnosed with the tibial fracture. On 6/5/24, R2 was found on the floor beside his bed at 4:50 AM but was last observed in bed at 2:50 AM sleeping. On 6/12/24 at 11:50 AM, V2 (director of nursing) stated, (R2)'s second fall on 6/5/24 happened on the night shift when the nurse (V29) found him on the floor on kneeling position. According to the 3-11 shift CNA (V30), around 4:15 PM, V30 noticed the remote was not working on the bed so V30 could not lower the bed to the lowest position. V30 told the nurse (V29) but didn't do anything about it. The next day V29 was no call-no show and quit. Regarding the bed functioning properly, V2 stated, We're supposed to keep his (R2) bed in the lowest position to keep him safe and (V29) knew that. She (V29) should've informed someone that the bed was not working because otherwise (R2) may not have fallen from the bed. Interviews of staff are as follows: On 6/11/24 at 10:30 AM, V2 (director of nursing) stated, (R2) was in the dining room attending an activity when one of the residents alerted the activity aide (V3) that the resident was on the bottom of the reclining chair. He (R2) slid there but it is still considered a fall. On 5/23/24 at 2:00 PM was when the activity was going on. V8 (RN) was the nurse but did not report this as a fall because she thought because the resident did not hit the ground that it wasn't a fall. I in serviced her (V8) about falls after this. So, the 3-11 shift nurse was not aware of any bruising that day until the night shift CNA (V7) reported to the nurse the next morning that she saw swelling on the resident. The resident's (R2) leg was under his right leg, and it got bent or caught somewhere. If there was a foot rest that could have prevented him from sliding down. On 6/11/24 at 10:50 AM, V3 (activity aide) stated, (R2) is one of our residents that goes to activities, and he does not walk and only uses his left hand. He is on a recliner chair. He comes to activities by a CNA bringing him to the activity room. He is very friendly to staff and does not have any behaviors. He is slightly confused. He's Spanish speaking only. So, when he fell , I was doing activities and one of the residents called out to me and said that (R2) is sitting near the foot of his recliner chair and his right foot was angled like a figure four and it was under his left knee. The CNA that was supposed to be monitoring the residents left the room when R2 fell , and she was supposed to stay there or get someone else to watch if she had to leave. Surveyor asked how many residents were attending the activity at the time, V3 stated, It was around 25 residents. On 6/11/24 at 11:45 AM, V4 (CNA) stated, I came to the dining room where they were having activities and V6 (CNA) called me over to help get a resident back up from his recliner. She (V6) told me the patient (R2) was near the ground, so I helped boost him back up. His leg was twisted under his other leg and looked like it got caught under the chair and he didn't have a leg protector or leg rest on him form keeping him from sliding which he should have had. We told the nurse what happened, and she came and assessed the resident (R2). On 6/11/24 at 11:50 AM, V6 (CNA) stated, I was not (R2)'s aide that day, I was just the one helping (V4-CNA) pull the resident up. His leg was bent because he slid down to the bottom of this recliner chair. He didn't have a foot rest, so he slid down and he got his leg caught from under the chair. Surveyor asked V6 to accompany surveyor to R2's room to look at the chair used. V6 pointed to the recliner which appeared more like a high back wheelchair. V6 pointed to the foot rest now resting on top of the chair. V6 stated, That was not on the chair at the time we scooted him up from the bottom of the chair and it should have been put there otherwise he wouldn't have slid down and bent his leg. On 6/12/24 at 10:55 AM, V8 (RN) stated, (R2) was sitting in the dining room around after 1:00 PM but I was on my break when the activity aide (V4) came and told me that the resident slid down on his knees to the reclining chair with his right knee bent backward. I assessed the patient and checked for pain, redness or edema. (R2) nodded he was in pain, so I gave Tylenol. We took him with mechanical lift to bed, but I didn't notify anyone that it was a fall, but I know now it was because the DON (V2) told me. Later on, the morning time the night shift found edema on the resident so they called the doctor and so they sent the patient out to the hospital, and they found the right leg or ankle was fractured. He came back. he was non weight bearing. He was total assist, but he was a low fall risk. Surveyor asked what fall preventative measures were taken to keep R2 safe, V8 stated, We do the rounds, and we keep him in bed at the lowest position and checking on the patients' needs. He's incontinent and knows how to pull the call light. He's nonverbal and alert and oriented times two. (R2) came back from the hospital after 4 or 5 days in the hospital then he fell from the bed because the bed could not be lowered, I guess due to mechanical failure I was told. On 6/12/24 at 12:05 PM, V25 (CNA) stated, He's (R2) very quiet patient and he is a 2-person assist with a mechanical lift. He needs help with feeding and incontinence, and right sided paralysis. We get him up every day on recliner chair. I put him in the dining room, but he was not a fall risk. I was supposed to be in dining room watching the residents, but I had to help another CNA, so I left, but I should have asked somebody to come to sit and watch. Hospital record dated 5/24/24 12:53 PM, written by emergency room doctor (V26) reads in part, (R2) is a [AGE] year old male who is being seen for right leg pain. Per nurse, he is confused at baseline. He is Spanish speaking. He lives at nursing home and was brought here for evaluation of his right leg. It is currently in a post mold. Indication: trauma (fracture). Findings: Comminuted fractures of the proximal tibia and fibula are identified. Hospital record for the second fall and emergency room visit dated 6/5/24 reads in part, Patient is a [AGE] year old male presenting to the emergency department from a musing home after being found down. Per EMS patient is currently at his baseline. Patient mumbles, does not answer questions, does not follow commands. No acute intracranial process or significant interval change when compared to prior CT head dated 5/24/24 (previous admission). Stable subdural hematomas bilaterally, right greater than left. Policy revised on 7/2023 titled Fall Prevention reads in part, The intent of this policy is to provide an environment that is free form accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. Residents shall be evaluated by a licensed nurse during the admission process, routinely and as indicated to identify potential risk of fall. The interdisciplinary team shall identify individualized interventions to reduce the risk of falls.

Based on interview and record review, the facility failed to adequately supervise one (R73) resident who has a history of falls and required staff supervision/assistance with all Activities of Daily Living (ADLs). This failure affected one resident (R73) of seven residents reviewed for accidents and resulted in R73 being diagnosed with a displaced nasal bone fracture. Findings include: R73 is a [AGE] year-old- female who was admitted to the facility on [DATE]. Past medical history includes, but not limited to, progressive supranuclear, dystonia, hyperlipidemia, unsteadiness on feet, need for assistance with personal care, anxiety, essential primary hypertension, etc. R73 has had three falls since January 2024. On 1/16/2024, R73 had an unwitnessed fall while at the nursing station. On 2/16/2024, R73 was found face down while at the nursing station and sustained some injuries on both knees, fall was unwitnessed. On 3/10/2024, R73 was found on the floor in activities room, was sent to the hospital and was treated for a minimally displaced nasal bone fracture. On 4/29/2024, R73 was observed in her room, awake and alert, but unable to answer any questions. Bilateral floor mats noted in the room. Oxygen concentrator noted at bedside but not connected toR73. No broader chair or Geri-chair noted in the room. On 4/30/2024 at 9:50AM, R73 was observed again in bed on a concave mattrass. R73 was lying on her back with floor mats on the floor. There was no wheelchair, broader chair or Geri chair noted inR73's room. Fall care plan dated 3/26/2023 stated R73 is at risk for fall related to decreased safety awareness. Interventions include closely monitor when in room, offer her to sit in recliner after lunch (6/24/2023), try to keep near nurses' station and keep her involved in things she likes. Minimum data set assessment (MDS) section GG (functional status) indicated R73 requires partial/moderate assistance to substantial/ maximal assistance from staff for all ADL needs. MDS section C: 2/6/2024 BIMS - 10 indicating cognitive impairment. Facility reported incident dated 3/15/2024 documented R73 was found on the floor on 3/10/2024 at 2PM. Upon head-to-toe assessment, R73 was having nose bleeding, first aid was provided, andR73 was sent to the emergency room and returned to the facility with a diagnosis of nose fracture, facility started an investigation. CT facial bones without contrast from the hospital dated 3/10/2024 showed a minimally displaced nasal bone fracture. Review of all staff statements indicated that no one witnessed the fall except the activity aide. On 05/01/24 at 11:25 AM, surveyor observed R73 in bed with the assigned nurse and V12 (R73's POA) at the bedside. V12 stated, she is usually at the facility every day and has a lot of issues with the care the R73 is receiving. V12 (POA) said, R73 had so many falls because the facility always put her in the activities room or the nursing station. V12 said, R73 likes to stay in her room and watch TV, but facility stated they do not have enough staff to watch her, and they do not provide 1:1 supervision. V12 said, she has consistently asked the facility to put R73 in a broader chair when she is out of bed instead of a regular wheelchair. The facility provided a broader chair for a while, and it disappeared. V12 said, the last fall R73 had with a nose fracture happened because the staff in activities room did not want to watch R73 and told the nurse to take R73 with her. V12 said the facility stated R73 jumped out of her wheelchair but R73 has unsteady feet and weakness in her lower extremity and there is no way she can jump out of her chair. On 05/01/24 at 2:33 PM, V2 (DON) said she is familiar with R73. R73 is unsteady, a high fall risk and requires 24 hours seven days a week 1:1 supervision. V2 said, one of the interventions the facility has in place for R73 is for her to be monitored closely. R73 is always at the nursing station or activities, but for some reason, R73 always falls when the staff is not looking. V2 said The staff can turn around and the next thing, R73 is on the floor. V2 added, R73 is not able to jump out of her wheelchair but tries to slide out of her chair. On 5/2/2024 at 10:13AM, V19 (C.N.A) said that she is familiar with R73, she is calm and sometimes tries to crawl out of bed. V19 said R73 is a fall risk and requires constant supervision. V19 stated R73 had three different fall incidents on 3/10/2024. The first time she slid out of her wheelchair to the floor while in the hallway. The second time, an activity staff saw R73 slid out of her wheelchair to the floor while at the nursing station and the third time R73 was found in the floor face down in the dining room. V19 added R73 was in a regular wheelchair for all the three incidents. On 05/02/24 at 10:26AM, V16 (Activity aide) said, she was in the activity room on 3/10/2024 when R73 fell and sustained an injury. V16 was watching R73 in activity and told the nurse that V16 could not watch R73. V16 said the nurse was leaving the room, R73 followed the nurse in her wheelchair and before V16 could reach R73, she fell face down from her wheelchair. V16 added, there were 20 to 25 residents in the activities room, and V16 cannot watch all of them. Fall policy provided by V2 (DON) with a revision date of 01/2026 states in its policy statement that the purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Under policy details, the document states in part that the fall risk assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process. A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident's clinical record. The falls should be reviewed at the daily stand- up meeting following the fall for identification of additional individualized interventions to reduce the risk of falls.