Every finding on record at Helia Healthcare of Energy

Based on interview and record review, the facility failed to provide timely ADL (Activities of Daily Living) assistance to dependent residents for transfers for 1 (R1) of 3 residents reviewed for ADL assistance in the sample of 5. The findings include:R1's Resident Face Sheet dated 6/18/26 documents an admission date of 4/30/24 and included diagnoses of chronic obstructive pulmonary disease, difficulty in walking, weakness, chronic atrial fibrillation, absence of left leg below knee, type 2 diabetes, chronic kidney disease and cardiomyopathy.R1's most recent Care Plan documents a Problem area of R1 is at risk for falls with a problem start date of 5/8/24. A corresponding Approach listed for this problem area documents to transfer with the assist of 1 and gait belt. The approach start date lists 3/1/26, however the approach lists a created date of 6/18/26 by V2 (Director of Nursing). Other Approaches listed document to keep call light in reach at all times with an approach start date 1/14/26 and to provide toileting assistance as needed with a start date of 1/14/25. Another Problem area documents R1 has impaired physical mobility related to left leg below the knee amputation and weakness with a start date of 5/8/24. The Goal listed for this problem area documents R1 will improve current mobility status to be able transfer without (Mechanical) lift. An Approach listed documents to provide extensive assistance during bed mobility, dressing, showering, locomotion, set up for meals, and mechanical lift transfers with an approach start date of 1/14/25.R1's most recent Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documents R1 requires substantial to maximum assistance of staff to roll left and right, sitting to standing, from chair to bed transfer, and toilet transfer.R1's Point of Care History dated 6/22/26 for transfers documents R1 was dependent for 18 out of 22 transfers from 5/23/26 - 6/22/26. On 6/18/26 at 8:41 AM, R1 stated last Saturday, 6/13/26 about 2:00 PM, R1 was sitting just inside the doorway of his room with his call light on. R1 said he had an episode of bowel incontinence and needed to be changed. R1 stated there was one Certified Nurse Aide (CNA), who passed his room multiple times going into rooms that didn't have their light on. R1 could not recall the name of the CNA. R1 stated the CNA and V8 CNA finally came to his room at about 4:00 PM. R1 said the CNA's walked out of his room without helping him. R1 stated he sat there in bowel incontinence for another 4 hours until the next shift came on at about 6:00 PM and assisted him with toileting hygiene and getting laid down into bed as he wanted originally at 2:00 PM.On 6/18/26 at 12:47 PM, V9 (CNA) stated R1 had initially wanted to get out of bed for the day at approximately 11:00 AM, at which time she and V8 used a mechanical lift to transfer R1 from bed to his wheelchair. V9 stated R1 then went back down to his room after lunch at approximately 2:00 PM, put his call light on and asked her to put him to bed. V9 stated she explained to R1 there were other residents who had been up longer and needed to lie down first. V9 stated R1 never told her he had an episode of bowel incontinence. V9 stated R1 is currently a 2 person transfer with a mechanical lift, so it would have taken her and V8 to safely put R1 to bed. V9 said R1 became angry with her at the time but did not remember what exactly he said. V9 stated she left the room and went back to work assisting the other residents getting laid down. V9 stated she finally got back to R1's room at around 4:00 PM to lay him down as he'd requested earlier. V9 stated R1 became angry and began to yell at her why she had not answered his call light and put him to bed sooner. V9 stated she explained to R1 again there were other people who needed to be laid down first. V9 stated she didn't tell R1 this, but there was also another resident who had an episode of bowel incontinence which took her a lot of time to get cleaned up which caused her to run later. V9 stated R1 then began to escalate in his anger and grabbed her by the arm which scared her. V9 stated at that time she removed herself from the situation and