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse prevention by not ensuring an agency staff received a thorough criminal background check, not identifying a resident's behaviors that increase their risk for abuse, and not ensuring an abuse risk or behavior care plan was developed for a resident with a history of refusing care. This failure applied to one of one (R1) resident reviewed for abuse and resulted in R1 being physically and verbally abused and sustaining physical and psychosocial harm. Findings include: R2 is an [AGE] year-old female with a diagnoses history of Cerebral Infarction, Aphasia, Partial Paralysis due to Cerebral Infarction, Dysphagia, and Adult Failure to Thrive, and Major Depressive Disorder who was admitted to the facility 07/08/2020. On 02/26/2024 from 2:38 PM - 2:55 PM Observed R2 in her room sitting up in her bed with her head down in front of a meal tray laying on a bedside table over her bed. Observed R2 could not communicate verbally. Observed R2 to communicate through gestures, nods, and sounds. Observed R2 push her tray towards surveyor not wanting to eat it. Observed R2 to be agitated and nearly knocking her tray to the floor before surveyor caught it. Surveyor handed R2's tray to V25 (Agency Certified Nursing Assistant). V25 stated R2 is not interested in eating her meal. V25 stated R2 is highly agitated and is often that way. Observed R2 exhibit agitation in the form of pulling her call light button and bed remote aggressively towards her chest and gesturing and making sounds indicating refusal of V25's offers when attempting to adjust her bedside table and ask what her needs were. Observed V25 plug back in R2's call light. V25 stated R2 pulls out her call light. Observed R2 press her call light multiple times. Observed V10 (Unit Secretary) respond to R2's call light. Observed V10 redirect R2 not to try and get out of her bed. Observed R2 respond to V10 with head nods and pointing in an agitated manner when being redirected. V10 stated she had been to R2's room at least 8 times because she keeps pressing the call light. R2's social service progress note dated 10/13/2023 documents upon notification of immediate care concern social services contacted V29 (Family Member) regarding nature of concerns. V29 reports that V29 understands R2 does refuse care at times and can be a little tough to deal with since her stroke. R2's Full Care Plan does not include refusal of care or behaviors. R2's Care plan initiated 05/23/2023 documents R2 is experiencing new symptoms of depression without a description of what those new symptoms of depression are with interventions including observe R2 for changes in mood status. Incident Investigation report dated 10/13/2023 documents on 10/13/2023 two student CNA's (Certified Nursing Assistant) who were at the facility notified their instructor they witnessed a CNA being rude to R2 while giving her care. The instructor notified the DON (Director of Nursing) around 2:30 PM. The alleged CNA V19 (Agency CNA) was interviewed by the Director of Nursing and Administrator and denied hitting R2. During a head-to-toe assessment R2 was observed with a fading light purplish skin discoloration on the right wrist with a surrounding yellow hue, a dried scab was also noted on R2's right forearm. R2 is unable to communicate verbally, has right sided partial paralysis due to stroke. R2 is interviewable and through non-verbal communication indicated V19 hit her on the arm and began to cry. An order for x-ray of right wrist was given and was negative for fracture or dislocation. The two CNA students who witnessed the incident were interviewed by the administrator and the director of nursing along with the clinical instructor. V21 (Student Certified Nursing Assistant) reported he observed CNA strike R2 multiple times on R2's forearm and observed the CNA asking R2, why are you always like this. Do you want me to leave you?. V21 stated V21 observed the CNA laughing at the resident causing her to cry. V20 (Student Certified Nursing Assistant) reported he did not observe the CNA hitting R2. The CNA did not assist R2 with getting out of the toilet and used force to make her get up. Law enforcement was notified, and a report was made. It was concluded that based on R2's interview and witness interviews from V20 and V21, the facility can substantiate physical abuse by V19 and V19 is no longer working at the facility. Witness statement dated 10/13/2023 from V20 (Student Certified Nursing Assistant) documents he observed the CNA be very rude towards R2 including laughing at her when she struggled on the toilet, not helping her properly transfer from toilet, using force to make her get up, continuing to force her to get up while she screamed in pain. R2 was very upset after all that occurred. Witness statement dated 10/13/2023 from V21 (Student Certified Nursing Assistant) documents the CNA struck R2 multiple times on her forearm, insulted her stating, Why are you always like this?, and threatened R2 stating Do you want me to leave you? Serious Injury Incident Report dated 10/13/2023 documents R2 was the victim of alleged abuse, Agency Certified Nursing Assistant V19 was terminated. V19's (Agency CNA) Personnel file reviewed 02/28/2023 does not include IDOC (Illinois Department of Correction) criminal background check, or Fingerprinting background check. On 02/29/2024 at 9:44 AM V1 (Administrator) stated agencies complete background screens but not fingerprints for their staff. V1 stated the facility does not have a policy for screening agency staff. V1 stated the staffing coordinator reaches out to agencies for staffing and there is a coordination with leadership to bring in the right staffing to the building. V1 stated most of the agencies have a platform where you can find background information for all the staff who have been screened and credentialed. V1 stated all the screening information available from the agency for V19 was in his personnel file. On 02/29/2024 at 11:26 AM V1 (Administrator) stated social services handles completing abuse risk assessments for residents. V1 stated if a resident is determined to be at risk for abuse, they should be care planned for abuse risk. V22 (Director of Quality Control/Registered Nurse) stated the facility educates staff regarding abuse and neglect so he doesn't believe there is anything further that could have been done to prevent the abuse incident for R2. V22 and V3 (RN/Nurse Manager) stated they conducted a background check on V19 (Certified Nursing Assistant) and there is no way to tell if a staff member is going to be abusive to residents. On 02/29/2024 at 12:08 PM V26 (Social Services Director) stated there are no assessments to determine if residents are at risk for abuse. V26 stated if we determine a case of abuse took place on site social services would do a screening to determine if any other residents were at risk for abuse. V26 stated abuse risk assessments are performed as needed. V26 stated risk factors that would increase a resident's likelihood of being abused include a psychiatric history of being abused, history of substance use, any behaviors such as anxiety, anger, fear, withdrawn behavior. V26 stated all the social factors that involve a history of abuse would be the same social factors that would potentially increase a resident's risk of being abused especially if there are changes in a resident's behavior. V26 stated agitation would not necessarily be a risk factor of abuse. V26 stated if a resident has an indicator of agitation which is a comorbidity of mental illness that would not necessarily be a risk factor for abuse. V26 stated R2 has periods of refusing care, can be agitated at times, and has a diagnosis of major depressive disorder. V26 stated when R2 is agitated she refuses care at times, presents with a sad affect, exhibits anxiety all of which are part of her mental status and would not necessarily be an indicator or risk factor for abuse. V26 stated when R2 refuses care it presents as agitation, combativeness, not wanting to be bothered, pushing things away if you try to hand them out to her, sometimes she pretends to sleep. V26 stated these have been her personal observations of R2. V26 stated she doesn't want to believe that R2's behaviors could lead to abuse because that would be very concerning. V26 stated a behavior care plan is developed for resistance to care. V26 stated one instance of exhibiting these behaviors would not warrant a care plan, multiple observations would be required before it is care planned. V26 stated if there is a care plan missing regarding R2's refusal of care it would possibly be because she is still under observation for those behaviors, and we complete quarterly updates to care planning. V26 stated within that quarter there would need to be at least three observations of this behavior before it is care planned. V26 stated behavior observations can be communicated verbally or in writing. On 02/29/2024 at 2:06 PM V29 (Family Member) stated R2 had a stroke and has these seizures and there's times where she can be mean which is usually during the times seizures come. V29 stated R2's been this way a number of years. V29 stated R2 had a stroke [AGE] years ago. V29 stated the facility has reported to him periodically that R2 refuses care at times and one of the most recent reports of this was three or four months ago. V29 stated he would say R2's refused care a few times over the course of the years she's been there. V29 stated he used to be able to have some influence over this behavior and calm her down when he was able to visit her more consistently. V29 stated he would redirect R2 not to behave that way. The facility's Abuse Prevention Policy received/reviewed 02/28/2024 states: Our residents have the right to be free from abuse. The objective of the abuse policy is to comply with the seven step approach to abuse detection and prevention. The community's goal is to achieve and maintain an abuse-free environment. As part of the resident abuse prevention program, the administration will provide a safe resident environment and protect the residents from abuse by anyone including, but not limited to: community associates, associates from other agencies. It is the policy of this community to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Will not knowingly employ or otherwise engage any individual who has: Been found guilty of abuse or mistreatment by a court of law; Had a finding entered into the State nurse aide registry concerning abuse or; Had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse or mistreatment of residents. The community will provide training for associates at new hire orientation and through ongoing programs that include, but not limited to, such topics as: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: a. Aggressive reactions of residents; c. Resistance to care.

Based on interview and record review, the facility failed to administer physician ordered pain medication consistent with professional standards of practice for a terminally ill resident (R1) of 3 residents reviewed for pain management. This failure resulted in R1 crying and yelling out in extreme pain. The facility also failed to administer pain medications after an unwitnessed fall after showing signs of pain (moaning) and led to adverse consequence of transfer to an acute hospice facility. Findings include: R1 is an [AGE] year-old hospice resident with diagnosis of acute cerebral hemorrhage, congestive heart failure, chronic obstructive pulmonary disease, and chronic back pain. On 1/19/24 at 11:50 AM, V2 (Director of Nursing) was asked for R1's care plans. A review of care plans received from V2 did not have a care plan specific to pain management. Surveyor verified with V2 whether all care plans were received as requested, V2 stated, Yes. I gave you everything. Surveyor asked if pain management was part of the facility's and/or hospice responsibilities, V2 indicated that hospice's goal was for palliative care and to keep residents as pain-free as possible. R1's Physician orders dated 1/11/24 shows in part, Admit to hospice. No hospitalization . Comfort care medications: 1. Tylenol every 4 hours PRN (as needed), Morphine 5 mg or 0.25 ML every hour as needed for pain. 2. Morphine 10 mg or 0.5 ML every hour as needed for increased pain. 3. Lorazepam 0.5 mg or 0.25 ML every 2 hours as needed for anxiety (sign of pain). 4. Lorazepam 1 Mg or 0.5 ML for increased anxiety. 5. May give Lorazepam 0.5 mg or 0.25 ML for sleep as needed. 6. Screen for pain every shift and record using 0-10 scale; Monitor for occurrences of anxiety; Monitor for side effects of anti-anxiety every shift. On 1/19/24 at 2:45 PM, V6 Hospice RN stated, I'm the hospice nurse and when I accessed (R1) she was crying and yelling out and very agitated. I asked the nurse on duty at the time (V15) if she had given R1 anything for agitation or for pain, V15 indicated she had given R1 morphine in the morning around 10:30 but hadn't given it on an hourly basis as needed. V15 wasn't even aware the patient had an order for Lorazepam until I asked her to give it to the resident. From what V15 told me, they didn't seem to be giving the patient any anti-anxiety medications at all since R1 was admitted . I don't think they were even accessing her pain as ordered. Surveyor asked what the signs of pain were, V6 stated, Increased agitation would be a clear sign that the resident was in pain. Efforts to reach V15 were met with no return calls to speak with surveyor. Hospice clinical notes dated 1/14/24 at 4:36 PM authored by V6 (Hospice RN) shows in part, Received patient in highly agitated state. Patient yelling out and crying. Requested that staff administer Lorazepam and Morphine. Patient is confused continuously. Non-verbal. Son reports that patient has not been eating in more than eighteen days. Little fluid ingestion. Oxygen 2 liters by nasal cannula. Patient is combative during assessment. Pushing writer away. Writer unable to redirect patient. Contacted doctor for orders to transfer patient to the acute hospice facility for agitation exacerbation. Facility not administering medication as ordered. Patient was highly agitated this AM. Staff at facility reports that patient had an unwitnessed fall where she was found face down on the floor at the side of her bed. Staff is unaware how long the patient was in that position and did not notify hospice primary care triage that patient had fallen. Son reports that patient has been highly agitated for days. Staff at the facility was asking son what medications (R1) patient was to receive. Pain Assessment score 7/10. Lorazepam (for agitation): No administration today or yesterday. Morphine Sulfate 0.25 ml 1 time today and 1 time yesterday. On 1/19/24 at 1:15 PM, V16 (family) stated, I'm currently at my mom's funeral so I can't talk long. If you speak with the hospice nurse (V6), she can tell you the problems I had when I came to visit my mom. I was very upset with the home because no one seemed to be managing (R1) very well. She was very agitated and screaming out and no one seemed to notice or care. When I got there the first day, the nurse didn't seem to know what to do or what to give my mom. I called the hospice agency right away to get over there to ensure that home knew what they were doing. On 1/19/24 at 1:22 PM, interview with V3 (LPN) was asked about R1's fall incident and interventions. V3 stated, I work night shifts and I was passing my medications which I started at 5 in the morning, when I got to R1's room around 6:15 AM, I didn't see R1 in bed and I heard moaning so I went in the room and she was face down on the floor next to her bed. The last time I saw her was around midnight when I assisted the CNA (V4) to turn her so she could be changed. Surveyor asked if R1 was at risk for falls, R1 indicated she was not aware of her fall risk status. V3 stated, I just know that she is on a specialty air mattress for her skin, so I guess that could cause her to fall. Surveyor asked if she was considered a fall risk, what fall precautions the facility would use, V3 stated, I'm not sure, I didn't have her long. Surveyor asked if she was provided any specific instructions on how to care for R1, V3 stated, I didn't get special instructions, I just know that she is hospice. Surveyor asked V3 if she was certain she last saw R1 around midnight, V3 stated, Yes it was either 12 or near that time. Surveyor asked what the standard would be to monitor residents, V3 stated, Well it's every two hours but I'm the only nurse at night on the floor and I only have one CNA. Surveyor asked if she had given R1 anything for pain since R1 was found on the floor face down and moaning, V3 stated, No. I didn't give her anything. A review of R1's MAR (medication administration record) affirmed V3's statement and showed no pain medications or anti-anxiety medication were provided throughout V3's shift to the resident either before or after R1's fall. R1's medication administration records during her stay at the facility showed Lorazepam given once by V15 (RN) when the hospice nurse asked her to give it to the resident. Morphine pain medication was administered on the last day of R1's stay (1/14/24) and on the previous day (1/13/24) but given only once for the entire 24 hours. There were no other administration of pain medications including Tylenol being administered for R1 to keep the resident comfortable and pain free. Hospice policy dated 12/2017 titled Hospice Program reads in part, Hospice providers who contract with this community are held responsible for meeting the same professional standards and timeliness of service. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/resident representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. Pain Policy dated 12/17 titled Pain Assessment and Management reads in part, The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that addresses the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: Evaluating the potential pain; Effectively recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the pain. Recognizing pain: Verbal expressions such as groaning, crying, screaming.