reported the incident to V2 (Director of Nurses/DON) who told her to write a statement about what happened. V9 stated V14 (CNA) took care of R1's needs the rest of the evening. V9 stated she knew R1 did not get laid down till about 6:00 PM. V9 stated she was not sure why it was another approximate two hours before R1 got laid down in bed from 4:00 PM-6:00 PM. V9 stated V2 told her she would get another two CNA's to lay R1 down. V9 stated she was also told by V2 not to go back into R1's room the rest of the evening.On 6/18/26 at 2:52 PM, V8 (CNA) stated she worked on Saturday, June 13th with V9. V8 stated she remembers getting R1 up initially for the day right before lunch which would have been between 11:00 AM-11:30 AM. V8 stated she remembered R1 had put his call light on sometime after lunch requesting to be laid down, but she didn't remember exactly what time. V8 stated she remembered V9 stopping by and explaining to R1 they had a few other residents that had been up longer than him and needed to be laid down first. V8 stated they laid the residents down who had been up longer than R1, and then when they got back to R1 at a little after 4PM, R1 started yelling at V9 about why she didn't lay him down sooner. V8 stated after the argument and R1 yelling, she and V9 did not return to R1's room. V8 stated yes, four hours was too long for a resident to have to wait after requesting to be laid down.On 6/18/26 at 1:15 PM, V6 (CNA) stated she remembered putting R1 to bed the evening of Saturday June 13th. V6 stated she remembered it being sometime between 6:00 PM - 7:00 PM when she laid R1 down. V6 stated she remembered R1 telling her he'd been up for at least a couple of hours, and he was angry about that. V6 stated she did not remember if R1 was incontinent of bowel or bladder at the time, but she does know it's more difficult for R1 to use his urinal when he's sitting up. V6 stated V7 (CNA) assisted her to put R1 to bed. V6 stated it currently takes two CNA's to assist R1 with transfers because he is a mechanical lift for transfer. On 6/18/26 at 2:19 PM, V7 (CNA) stated she worked the evening of Saturday, June 13th. V7 stated she remembered assisting V6 with placing R1 into bed. V7 stated they got R1 into bed about 6:30 PM. V7 stated while they were assisting R1 into bed he complained he hadn't been changed in a while. V7 stated she remembered R1 had been incontinent of bladder but could not remember if he had been incontinent of bowel as well. V7 stated R1 also mentioned he had been up in his wheelchair since noon. On 6/22/26 at 12:35 PM, V14 (CNA) stated she worked on Saturday, June 13th on day shift. V14 stated she was never told by V2, V8 or V9 to provide any type of care to R1 on that day. When questioned if V14 believed four hours was too long for a resident to have to wait to be laid down from the time of their request to getting laid down in bed, V14 stated yes, she believed that was too long.On 6/18/26 at 3:23 PM, V2 (DON) stated she worked Saturday, 6/13/26 from 6:00 AM-7:00 PM as a staff nurse. V2 stated she remembered V8 and V9 coming to her to report the incident that had occurred with R1 yelling at V8 and V9. V2 stated she told V8 and V9 to make sure they always have a 2nd person with them when they provide care to R1. V2 stated she did not remember telling V8 and V9 to not go into R1's room again or that she would have someone else to put him to bed. V2 stated she did direct V8 and V9 to retrieve other CNA's to assist R1 to bed since he was being argumentative with them. V2 stated she believes it was about 4:45 PM when V8 and V9 approached her. When this surveyor asked if the approximate time of 11:00 AM-6:00 PM was too long for a resident who had initially requested to be laid down at approximately 2:00 PM was too long to wait, V2 stated, I believe residents should be accommodated at their request if they are cooperative with staff providing care. When V2 was asked if 4 hours was too long to wait between the time of the request of R1 to lay down and the actual time R1 waited to get laid down, V2 stated yes, it was.The facility's Safe Patient Handling Program Policy dated 9/8/23 documents, All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's Care Plan.