Based on interview and record review, the facility failed to follow residents' plan of care by not monitoring a resident (R1) at all times and keeping the resident free from injury; and failed to conduct a proper resident transfer by utilizing only one staff member for a resident (R3) assessed to require two staff members for transfers. These failures applied to two (R1, R3) of three residents reviewed for resident injury and resulted in R1 having an unwitnessed fall in room and obtaining a left wrist fracture and R3 obtaining a right ankle fracture during improper transfer. Findings include: 1. R1 was admitted to the facility with diagnoses that include: cerebral infarction, heart failure, Parkinson's disease, difficulty in walking, and need for assistance. R1 is no longer in the facility and expired on [DATE]. R1's current care plan documents the following: Problem Onset: [DATE] - (R1) is at risk for falls due to decreased safety awareness, decreased strength and endurance, decreased mobility, impaired balance, unsteady gait, h/o CAD, HTN, CHF, DM, dyspepsia, hypocalcemia, carotid stenosis with hx of carotid endarterectomy, anemia, a-fib, GI bleed, CVA, Parkinson's, arthritis, thyroidectomy, s/p hosp for non-radiating left chest pain at rest, associated SOB Approaches include: Orient resident/significant other to environment and how to call for assistance, keep equipment within reach (i.e., call bell, phone, urinal, etc.), and educate resident and family regarding safety issues and risks for falls. Other care plan interventions include: assign staff to account for resident whereabouts at all times. On [DATE], R1 had a fall in the facility in her room. Facility submitted final incident report that reads: On [DATE] around 5:45 pm, the roommate of the resident (R1) alerted the nurse on duty (NOD) that (R1) was found on the floor. The NOD immediately rushed to the room and noted (R1) sitting on the floor in her room against the wall with her hands embracing her body. The NOD immediately performed a head-to-toe assessment and noted some swelling to her left wrist. (R1) agreed to having pain to her left wrist when palpated. No bruises or skin tears noted on the exam. First aid was provided and (R1) was transferred to her bed with 1 person assistance. (R1) was made comfortable, fall precautions maintained and care plan updated. MD notified with orders to send (R1) to the ER. Daughter made aware. (R1) was transferred to (local) hospital ER via ambulance transfer on [DATE] at 5:55pm. (R1) was discharged from theER on [DATE] and was admitted back to the facility at around 9am on [DATE] with a diagnosis of left wrist closed fracture. (R1) has a posterior mold applied to her left wrist. Facility immediately started an investigation. Conclusion: Based on the investigation, chart review and staff interviews, it was determined that the fracture had resulted from the fall. Care plan was updated with new fall interventions in place. All staff were educated on fall prevention. The NOD on [DATE] was V10 (RN). (V10) was interviewed and per (V10), (R1's) son visited R1 on [DATE] around 4pm, left (R1) in her bedroom alone in a wheelchair and left the building without informing any staff. The last time (V10) saw (R1) prior to the incident was when R1 was with her son and (V10) thought (R1) was with her son. Incident witness statement dated [DATE], written by V10 (RN), reads: When I am passing the medication in the hallways, one of my residents called me to her room. When I went to her room, the resident was on the floor in a sitting position. Leg extended and her hand braced her body. I called other nurse to put her in the bed. Head to assessment done. Noticed left hand wrist swelling. Informed doctor. Sent to (local hospital). [sic] Root cause analysis for incident dated [DATE] at 5:45PM, completed by V10 (RN) documents, Resident (R1) was trying to stand from wheelchair and trying to walk to her room and fell near chair and was in wheelchair; intervention most appropriate is listed as close supervision. [DATE] at 9:50AM, V1 (DON) stated, I don't know too much about (R1), but I do know that she was a frequent faller. We tried to keep her near the nurses station and monitor her at all times. She should have been monitored every hour; we don't document that anywhere. There are assigned CNA's when they are in the dining room to keep an eye on the residents. In this instance, it does look like she fell by trying to get up from her wheelchair. Even if we would tell her not to stand up by herself, she would do it anyway. 2. R3 was admitted to the facility with diagnoses that include: multiple sclerosis, obesity, overactive bladder, and insomnia. Per MDS dated [DATE] and [DATE], R3 requires extensive assistance, one-person physical assist. Interview with V14 (RN/Restorative) on [DATE] at 12:50 PM, confirmed the MDS was coded as one person assist in error. V14 provided copy of R3's care card (undated) that shows resident is two person assist for transfers and bed mobility; but since she fell , now she requires a mechanical lift. V14 added that moving forward the care cards should be dated. R3's current care plan documents the following: Problem Onset: [DATE] - (R3) requires extensive assist with ADL's, due to decreased strength and endurance, decreased balance, decreased mobility, unsteady gait, h/o overactive bladder, insomnia, MS, mood disorder, T12 and L3, compression fx, resident transferred to [NAME] from another SNF due to onset of progressive weakness secondary to MS. Approaches include: [DATE], 2 staff members to assist with transfers, and [DATE] educate patient 'to call, don't fall' (sign on the wall), and toilet patient before and after meal; offer to use toilet before going to bed. On [DATE], R3 had a fall in the facility in her room bathroom. Facility submitted final incident report that reads: (R3) complained of right ankle pain and swelling on [DATE]. MD was notified with orders for an X-ray of the right ankle. The X-ray was taken on [DATE] and the results were received on [DATE] which showed acute displaced trimalleolar fractures with ankle malalignment. MD was notified of X Ray results. MD gave orders to send (R3) to (local hospital) ER and the resident got admitted at the (hospital) on [DATE] with right trimalleolar fracture. Family was notified. The facility immediately started an investigation. Investigation: (R3) is alert and oriented X4. (R3) has multiple sclerosis and has right lower extremity weakness. As a part of the investigation, we conducted staff interviews and chart review. The CNA (V15) who took care of the resident on [DATE] was interviewed. Per (V15), the resident asked her to help her with changing and preparing her for bedtime around 8pm. (R3) indicated that she would like to use the restroom prior to going to her bed. (V15) assisted (R3) to transfer her to the toilet. After (R3) used the toilet, she informed (V15) that she was finished. (V15) assisted (R3) to get up from the toilet with (R3) holding on to the railing. (R3) informed (V15) that she was feeling fatigued and was not able to continue standing and needed to sit down. (V15) offered (R3) assistance to transfer her to the wheelchair that was placed next to her but (R3) remained immobile and verbalized her concerns of falling. (V15) immediately lowered (R3) to the floor in a sitting position and called for assistance. With the assistance of another CNA, (V15) safely transferred (R3) to the wheelchair and returned her back to her bed. (V15) immediately notified the nurse on duty (NOD) about what had happened. The NOD completed an assessment and (R3) complained of having right ankle pain and swelling. Upon interview, (R3) told the NOD I did not fall but I may have twisted my ankle when I moved, I am not sure. The NOD immediately provided first aid to (R3) and notified the MD. The MD gave orders for an Xray of the right ankle and pain management with Tylenol. The X Ray was taken on [DATE] and the results were received on [DATE] which showed acute displaced trimalleolar fracture with ankle misalignment. The MD was notified of X Ray results with orders to send (R3) to (local hospital) for further evaluation and treatment. Family was notified. (R3) got admitted at local hospital on [DATE] and had a right ankle open reduction and internal Fixation (ORIF) done on [DATE]. (R3) returned back to the facility on [DATE] with orders for non-weight bearing to the right foot. (R3) will follow up with MD (ortho surgeon) in 2 weeks on [DATE]. Conclusion: Based on the investigation, it was noted that (R3) was eased to the floor while she was assisted during transferring from the toilet to the wheelchair. During the process of transfer, she may have twisted her ankle which may have resulted in the right ankle fracture. The facility couldn't substantiate any form of abuse or neglect. Incident witness statement dated [DATE] written by V18 (RN) documented, V18 did not witness fall but that around 9:30PM CNA approached her that resident was complaining of right ankle pain. V18 documented, resident (R3) complained of pain to touch (ankle). Per CNA, resident was lowered to the floor during transfer because she was heavy, then CNA had to call for help. Incident witness statement dated [DATE], written by V15 (CNA) reads: On Friday, [DATE], during my ,d+[DATE] shift at Ascension Living Resurrection Place, I provided care to (R3) at approximately 8 PM. (R3) expressed her desire to retire to her room for the night. Consequently, I accompanied her to her room to assist with changing and preparing her for bedtime. Upon arriving in her room, (R3) indicated that she needed to use the restroom. In response to my inquiry, she affirmed her ability to stand for a brief period. I proceeded to assist her in transferring to the toilet, which involved helping her stand, lowering her pants, and seating her on the toilet. She spent approximately 2 minutes on the toilet before informing me that she was finished. I assisted her once again in rising from the toilet, providing support as she held onto the railing. It was at this point that (R3) expressed fatigue and an inability to continue standing, stating that she needed to sit down. In response, I suggested that we turn her toward her wheelchair so she could sit on it, reassuring her that I was holding her securely. However, (R3) remained immobile, reiterating her inability to support herself and her fear of falling. Despite my efforts, I was unable to lift her due to her weight. In light of the situation, I suggested that she sit on the restroom floor while I sought assistance from another CNA to aid in her return to the wheelchair. After carefully placing (R3) on the restroom floor, I promptly summoned the assistance of another CNA to facilitate her safe transfer back into the wheelchair. Once (R3) was comfortably seated in her wheelchair, I assisted her in returning to her bed. Before leaving her room, I inquired about her well-being, to which she responded in the affirmative. Subsequently, I provided her with the call light in the case she may require any further assistance. I subsequently reported the incident to the nurse responsible for the wing, who acknowledged the information. A few minutes later, (R3) utilized her call light to request assistance with her foot, which she stated was hurting. I inquired about the cause of the discomfort, and she mentioned that she believed she had twisted it. I promptly informed the nurse, who conducted an examination to assess (R3's) condition. [sic] Nursing Progress Notes document the following: [DATE] 12:47 AM LATE ENTRY [DATE] 9:30 PM Resident lying in bed complained of pain on right ankle. Resident states she might have twisted her ankle. No bruise, or redness, swelling is more than the left ankle. Doctor was paged with order to do x-ray of the right ankle. And Tylenol 650 mg po every 6 hours as needed for pain. [DATE] 7:28 AM 11PM- 7AM shift late entry: Patient noted with swelling and tenderness on the right ankle. She verbalized that it is painful when she moves it. No redness, skin intact. Pain/discomfort is alleviated with rest and keeping her leg still. x-ray of right ankle scheduled to be done today. Endorsed to oncoming nurse. [DATE] 11:29 AM 1025AM: Followed-up with (x-ray company rep) for right ankle x-ray result. 