Based on interview and record review, the facility failed to adhere to the guidelines for conducting a Resident Assessment to ensure accurate documentation and plan of care follow up resulted for 1 (R1) of 4 residents reviewed for assessments in the sample of 10. Findings include: R1's admission Record documented an admission date of 6/6/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R1's Minimum Data Set (MDS) Brief Interview dated 1/16/26 documented a Mental Status (BIMS) score of 3, showing R1 had severe cognitive impairment. This same document under Section K Swallowing Disorder had a check mark next to coughing or choking during meals or when swallowing medications.R1's (MDS) Brief Interview dated 2/12/26 documented a Mental Status (BIMS) score of 4, showing R1 had severe cognitive impairment. This same document under Section K Swallowing Disorder had a check mark next to coughing or choking during meals or when swallowing medications. R1's Minimum Data Set (MDS) Brief Interview dated 3/03/26 documented a Mental Status (BIMS) score of 3, showing R1 had severe cognitive impairment. This same document under Section K Swallowing Disorder had a check mark next to coughing or choking during meals or when swallowing medications. R1's Care Plan did not have any focus areas related to R1 choking or coughing during meals or with swallowing medications.R1 Electronic Health Record did not contain any screenings related to coughing or choking.R1's Final Reportable sent to IDPH (Illinois Department of Public Health) documents on 3/10/26, R1 experienced an episode of choking while eating during meal service. The Heimlich maneuver was conducted and R1 was transported to the hospital. The report documents R1 was on a regular diet with thin liquids.On 4/8/2026 at 11:09 AM, V10 (Remote MDS Coordinator) stated she does work remotely and had completed R1's MDS's dated 1/16/2026, 2/12/2026 and 3/3/2026. V10 stated, she completed Section K, signs and symptoms of swallowing disorder with documentation of coughing or choking during meals or when swallowing medications with a check mark. V10 stated she based this assessment on R1's plan of care (POC) responses documented in his electronic health record (EHR) by the CNA (Certified Nursing Assistant) staff. V10 stated, upon review of January 2026, R1 had documentation of coughing or choking during meals on 1/4/26, 1/5/26, 1/8-1/11/26, 1/14/26, and 1/16/2026. V10 stated, in the month of February 2026, R1 had documentation of coughing or choking during meals on 2/5/2026, 2/10/2026, and 2/11/2026. R1's Plan of Care (POC) Responses for ADL-Eating documented on 1/16/2026 at 2:43 PM by V11 (CNA), R1 coughed or choked during meals or when swallowing medications. On 1/14/2026 by V4 (CNA) at 9:39 AM R1 coughed or choked during meals or when swallowing medications. On 1/11/2026 at 2:08 PM R1 coughed or choked during meals or when swallowing medications. On 1/9/2026 at 8:35 AM by V4 (CNA) R1 coughed or choked during meals or when swallowing medications. On 2/11/2026 at 11:31 AM by V4 R1 coughed or choked during meals or when swallowing medications. On 2/10/2026 at 9:00 AM by V4 R1 coughed or choked during meals or when swallowing medications. On 2/5/2026 at 12:21 PM by V11 R1 coughed or choked during meals or when swallowing medications. The was not documented for March 2026 look back period. On 4/8/2026 at 11:23 AM, V4 (CNA) stated he had documented under the POC response section for R1 in January and February of choking or coughing during meals or swallowing medications. V4 stated, R1 would make sounds of clearing his throat during meals and non-mealtimes but did not think there was an issue with him doing it. On 4/8/2026 at 11:41 AM, V11(CNA) stated over the last few months R1 did have some coughing at times when he would eat or drink and she documented this in his POC response areas. V11 stated, she thought R1 had some congestion, and the nursing staff would give him cough medicine. On 4/8/2026 at 3:07 PM, V10 further explained, she completed R1's assessment by reviewing R1's EHR that included the CNA's documentation of choking or coughing during mealtimes or medication administration, all progress notes, therapy notes, etc. V10 stated, there is no interview or observation from her for his assessments. V10 stated, she does not report any concerns documented in the MDS, except if it was not accepted. V10 stated, it is protocol for the CNA staff to report issues to the nurses. On 4/9/2026 at 12:47 PM, V14 (Assistant Director of Nursing/ADON) stated MDS assessments are completed by V10 (MDS), remotely. V14 stated, R1's MDS's have not had proper follow up on concerns documented and V10 did not report concerns to the nursing staff as required. On 4/9/2026 at 2:42 PM, V1 (Administrator) stated, it is his expectations that staff are to follow the assessments policy and procedures and communicate with staff as required. Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (effective October 1,2025) documented under Section K, Steps for Assessment: 1. Ask the resident if they have had any difficulty swallowing during the 7-day look-back period. Ask about each of the symptoms in K0100A through K0100D. Observe the resident during meals or at other times when they are eating, drinking, or swallowing to determine whether any of the listed symptoms of possible swallowing disorder are exhibited. 2. Interview staff members on all shifts who work with the resident and ask if any of the four listed symptoms were evident during the 7-day look-back period. 3. Review the medical record, including nursing, physician, dietary, and speech language pathologist notes, and any available information on dental history or problems. Dental problems may include poor fitting dentures, dental caries, edentulous, mouth sores, tumors and/or pain with food consumption.