1040AM: Right ankle X-ray result received with impression acute, displaced trimalleolar fractures with ankle malalignment. Orthopedic consultation is recommended. Relayed to Doctor with order to send to (local hospital) ED for further evaluation and treatment. 10:42AM: Informed resident and she is amenable to be sent to (hospital) ED. 10:47AM: Attempted to call daughter, but phone is not accepting any calls. 10:48AM: Called (ambulance services) - ETA between ,d+[DATE] minutes 11:10AM: Called local hospital ED c/o (staff name) - gave report. 11:30AM: EMS 2 persons arrived to pick up resident. 11:40AM: Left the unit Addendum [DATE] 2:16 PM On [DATE] at 4:11PM, V18 (RN) re-affirmed what she documented in her statement and added that the CNA (V15) transferred the resident from the toilet to the wheelchair by herself and that she couldn't do it because the patient is heavy. There should be two CNA's; R3 has MS (multiple sclerosis) and uses a wheelchair. R3 was given pain medication. Review of x-ray report for R3 dated [DATE] documents R3 had an acute, displaced trimalleolar fracture with ankle malalignment of the right ankle; orthopedic consult was recommended. Facility provided policies: Fall Policy dated ,d+[DATE] reads: Policy Statement/Overview The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Policy Detail 1. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls during the admission process. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall. 2. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall notify the resident's Attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record. The falls should be reviewed at the Daily Stand - up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs. Falls Prevention dated ,d+[DATE] reads: Policy Statement The intent of this policy is to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. 1. Fall Risk Evaluation Residents shall be evaluated by a licensed nurse during the admission process, routinely and as indicated; to identify potential risk of fall. If the resident scores a higher risk for falls, the resident shall be placed on the Falling Star Program. II. Fall Risk Intervention the Interdisciplinary Team shall identify individualized interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the associates may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 1. Falling Star Program Residents identified as members of the Falling Star Program shall have: a. A star placed next to the nameplate outside the resident room. b. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. c. If falling recurs despite initial interventions, associate shall implement additional, different interventions, or indicate reason the current approach remains relevant. This documentation should be maintained in the clinical record. 2. Graduation from the Falling Star Program a. The interdisciplinary team may identify residents who previously scored at a higher fall risk to consider if there is a benefit of maintaining the resident on the Falling Star Program. To be considered for graduation: 1. The resident should not have a fall within 6 months of the evaluation or no change in Psychotropic Medications in past 90 days or no orthostatic hypotension within 6 months of evaluation. it. Previous indicators identified as High Risk for a fall may be resolved or identified interventions are effective. b. Interdisciplinary Team shall review residents current status and determine whether graduation from program is indicated c. Interdisciplinary Team shall review care plan interventions to be maintained post-graduation.

Based on interview and record review, the facility failed to provide care and services in a timely manner for residents with suspected injuries, who had orders for x-rays and resulted in delay of treatment for injuries. This failure applied to two (R2, R3) of three residents reviewed for resident injury and resulted in R2 and R3 waiting over 24 hours after injury to be transferred to hospital for further evaluation and treatment of fractures. Findings include: 1. R2 was admitted to the facility with diagnoses that include: Parkinson ' s Disease, difficulty walking and gastrostomy tube. Facility provided incident report for incident on 7/28/23, which documented the following: (R2) is AxO (Alert and Oriented) x0. BIMS score of 99. On 7/28/23 around 12:15pm, the resident's daughter notified the nurse that her mother (R2) was yelling when she grabbed her right ankle. Nurse immediately assessed the resident's right ankle and notified the Nurse Practitioner who ordered an Xray of the right ankle. The X Ray results came back on 07/29/23 which showed acute right ankle fracture and marked osteopenia and DJD of the right ankle. Resident's PCP was notified, and he gave orders to send the patient to (local hospital) for further evaluation and treatment .Facility immediately started an investigation. R2 returned from hospital the same day with orders for CAM Boot to the right foot and recommendations for non-weight bearing of the right lower extremity, and to follow up with an orthopedic clinic in 1 week. As a part of the investigation, we interviewed staff and residents, and conducted a chart review. Staff interviews revealed no noticeable changes to patients' right ankle while providing care prior to 7/28/23. However, staff did note that R2 is impulsive and restless in bed all the time with multiple attempts to exit from the bed .Conclusion: Based on the patient's diagnosis of primary osteoarthritis of right ankle and foot, disorder of bone density and structure of right ankle and foot, X-ray results from 7/28/23 indicating marked osteopenia and DJD of right ankle, and calcium level of 8.2 on 7/19/23, (R2) is at a higher risk for pathological fractures. Based on the investigation, staff and resident interviews, the facility could not substantiate any type of abuse or neglect . Nursing Progress Notes document the following: 7/29/2023 7:55 PM Nursing Notes for R2: LATE ENTRTY 7/28/23: At 12:15pm Patient's daughter approached this charge nurse on duty at nursing station to say that patient is yelling when right ankle is grabbed. Ankle was assessed, at the time no redness, discoloration or swelling noted on ankle. Informed and NP ordered a STAT ray of the right ankle to be performed. Called (x-ray company) portable to put in new order for x ray. Relayed information to nurse taking care of patient and Manager on duty notified. 7/29/2023 10:03 PM Nursing Notes for R2: LATE ENTRY, at 7:45 am. X-ray technician came and did x ray to her (R2) right angle. Her vitals are stable (BP-123/78 MMHG, P 76B/M, R 18b/m, temp 98f. At 11am her son came and put her in the wheelchair with the help of the CNA. The POA went to the small dining room with her and fed her lunch . After two hours (R2) was put back to the bed. The x-ray result came through fax (approx. 1:00 pm 7/29/23). The supervisor paged doctor to inform of the X-ray result, but no response. After that, supervisor called the doctor's phone and informed her of result. Send to the ER for further evaluation. Informed the manager on call and DON by supervisor. Ambulance took her (R2) to (hospital). ER (according to the paramedic she has hypotension on the way to ER) informed the POA also regarding the hospital transfer. The writer gave the report to the ER doctor also. 7/29/2023 11:09 PM Nursing Notes for R2: At 6 pm the writer and supervisor assessed the resident's right ankle. There is no redness or swelling in the right ankle. Informed the on-call manager and DON also. 7/30/2023 1:47 PM Nursing Notes for R2: The resident came from (hospital) at 11.15 am via ambulance. Vitals checked (bp 135/80 mmhg, P 81b/m, R 20 b/m, TEM 98 F). Fed lunch, ate 70%. Gave due medication and started the feeding . She is sleeping in the bed. Boot on the right leg. She has a follow up appointment on 8/6/2023 with her orthopedic surgeon. X-ray report for R2 date of service 7/29/23 documents impression findings of closed acute fractures of the distal tibia and lateral malleolus and marked osteopenia and DJD of the ankle. 2. R3 was admitted to the facility with diagnoses that include: multiple sclerosis, obesity, overactive bladder, and insomnia. Facility provided incident report and investigation documenting that on 9/22/23, R3 was involved in an incident that resulted in a right ankle fracture. Per CNA (V15), that was involved in the incident, on 9/22/23 at approximately 8 PM, while assisting R3 transfer from toilet to wheelchair, the resident had to be lowered to the ground because she was too heavy for V15 to transfer alone and R3 was no longer able to sustain herself while standing. After being placed in bed, R3 notified V15 that she was experiencing pain to her right foot. When V18 (RN) assessed R3's foot, V18 identified pain and swelling. V18 notified the doctor, who ordered an x-ray to be taken. Facility investigation concluded that based on the investigation, it was noted that (R3) was eased to the floor while she was assisted during transferring from the toilet to the wheelchair. During the process of transfer, she may have twisted her ankle which may have resulted in the right ankle fracture. The facility couldn't substantiate any form of abuse or neglect. Nursing Progress Notes regarding R3 document the following: 9/23/2023 12:47 AM LATE ENTRY 9/22/23 9:30 PM Resident lying in bed complained of pain on right ankle. Resident states she might have twisted her ankle. No bruise, or redness, swelling is more than the left ankle. Doctor was paged with order to do x-ray of the right ankle and Tylenol 650mg po every 6 hours as needed for pain. 9/23/2023 7:28 AM 11PM- 7AM shift late entry: Patient noted with swelling and tenderness on the right ankle. She verbalized that it is painful when she moves it. No redness, skin intact. Pain/discomfort is alleviated with rest and keeping her leg still. X-ray of right ankle scheduled to be done today. Endorsed to oncoming nurse. 