Based on interview and record review the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 5 residents (R7) reviewed for urinary tract infections in a sample of 39. This failure resulted in R7 being admitted to the hospital for disorientation and acute cystitis without hematuria.Findings include:R7's admission Record documented an admission date of 07/07/2025 with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance, mixed incontinence, personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits.R7's Minimum Data Set (MDS) dated [DATE], documented under section C (Cognitive Patterns) a BIMS (Brief Interview for Mental Status) score of 11, indicating R1 has moderate cognitive impairment. This same MDS documents under section H (Bladder and Bowel) that R7 has urinary continence with occasionally incontinence (less than 7 episodes of incontinence).R7's Care Plan documented a focus area of urinary tract infections dated 1/14/2025 with interventions that include to observe for signs and symptoms of a urinary tract infection and notify physician as indicated.R7's Progress Note documented by V20 (Registered Nurse/RN) dated 11/27/2025 at 5:43 AM documents order from V22 (Nurse Practitioner/NP) on secure messaging to straight cath and send urine for urinalysis and culture in response to a message sent by prior shift nurse stating resident is confused and hallucinating and incontinent.There was no documentation provided by the facility of urinalysis with culture results from 11/27/2025 or any follow up documentation to V22 (Nurse Practitioner/NP) on R7.On 1/28/2026 at 10:29 AM, V20 stated she did remember making a note in R7's chart in regards to a straight catheter for diagnosis that included confusion. V20 stated she does not recall obtaining the urine sample since it was around 5:45 AM in the morning, she would have reported that off to the day shift nurse.R7's Progress Note documented by V25 (RN) dated 12/14/2025 at 8:48 AM documented entered R7's room to find her passed out in dinner plate. Left resident sitting up on side of bed eating dinner. Resident was alert to baseline at this time. Came back to check on resident where she was found, pulse present at 35, resp (respirations) 14, O2 (oxygen saturation) 94%, bs (blood sugar)-160. Responsive to verbal stimuli but not focusing with eye movement. (Name of ambulance company) contacted and picked resident up taking to (name of local hospital) ED (Emergency Department) at this time. On call notified, as well as POA (Power of Attorney). NP notified secure messaging. All necessary paperwork was sent with EMS (Emergency Medical Services).R7's Progress Note by V25 (RN) dated 12/15/2025 at 12:34 PM documented spoke to nurse at local emergency room who stated resident was stable, family present at bedside, and resident would be admitted for urinary tract infection.R7's After Visit Summary from the local hospital documents R7 was admitted on [DATE] and was discharged on 12/17/25. Under Discharge Information for the Receiving Facility documents encounter diagnoses of disorientation-primary, acute cystitis without hematuria, and essential hypertension.On 01/29/2026 at 9:12 AM, V22 stated she does have documentation of request with order given to obtain a urine sample by straight catheter for R7 in regard to confusion, hallucinations and incontinence through secured messaging on 11/27/2025. V22 stated looking at hospital records it does not appear there were any urinalysis results from 11/27/2025 completed. V22 stated that the nursing staff should follow physician orders and contacted her if the urine sample was not able to be obtained. On 01/29/2026 at 9:33 AM, V2 (Director of Nursing/DON) and V19 (Assistant DON) both stated their expectations are for nursing staff to follow physician orders. V2 and V19 stated, V22 should have been contacted if the urinalysis could not be obtained for further orders. On 01/29/2026 at 9:46 AM, V1 (Administrator) stated his expectation is that all nursing staff follow physician orders by policy and procedure. The facility policy titled Obtaining and Following Physician Orders (revised July 2017) documented under Policy: It is the policy of (company name) that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgement think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified.