9/24/2023 11:29 AM 1025AM: Followed-up with (x-ray company rep) for right ankle x-ray result. 1040AM: Right ankle X-ray result received with impression acute, displaced trimalleolar fractures with ankle malalignment. Orthopedic consultation is recommended. Relayed to Doctor with order to send to (local hospital) ED for further evaluation and treatment. 10:42AM: Informed resident and she is amenable to be sent to (hospital) ED. 10:47AM: Attempted to call daughter, but phone is not accepting any calls. 10:48AM: Called (ambulance services) - ETA between 20-30 minutes 11:10AM: Called local hospital ED c/o (staff name) - gave report. 11:30AM: EMS 2 persons arrived to pick up resident. 11:40AM: (R3) Left the unit. Addendum 9/24/23 2:16 PM 01415PM: Followed up with (hospital) ED c/o (staff name) - resident admitted with diagnosis of right trimalleolar fracture, closed. X-ray report for R3 has date of service as 9/23/23 and documents that R3 had an acute, displaced trimalleolar fracture with ankle malalignment of the right ankle; orthopedic consult was recommended. Notation on report reads, 9/24/23 @ 10:40am, Relayed MD send to (local hospital) for eval and treatment. Interview with V18 (RN) on 9/29/23 at 4:11PM, V18 re-affirmed what she documented in her statement and added that the CNA (V15) transferred the resident from the toilet to the wheelchair by herself and that she couldn't do it because the patient is heavy. V18 stated, There should be two CNA's; (R3) has MS (multiple sclerosis) and uses a wheelchair. (R3) was given pain medication. V18 was asked if x-ray was ordered STAT (immediately). V18 responded that she did ask the doctor to do the x-ray in the morning since it was late, but that it should be done in the morning since the resident was in pain. Surveyor asked if it was reasonable for the injury to have occurred on 9/22 but the resident not sent out to the hospital until 9/24. V18 said she only works weekends and doesn't know when the resident was finally x-rayed or sent out but that it is not practical to wait two days to get the x-ray and send the resident to the hospital. V18 stated, If the resident complains of pain and x-rays are not done yet, we can call the doctor and get the resident sent to the hospital. Interview with V2 (Nurse Manager) on 9/29/23 at 3:45 PM, V2 stated, Normally, if residents have symptoms, we will let the doctor know what is going on so they can order the x-ray STAT. If there is pain and swelling upon assessment, we usually get a STAT x-ray. Otherwise, I think it's two days to get the x-ray. Interview with V1 (Director of Nursing) on 9/30/23 at 2:40PM, V1 stated, My expectation is that a STAT x-ray should be done at least within four hours but (x-ray company that facility uses) has told us that their time frame for a STAT x-ray is 12 hours. I will call them first thing Monday morning and let them know that it is unacceptable. I will have to continue to educate my nurses and let them know that if a fracture is suspected that they cannot wait over four hours and will have to call the doctor back and request for the resident to be sent to the hospital. I'm not sure what the policy is but it is my expectation that the nurses would call the doctor and send the resident to the hospital if they need an x-ray. I will discuss this with Corporate as well. Interview with V16 (Medical Director) on 10/01/23 at 3:37PM, V16 stated he has not been made aware of any issues with the facility obtaining x-rays for residents and that he regularly attends quality assurance meetings with the facility. V16 added that since COVID there have been more delays, maybe because of lack of staff or something. Regarding x-rays, V16 said, In this setting I understand that we have to wait for someone to get to the facility and such, but I would expect it (STAT x-ray) to be done within about two to three hours. If the patient is having symptoms like pain and there is an obvious fall, we can send them to the ER if we think or know that there will be a delay in getting the x-ray. If the person is in extreme pain, then we would not wait and just send them to the ER. If this is a problem that is happening, then I will follow up with the Director of Nursing personally because this shouldn't be happening. Facility provided contract from x-ray company, which did not have any indication of the expected time frame for services. Facility provided policies: Fall Policy dated 07/2023 reads: Policy Statement/Overview The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Policy Detail 1. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls during the admission process. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall. 2. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall notify the resident's Attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record. The falls should be reviewed at the Daily Stand - up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs.

Based on interview and record review, the facility failed to inspect outside food brought in by family; failed to follow their protocols on providing emergency choking procedures; and failed to provide training to staff on how to properly provide emergency choking care. This failure affected 1 (R1) of 3 residents in the sample which caused R1 to go in to respiratory distress and [CONDITION(S)] resulting in death. Findings include: R1 was a confused [AGE] year-old resident with diagnosis of [CONDITION(S)] following cerebral infarction, diabetes, and [CONDITION(S)] and with diet orders for consistent carbohydrate mechanical soft diet and thin liquids consistency. R1's care plans dated [DATE] reads in part, (R1) has diagnosis of left basal ganglia [CONDITION(S)] (Cardiovascular Accident), history of multiple [CONDITION(S)] and has expressive [CONDITION(S)], right facial drooping; at risk for neurological changes; risk for aspiration. Goal: (R1) will remain free from signs and symptoms of complications from [CONDITION(S)], aspiration. Approaches: Monitor to assure adequate fluid intake to prevent dehydration; Monitor and document resident abilities for activities of daily living and assist as needed; Monitor for signs and symptoms of aspiration. Additional care plans read: (R1) requires supervision to occasional limited assistance with ADL's. Goal: Will receive ADL assistance to maintain safety. (R1) is following a consistent carbohydrate diet, mechanical soft, thin liquid diet to ease chewing/swallowing function, BMI obesity class 1 (At risk of malnutrition and aspiration). Goal: Resident will adhere to therapeutic diet. On [DATE] at 10:30 AM interview with V2 (director of nursing-DON) stated, Yes, I know (R1), she was a hoarder and when we searched her room she stored a lot of different food items in her room and I believe she hid a lot of food behind a curtain. Her ex-husband came in the day before this incident and gave (R1) grapes to eat and he told the staff that she tolerated it well so there didn't seem to be a problem. Surveyor asked if grapes were allowed or safe for her to eat, V2 stated, I don't think it was, but the dietician can answer that for you. Surveyor asked if residents are allowed food from outside who monitors any leftover food, V2 stated, We should be. Surveyor asked about the emergency procedures, V2 stated, I was not part of the code and did not participate in the code. I just came up and asked to see if they needed anything. I observed them: V4 (PM supervisor) was performing CPR, and V3 (RN), and V5 (CNA) were all performing CPR. Surveyor asked what role each of the 3 staff she mentioned, V2 stated, I'm not sure, I just know there were a lot of nurses in the room. Surveyor asked if anyone of her staff were able to revive R1 or start an IV, V2 stated, No one started the IV. I just saw two separate paramedic teams coming in. I called the B-team was in there first because they didn't seem to be able to do anything and then I saw another paramedic team come in. I call them the A-team because they seemed to do CPR fast and placed an electronic machine over her, but it still didn't work to revive her. They hooked her up to a monitor and I believe during CPR, a full grape popped out of her throat. I saw this. I also heard back from the coroner's office, and they said that (R1) died of asphyxia ruled as accidental according to corners office. On [DATE] at 1:15 PM V4 (PM Supervisor) stated upon interview, The nurse V3 (RN) came to the nurses station that the resident (R1) was choking. When I got to the room, the resident was sitting down next to her bed, and they were letting me know she was choking. She was still conscious, and you can tell she was in distress. I tried to sweep the mouth, but she was clenching her teeth. She's a confused resident and she had a stroke, and she was unable to say any words. I did the [MEDICATION(S)] maneuver with thrust on the abdomen. I was behind her and she (R1) was sitting down. At that point the CNA (V5) moved her back to the bed and at that time she became unresponsive. We were checking her pulse if she was breathing and there was no pulse for 10 seconds and so we started CPR. I did the chest compressions, but the crash cart was not there at the time. They attempted to start an IV, but I did know who started the IV, I don't recall there were a lot of staff in the room. Then the paramedics came they took over and I stepped out. Records show nursing progress notes entered by V3 (RN) dated [DATE] at 10:16 PM reads, 4:15 PM. Reached to the room to check the blood sugar. Resident was coming out from the bathroom with few grapes in her hands whole and broken. She looks like coughing slightly and nauseated. Front of the shirt was wet with something. Took her back to the bathroom near the sink. Took the grapes from hand and throw to the garbage. Resident sit in the toilet without pulled the pants. Looks tired and lean backward. Looks like choking. Suddenly get her up and did [MEDICATION(S)] by abdominal