Based on observation, record review, and interview, the facility failed to ensure a medication cart was kept locked when out of staffs visual control. This has the ability to affect all 74 residents living at the facility.The findings include:On 01/27/2026 at 12:00 PM, V23, Licensed Practical Nurse, was observed passing medications in the facility's Suites dining room. V23 took glucometer supplies from the cart, left the cart unlocked, and went down the hall and into a resident room, leaving the unlocked cart out of her visual control.On 1/30/26 at 9:08am, V2, Director of Nurses, stated the cart is to be locked when out of staff's visual control.The facility Medication Administration Policy dated 10/25/14 documented, 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.The facility Midnight Census Report A dated 1/27/26 documented a total of 74 residents living at the facility.

Based on observation, interview and record review the facility failed to ensure that dishes were effectively sanitized in the dish machine. This failure has the potential to affect all 74 residents residing in the facility. The Findings Include:On 1/26/26 at 9:15 AM during the initial tour of the kitchen the sanitizer level in the dish machine was checked with sanitizer strips by V7 (Dietary Manager) and no sanitizer was registering. V7 attempted to run 2 more cycles stating that sometimes after it sits all night the sanitizer tubing gets clogged. V7 stated that she would contact the maintenance department and see if they could get the dish machine to dispense sanitizing solution appropriately due to the sanitizer strip not registering any sanitizer in the machine. V7 then confirmed that they had washed some dishes this morning and that no one had recorded a sanitizer level on the dish machine sanitizer log that morning. V7 confirmed this indicated that the level had not been checked prior to starting the breakfast dishes. V7 stated that it should be checked prior to starting the breakfast, lunch and dinner dishes. The facility's Machine Ware Washing policy revised January 2012 documents: Dishes, glassware, cups, utensils, and other dishware are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure that it is functioning properly. 1 Check sanitizer concentration using appropriate test strips . Record the date, temperatures, water pressure, and sanitizer concentration and initial the entry on the Dish Machine Monitoring Form. 2 .Check the Dish Machine Monitoring Form to ensure that temperatures, sanitizer concentration, and water pressure meet standards and that they are recorded daily. The Long Term Care Facility Application For Medicare and Medicaid dated and signed 1/27/26, documents 74 residents reside in the facility.

Based on observation, interview and record review the facility failed to follow the recipe for pureed spaghetti and failed to provide the correct amount of bread for the lunch meal for 5 of 5 residents (R9, R12, R30, R45, R52) reviewed for altered diets in the sample of 39. The Findings Include: R9's admission profile documents an admission date to the facility on [DATE]. This same document includes the following diagnosis: Malignant neoplasm of oropharynx, other sequelae of cerebral infarction and generalized anxiety disorder. R9's current month's physician order sheet document that R9 has a pureed diet as tolerated. R12's admission profile documents an admission date to the facility on [DATE] and includes the following diagnosis: Alzheimer's, Dementia, and Cerebellar stroke syndrome. R12's current month physician's order sheet documents that R12 has a puree diet with thin liquids. R30's admission profile documents an admission date to the facility on [DATE]. This same document includes the following diagnosis: other sequelae of cerebral infarction, dysphagia, and depressive disorders. R30's current month physician order sheet documents that R30 has a puree diet order with double portions and nectar thick liquids. R45's admission profile documents an admission date to the facility on 6/21/2024. The same document includes the following diagnosis: cerebral infarction. R45's current month physician order sheet documents that R45 has a pureed diet with nectar thickened liquids. R52's admission profile documents an admission date to the facility on [DATE]. This same document includes the following diagnosis: Alzheimers, Dementia, depression and anxiety. R52's current month physician order sheet documents that R52 has a puree diet with thin liquids. An undated listed provided by the facility documents R9, R12, R30, R45, and R52 all receive puree diets.The facility's menu for Fall/Winter 2025 dated 12/1/25 the for the day of Tuesday 1/27/26 documents lunch was spaghetti, vegetable blend, wheat bread, chef's choice of dessert, margarine, milk/coffee/tea. On 1/27/26 at 11:15 AM, V18 (Dietary) was pureeing the spaghetti for the lunch meal. V18 stated at this time he had 5 residents with a puree diet order and one of those residents was to receive double portions, so he would prepare for 6 servings. V18 at this time using tongs dished 6 servings of noodles into the food processor and then using a large ladle scooped 6 portions of sauce into the processor with the noodles. V7 (Dietary Manager) told V18 to remember to add bread in the food processor when pureeing the main meal selection. V18 at this time added two slices of bread to the processor with the meat and noodle mixture. Once the mixture was at the desired consistency after adding beef broth, V18 scooped the pureed spaghetti into the serving dishes. The recipe for spaghetti with turkey meat sauce pureed is as follows for week 1 Day 3 lunch with a report date of 10/14/25 documents: Portion size= #6 scoop.Spaghetti - serving size 1 cupLow Sodium Chicken base- serving size 2/3 tablespoonWater- serving size 3/4 cupFood Thickener- serving size 2/3 Tablespoon 1. Prepare regular as directed. Strain liquid from turkey and pasta in the regular prepared recipe.2. Add turkey and pasta to food processor and process until fine in consistency.3. Add goulash liquid to processor, and process until smooth. Combine base and hot water and gradually add hot broth to mixture while processing to a smooth homogenous consistency.4. Add food thickener and process briefly until mixed. Scrape down sides of processor with a rubber spatula and process for 30 seconds. 5. Spread the mixture evenly into a steam table pan coated with food release.6. Cover tightly and heat to 165 degrees Fahrenheit.7. Portion one #6 scoop pureed Spaghetti with Turkey meat Sauce per serving. On 1/29/26 at 2:00 PM, V7 confirmed that 2 slices of bread is not adequate in serving size for 6 servings as listed on the menu/recipe. V7 stated they were advised by the dietitian to add bread and thickener to the main meal for better consumption even though the recipe does not mention that. V7 went on to state that the pureed food consistency was measured out by scooping the food into the serving bowls, so not measuring out the noodles was acceptable in pureeing the main meal selection.

Based on observation, interview, and record review the facility failed to maintain aseptic technique while performing wound care treatment for 2 (R3 & R10) of 8 residents reviewed for wound care treatment and infection control in a sample of 39.The findings include:1.R3's Resident Face Sheet documents an admit date to the facility on [DATE] with diagnoses including multiple sclerosis, non-pressure chronic ulcer of the left heel and midfoot with unspecified severity, neuromuscular dysfunction of bladder, unspecified, and unspecified-macrocytic anemia.R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating R3 had moderate cognitive impairment. This same MDS under section GG, Self-Care and Mobility, documented R3 is dependent, which means helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort for a chair/bed-to chair transfer.R3's Care Plan documented a focus area of Pressure Ulcer/Injury, impaired skin integrity related to wound, healing with risk of inadequate fluid and nutritional intake as evidenced by delayed, wound healing, poor oral intake, and signs of dehydration. Arterial ulcer right medial foot, skin tear left bottom of foot, deep tissue injury right buttock, and ulcer to posterior left knee, wound to right knee with interventions that included providing treatment/dressing changes as ordered.R3's Physician Orders by V17 (Wound Physician) dated 11/13/2025 documented silver sulfadiazine cream (SSD), 1 % (percent), cleanse the wound behind the right knee with normal saline or wound cleanser, apply SSD, Collagen powder, Calcium alginate, and dry dressing once a day; 1/01/2026 documented Betadine (povidone-iodine) solution, 10 %, cleanse the wound to the right plantar foot with wound cleanser or normal saline, apply betadine twice a day; silver sulfadiazine cream, 1 %, Cleanse the wound behind the left knee with normal saline or wound cleanser apply SSD, Collagen powder, Calcium alginate, triamcinolone cream, and dry dressing once a day; silver sulfadiazine cream,1%, cleanse the wound behind the lower right buttock with normal saline or wound cleanser, apply SSD, Collagen powder, Calcium alginate, and dry dressing once a day; and triamcinolone acetonide cream, 0.1%, cleanse the wound to behind the left knee with normal saline or wound cleanser, apply SSD, triamcinolone, Collagen powder, Calcium alginate, and dry dressing once a day.On 01/28/2026 at 1:20 PM, V17 (Wound Physician) observed in room to complete wound care with dressing changes for R3. V1 (Administrator) observed donning gown and gloves after hand hygiene. V2 (Director of Nursing/DON) observed outside of R3's door with wound cart and supplies. V17 observed gowned and gloved while standing by R3's bedside. V17 reached over and picked up the