thrusts also. Nothing came and the staff tried to sweep the mouth. Resident having very difficult to breath and called emergency. Put resident back to bed start to do CPR and called the 911. Interview with V3 (RN) on [DATE] at 1:40 PM stated, I was (R1)'s nurse. I call her (R1) but she doesn't pay much attention because she doesn't understand me but she's alert and oriented x ,d+[DATE] but only speaks Spanish. During the weekday in the evening around after 4:15 PM, I usually take blood sugars and she came out from the bathroom, and she was holding some grapes in her hand and she showed me the grapes. Surveyor asked why R1 showed her grapes that were in her hand, V3 stated, I don't know why she showed me grapes. I called her out of the bathroom so I could do her blood sugar check. I took her grapes and threw them in the garbage. She then smiled and she was making a facial movement and asked her if she wanted to throw up and I took her back to the bathroom and she was standing in front of the sink, so I went back to her, and she sat back on the toilet without taking her pants off and sat down. Then she leaned back on the toilet, and I asked her what happened. I then got her up right away and took her out from the bathroom and I tried to do the [MEDICATION(S)] right in front of the bathroom. Surveyor asked V3 if she believed R1 was choking at this point, V3 stated, Yes, she didn't look good like she couldn't breathe. Surveyor asked what she did next, V3 stated, So she (R1) was standing up and I came from behind her but she was heavy and obese so I could not get my arms around her to perform the [MEDICATION(S)] and so I came towards her front and I put my left hand on her back and my right hand on her sternal area and pushed but she still was choking so I told her to sit down and I went to get a CNA and V10 (CNA) came and I told her call someone for help. Another CNA (V5) came and said she will do the abdominal thrust and came from behind to do [MEDICATION(S)] and that time the patient was already fading so we put her right away on the bed. Then V4 (PM supervisor) and V11 (nurse) came. V4 was doing CPR but there were a lot of nurses coming in to the room. I called 911 that we had emergency and said patient could not breath and was choking. Surveyor asked if she saw food in the room being brought in by family, V3 stated, I only saw cereal in the room. I didn't notice anything else in the room. She is not a hoarder that I know of. She normally eats in the room for dinner because I work PMs. She's on mechanical soft diet and she eats by herself. I knew she was a swallow and choking risk. On [DATE] at 1:50 PM, Surveyor asked V3 to show R1's previous room and to walk surveyor through the incident that occurred. R1's room was on second hallway to the left of the nursing station in the far left hand side of the hall. V3 pointed to the first bed R1 occupied which was the bed nearest the bathroom. V3 stated, (R1) was standing here outside the bathroom door and she was kind of smiling or something. It's hard to know what she is saying because It's hard to understand her. Surveyor asked if R1 was providing her a universal sign of choking, V3 stated, What is that? Surveyor explained and asked whether R1 placed her hands on her throat to demonstrate she was choking, V3 stated, No. Surveyor asked how she knew she was choking, V3 stated, I saw grapes in her hand and I told her to go in the bathroom to try to throw it up and she couldn't. Surveyor asked why she asked R1 to throw up, V3 stated, Because she was choking. Surveyor asked if R1 is able to understand and follow commands, V3 stated, I don't know but I tell her to just go to bathroom. Surveyor asked if she went to the bathroom with the resident, V3 stated, No I waited for her to give her privacy and then I went in later and found her sitting on the toilet. Surveyor clarified when she knew R1 was choking, V3 stated, I knew she was choking when she had a weird expression on her face, so I told her to go to the bathroom. Surveyor asked to demonstrate how R1 was in the toilet. V3 pointed to the toilet and said V1 leaned way back in the toilet. Surveyor asked if R1 was still conscious, V3 stated, I think so, her head went way back, and she was leaning far back in the toilet. Surveyor clarified when she knew R1 was having difficulty breathing, V3 stated, When I saw her in the toilet leaning back so I walked her out of the bathroom, and I told her to sit down, and I did a thrust to her sternum. Surveyor asked again where she did thrusts on R1, V3 stated Her sternum. (and pointed to her own sternum to demonstrate location). Surveyor asked if she did a finger sweep of R1's mouth to dislodge the grape, V3 stated, No I didn't. She started looking bad and I called the V10 CNA- (certified nursing aide) to come in and help and they tried to do the [MEDICATION(S)] too but couldn't get her to breathe. I saw V5 (CNA) try to reach around her and V5 is a bigger girl, and she couldn't wrap her arm around her either. Surveyor asked what happened next. I went out and called the V4-nursing supervisor and they put her in bed and started CPR on her. Surveyor asked what she did while V4 was doing CPR, V3 stated, I was watching for 911 to come. V5 (CNA) could not be reached for interview during this survey. V2 (DON) stated, V5 had her own emergency and was not on duty but provided a telephone number. Efforts to call the number were left unanswered. On [DATE] at 2:45 PM, interview with V8 (Dietary manager) stated, We cannot upgrade her diet. It would have to be speech therapy and she was not upgraded so maintained mechanical soft, thin liquid diet. I observed her during breakfast meal and she appeared to be weaker and needed feeding in her room (on [DATE]). I think she remained in room to eat all her meals. With eating, we do a malnutrition assessment which consist of their BMI and or recent her MNA was 11. They put in the aspiration because she is at a higher risk for aspiration because she has dysphagia. Dysphagia is swallowing difficulty. Her appetite has been fair and per nursing staff she was eating 50% of her meals and we ordered a fortified oatmeal. There were some instances we saw snacks at bedside being brought in by family, but they were appropriate. Grapes are not appropriate for the diet she was on. If they were to give grapes, they would have to remove the skin. On [DATE] at 3:30 PM interview with V9 (Speech Language Pathologist) stated, We worked on her (R1) dysphagia and her swallowing disorder. I ultimately recommended mechanical soft and thin liquid diet and we did try regular solids, but she refused pureed foods, so I trialed mechanical soft foods which was least restrictive. I put elevated risk with advanced consistency regular solids and those mechanical soft solids and thin liquids are recommended as the safest least restrictive diet. She had poor responsiveness to cues and aggressive behaviors. Anytime I would cue her, she was aggressive by tapping clinicians hands and moving pushing hands away. (R1) has severe [CONDITION(S)] and she was non-verbal. Surveyor asked about grapes, V9 stated, Grapes are not a recommended as part of a mechanical soft diet. It's really because of the skin and the texture of it. Even if sliced it's the skin. Just a grape in general cannot be part of a mechanical soft diet. Surveyor asked if staff were aware of R1's diet, V9 stated, I put care instructions and give education with the patient's son and nursing staff and informed them that the diet level for R1 is supervision and aspiration precautions. I recommended and discussed this all with staff and it included the recommended diet level and precautions, so they are aware of this. The patient requires maximum cues for meals although with poor responsiveness with verbal or visual instructions. Surveyor asked to explain further, If we were to show her to cut her meals, she could not follow instructions. I let the staff know that she needs supervision, but she was not very responsive to the staff. Surveyor asked if R1 required assistance in feeding, V9 stated, I don't know and I don't have any documentation that they tried to feed her. As mentioned, she had severe expressive receptive [CONDITION(S)] which means a disorder of language. She did not have ability to repeat any words back, just a lot of mumbling and could not express verbally or comprehend instructions Records of V9' s' notes dated [DATE] showed R1's progress during her treatments that read in part, Treatment diagnosis: Dysphagia, oropharyngeal phase. The patient warrants maximum assistance although remains with poor responsiveness to cues and aggressive behaviors. Elevated risk of choking with advanced consistency (regular solids). Mechanical soft solids, thin liquids recommended as the safest, least restrictive diet. Emergency Medical Systems response record dated [DATE] read in part, Dispatch complaint: [CONDITION(S)]/death. Crew performed CPR with rhythm checks and Epi administration for 30 minutes. Patient rhythm remained asystole (no heart rhythm) for duration of the arrest. Crew given time of death of 1659 (4:59 PM) by doctor. Facility policy dated ,d+[DATE] (revised ,d+[DATE]) titled Emergency Procedure-Choking reads in part, Conscious resident-standing or sitting: Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. Ask the resident to cough or speak if at all possible, to determine if his or her airway is obstructed. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. Call for help but stay with the resident. If the resident cannot cough, only then should abdominal thrusts be performed as follows: Stand behind the resident. Wrap your arms around the resident's waist. Make a fist with one hand. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. Grasp you clenched fist with your other hand. Press your fist into the resident's upper abdomen with a quick upward thrust. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious resident--Lying down (or when unable to reach around the resident): Call for help if assistance is not already present but do not leave the resident unattended. Position the resident on his or her back with the arms at his or her side. Perform abdominal thrusts as follows: Facing the resident, kneel down and straddle the resident's upper thighs with your body. Place the heel of one hand on the resident's upper mid-abdomen, below the ribcage and above the navel and with fingers pointed towards the resident's chest .Perform a finger sweep maneuver if you see the foreign body. Perform abdominal thrusts until the object is expelled or until the person becomes unconscious. If the resident has no pulse or respirations, follow the procedure: Cardiopulmonary resuscitation and protected code blue.