television remote control from R3's bed with his gloved hands and placed it on the window seal. V17 did not doff gloves, perform hand hygiene, or don new gloves. V1 (Administrator) was at R3's bedside to assist V17 with wound assessment and dressing changes. V17 was observed measuring the right lateral foot wound, then cleaning the area as ordered. V17 did not doff gloves, perform hand hygiene, or don new gloves. V17 requested V1 to turn R3 on her left side. V1 assisted R3 on her left side for V17 to observe buttock area. Fecal matter was observed on R3's incontinent pad and in the crevice of her buttock. V17 then removed the old dressing from R3's right lower buttock area, dropped the dressing on R3's bed, and then measured the wound. V17 stated, to V2 (Director of Nursing) that a new area on the right upper buttock was noted with measurements given. V17 requested 2 dressings for R3's right buttock from V2. V17 doffed his gloves and donned new gloves that had been pulled from his right pants pocket. V17 did not perform hand hygiene prior to donning the gloves. V17 then put his bandage scissors in the front of his isolation gown by making a hole in the gown for them to be held there. At 1:26 PM, the bandage scissors fell from V17's isolation gown onto the floor of R3's room. V17 was observed picking up the scissors and walked them to V2 (DON) at the door. V17 did not doff gloves, perform hand hygiene, or don new gloves after picking the scissors up off the floor. V17 was then observed walking over to R3's bedside table and moved her soda can for V1 (Administrator) to place a barrier with open dressing supplies on table. Wearing the same gloves, V17 cleaned R3's right buttock and placed a dressing to the area. V17 doffed gloves at this time and he donned new gloves that he removed from his pant pockets, without performing hand hygiene. V17 cleaned R3's new area to her upper right buttock and placed a new dressing as ordered. At 1:31 PM, V17 removed an old dressing from R3's right knee and obtained measurements. V17 cleaned R3's knee then walked over to the door to request another dressing from V2 (DON) who was at the door. V17 did not doff gloves, perform hand hygiene, or don new gloves. V17 returned to R3's bedside to clean R3's knee and placed the dressing as ordered. V17 then doffed his gloves and donned new gloves from his pocket without performing hand hygiene. At 1:37 PM, V17 removed the dressing from R3's right foot, debrided the wound area with scabs falling from the area to R3's bed with no barrier. V17 then cleaned the site, placed a dressing then wrapped gauze around the site as ordered. V17 removed dressing from the left knee with measurements taken. V17 debrided this area with no barrier on R3's bed. V13 cleaned the site and applied new dressing with no doffing or donning of gloves or hand hygiene. V17 walked over and pushed R3's call light for staff to come complete incontinence care. There was no observation of V17 performing hand hygiene after the treatments were completed prior to V17 leaving the room. On 01/28/2026 at 3:15 PM, V10 (Regional Director) stated it is her expectation that fecal incontinence would be cleaned up prior to any wound treatment.On 01/29/2026 at 8:51 AM, V2 (DON) stated all staff and contracted employees should follow all facility policies and practices. V2 stated, it is her expectation that all staff and contracted employees adhere to standard infection control practices and that would include donning and doffing gloves appropriately, hand hygiene, and cleaning fecal incontinence prior to starting wound care. 2. R10's Resident Face Sheet documents an admission date of 8/22/2018 with diagnoses of Parkinson's disease without dyskinesia, Vitamin B deficiency, Hypertension, GERD without esophagitis, Urine Retention, Neuromuscular dysfunction, Type 2 Diabetes Mellitus, Long Term Insulin use, Hypothyroidism, Hyponatremia, Acute and Chronic Respiratory Failure, Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, History of Urinary Tract Infections. R10's MDS dated [DATE] documents a BIMS score of 15 indicating R10's cognition is intact. Section GG, Functional Abilities, documents R10's mobility is via of a wheelchair. R10 is dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, position changes and transfers. Section M, Skin Conditions, documents R10 is at risk for pressure ulcer/injuries. Treatment include pressure reducing device for chair and bed.On 01/28/2026 at 1:55PM, V1 (Administrator), V2 (Director of Nursing /DON), and V17 (Wound Physician), were wearing disposable gowns and gloves, began wound treatments/assessment of wounds on R10. R10 had a border gauze dressing noted to Left upper buttocks dated 1/28/2026. V17 removed dressing and measured wound. V17 then removed his gloves and walked outside the room to the treatment cart where V2 had prepared a dressing of calcium alginate, silvadene cream and collagen