Based on observation, interview, and record review, the facility failed to safely turn a resident during incontinence care for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 rolling out of bed onto the floor and sustaining a scalp laceration requiring an emergency room visit and staples. Findings include: R1's Facesheet documents R1 with a diagnosis of cerebral infarction. R1's quarterly fall assessment, dated 7/22/21, documents that R1 is a high risk for falls. R1's current Physician Order Sheet and Care Plan documents R1 is on a low air loss mattress. R1's Minimum Data Set (MDS), dated [DATE] documents R1 requires extensive assistance for bed mobility. R1's current care plan documents R1 has impaired mobility and needs physical assist with bed mobility due to decreased endurance/strength; cognitive/memory deficit; limited ROM (Range of Motion); impaired voluntary movement on right side; decreased trunk mobility/control; and pain/discomfort. This same care plan documents R1 to roll side to side in the bed with verbal cues and extensive assist of one to two staff with an approach of instruct and provide assistance to hold onto the rails when turning/repositioning (R1) to side. R1's Device Evaluation form, dated 9/20/21, documents an initial evaluation was completed to assess R1 for a right sided mobility device. This same form documents the right sided mobility device is new and the indication for use of the right sided mobility device is documented as safely assist resident with bed mobility and transfers and poor balance or trunk control. R1's Therapist Progress and Discharge Summary, signed and dated by V11 (Physical Therapist) on 8/19/21, documents R1's ability to roll left and right as Dependent and Helper does ALL of the effort. (R1) does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity. This same form documents the Analysis of Functional Outcome/Clinical Impression as (R1) requiring extensive assistance for bed mobility task of rolling side to side due to bilateral lower extremity weakness and that R1 has reached R1's maximum potential. R1's Final Report of Incident to the local state agency, dated 9/22/21, states, Describe nature of incident: Fall with injury. On 9/19/21 at 1:30 P.M., (R1) was receiving care and turned to (R1's) right side and rolled off the bed. Open area noted to left side of head and (R1) complained of back pain. Pressure dressing applied to the head. Physician notified and 911 was called. POA (Power of Attorney) notified of the incident. Investigation started immediately. Summation of findings: (R1) returned to the facility (from the local area hospital) later in the evening on 9/19/21. (R1) has four staples in place to the left side of (R1's) head. X-ray and CT (Computed Tomography) were negative. (R1) is alert times 1-2 and stated, 'It was just a freak accident I started rolling and couldn't stop myself.' (R1) was receiving care during this time and the staff member (V4/Certified Nursing Assistant) was on the left side of the bed providing care. (V4) was unable to hold (R1) and keep (R1) from rolling off the right side of the bed. After thorough investigation and review of medical records it has been determined that while receiving care (R1) rolled off the side of (R1's) bed and hit (R1's) head during the fall. (R1) was not hospitalized and remains at the facility. (R1's) plan of care has been reviewed and updated. R1's Level One Root Cause Analysis form, dated 9/19/21, states, 8. Was the resident using an assistive device? The response is marked as No. This same report also states, Based on the above information, what interventions are most appropriate? The facility response is documented as Need floor mattress and assistive devices on right and left side of the bed. R1's Resident Incident Report dated 9/19/21, documents R1 had a fall in R1's room resulting in R1 being sent to the local area hospital with injury. This incident was reported by V4 (CNA) to V5 (Registered Nurse). This same form states, (R1) was on air mattress. (V4) stand left side of (R1's) bed and turned (R1) to the right side of the bed to clean and change the wet linen and diaper at that time (R1) rolled over from the bed to the floor on (R1's) back to the right side of the bed. Bed was in low position. Laceration on back of head with bleeding, c/o (complains of) back pain. Immediate actions taken: Ice pack applied to lacerated area, Dry dressing applied to stop bleeding, vital signs taken. Called 911. R1's Incident Witness Statement Form signed and dated by V4 on 9/19/21 states, (R1) was laying on her right side in the bed, as I was changing her diaper. (R1) she slipped off the mattress and rolled off the bed onto the floor. I was on the left side of the bed. (R1) rolled off on the right side of the bed. On 10/31/21 at 9:50 A.M., R1 was lying in bed on an air mattress. R1 stated R1 fell recently and required four staples to R1's head. R1 does not recall further details regarding the incident. On 10/31/21 at 9:57 A.M., V6 (Registered Nurse/RN) stated, If I was turning a resident alone, I would turn them towards me, so they don't fall out of bed. On 10/31/21 at 9:58 A.M., V5 (RN) stated, The CNA that was changing (R1) came to me and said that (R1) had rolled out of the bed. (R1) was on an air mattress with no side rails. I called 911 because there was a laceration to the left side of (R1's) head. (R1) needed four staples (to the laceration). At this same time, V5 also stated, I would always turn a resident towards me if I was alone. There is only one device there (on R1's bed), that's the problem. On 10/31/21 at 10:20 A.M., V7 (Certified Nursing Assistant/CNA) stated, I would always make sure to have two people when turning a resident during incontinence care, especially with an air bed. If I was turning a resident on my own, I would always turn the resident towards me, so they don't fall off the bed. It's how we are trained. On 10/31/21 at 10:22 A.M., V8 (CNA) stated, I would always turn a resident towards me if I was alone. It's easy for them to just keep going and land on the floor, especially on an air mattress. On 10/31/21 at 10:35 A.M., V2 (Director of Nursing) stated, It's in all of my training that if you're turning a resident by yourself; that you would turn the resident towards you to prevent them from rolling out of the bed. On 11/1/21 at 9:12 A.M., V11 (Physical Therapist) stated it is common sense to turn a resident towards you if you are turning a resident alone. On 11/1/21 at 9:15 A.M., V9 (Physical Therapy Assistant) stated R1 has weakness, rigidity, limited ROM, is contracted, and doesn't want to move a lot due to pain it causes. V9 stated it is always safer to use two staff members when turning and repositioning residents in bed and to turn the resident toward you if you are turning a resident alone. On 10/31/21 at 9:40 A.M., V3 (Assistant Director of Nursing) verified R1 was turned away from V4 when V4 was providing cares and that R1 did not have a mobility aid on the side of the bed that R1 was turned towards. V3 stated the right mobility aid was added to R1's bed after R1's 9/19/21 fall. V3 also verified when turning a resident alone, the resident should be turned towards the staff member to reduce the risk of falling. V3 stated, It would make sense. On 10/31/21 at 12:11 P.M., V3 stated that if V4 had used another staff member to assist turning R1 during the incontinence care for R1, R1's fall may not have occurred. Repeated calls with messages left to V4 were not returned.

Based on interview and record the review the facility failed to prevent a resident to resident assault for 1 of 4 residents (R1) reviewed for abuse. The failure resulted in R2 attacking and pushing R1 to the floor R1 was sent to the local hospital and assessed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's BIMS (Brief Interview for Mental Status) dated 1/12/21 was 4 indicating severe cognitive impairment. On 5/3/21 at 11:18am, R1 was interviewed (through a phone patch Spanish speaking interpreter) but unable to get pertinent answer regarding 1/1/21 incident. R1 was observed using a rolling walker to ambulate. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/21 at 10:56am R2 was interviewed but unable to get pertinent answer about what happened on 1/1/21. R2's BIMS, dated 12/23/20 was 14- intact cognition. On 5/3/2021 at 1:38pm, V3 (Registered Nurse) said that on 1/1/21, after escorting (R1) to his room, and going back to the nursing station, she heard a sound coming from (R1) and R2's room. When V3 went to the room, she found R1 on the floor and R2 was sitting on his wheel chair. R2 said that he pushed R1. On 5/4/21 at 10:17 am V7 (Certified Nursing Assistant- CNA) said, I heard (R1) and (R2), they have an argument. (R2) was giving (R1) a hard time about the over-head light being on. I went there right away but when I reached their room (R1) was already on the floor. On 5/4/21 at 8:04am, V3 said that The reason I thought they (R1 and R2) need to be separated was because of the light issue. V3 was asked if the pushing incident could have been prevented if one of them has been transferred to another room, V3 said, Maybe, if they have been separated in different rooms. At night time they have an issue with the lights. V3 also said, I told the morning nurse (V4-RN), that they have issue at night time, the recommendation, on my mind, they should be separated. I do not think I told the DON (Director of Nursing), I only reported it to (V4) the morning nurse. On 5/3/21 at 2:13pm, interview with V4, she said that there was one report that she received from V3 about the issue between R1 and R2 during the night. R2's Progress Notes entered by V3 dated 1/1/21 stated in part; In the night complaints about the roommate (R1) that he is dirty not flushing toilet keep the light on. (R2) will scream at (R1) and there will be arguments between them. This night also there was some arguments between them. These residents needs to be separated in different rooms. R1 was sent to the hospital, and medical record (X-ray dated 1/1/21) stated in part; Findings: Impression: Non displaced fracture of the greater trochanter. A facility incident investigation dated 1/6/21 sent to state agency stated in part; Conclusion: Through investigation completed. Based on the information we received through interviewing the staff, (R2) and (R1), it has been substantiated that (R2) did push (R1) causing him to fall.