powder. V2 handed the dressing to V17 after V17 donned a pair of gloves and no hand hygiene was observed at this time. V17 then went and applied the dressing to the left upper buttocks and secured it with a border gauze. V17 began to measure other open areas as follows: left lower buttocks, right thigh, right upper buttocks, and scrotum. V17 then doffed his gloves and went outside the room and instructed V2 to get a dressing prepared of Calcium Alginate, silvadene, collagen powder and border gauze. V17 donned gloves that he removed from his pocket and without hand hygiene. V17 then took the dressing to R10's beside and applied the dressing to R10's left lower buttocks (open area). V17 then went back outside the room to V2 and had V2 to prepare another dressing of Calcium Alginate, Silvadene, Collagen powder and border dressing and V17 took the dressing to the bedside and applied to R10's right upper thigh (open areas). V17 then doffed gloves and stated, I guess you expect me to use hand sanitizer after I change my gloves. V17 then applied hand sanitizer to his hands and donned another pair of gloves that he retrieved from his pocket. V2 prepared another dressing of Calcium Alginate, Silvadene, Collagen powder and border gauze. V17 took the dressing into R10's room and applied it to R10's upper right buttocks (open area). V17 then instructed V1 to get silvadene and apply to the open area to R10's scrotum. V17 then removed the boots from R10's feet and noted a scab to R10's right heel. V17 removed the scab and stated the wound to the heel was healed. V17 then assessed V10's left heel where there were 2 scabbed areas noted and V17 stated this heel has already been healed out. V17 then doffed his gloves, used hand sanitizer and left the room.On 1/28/2026 at 2:25PM, V10 (Regional Clinical Director) was asked if she expected the staff, including contracted staff, to follow Infection Control Policy and Wound Care Policy, V10 stated yes. V10 was also asked if she would expect staff to use hand sanitizer in between glove changes and V10 stated yes. V10 was asked if she expected V17 to follow policy and procedures and V10 stated yes. The facility policy titled Dressing, Dry/Clean policy and procedure (January 2018) documented under Procedure: 1. Adjust bedside stand to waist level. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or open on the bed. 4. Pull strips of tape adequate for securing dressing at the end of the procedure and add date, time and initials. Place on edge of bedside table to enable easy access when needed. 5. Adjust the height of the bed to waist level. 6. Position resident and adjust clothing to provide access to affected areas. 7. Wash and dry your hands thoroughly. 8. Put on clean gloves. Loosen tape and remove soiled dressing. 9. Pull glove over dressing and discard it into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 12. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 13. Pour prescribed cleansing solution over the dry, clean gauze into clean basin section of tray. 14. Put on clean gloves. 15. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 16. Cleanse the wound. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 17. Use dry gauze to pat the wound dry. 18. Apply the ordered dressing and secure with tape. (Note: Use non-allergenic tape as indicated.) 19. Discard disposable items into the designated container. 20. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 21. Reposition the bed covers. Make the resident comfortable. 22. Place the call light within easy reach of the resident. 23. Clean the bedside stand. 24. Wash and dry your hands thoroughly. 25. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room.The facility Infection Prevention and Control Program Policies and Procedures (revised August 2018) documented under General Statement - The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention. This same document under Hand Hygiene General Statement- Good hand hygiene is a requirement of standard precautions. Wash or sanitize hands before and after each care contact for which hand hygiene is indicated by acceptable professional practice, utilizing designated time frames and products. Hands should be washed with soap and water when they are visibly soiled, or if they have come in contact with blood or other body fluids, before or after eating or handling food, and times specified by other applicable regulations.

Based on interview, observation, and record review, the facility failed to prevent the verbal and physical abuse of a resident from staff for 1 of 7 residents (R7) reviewed for abuse in the sample of 44. This failure resulted in psycho/social harm to R7 having feelings of irritation, anger, and continued complaints of pain to her right shoulder.The findings include:R7's face sheet, dated 12/22/25 documents an admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem of Falls R7 is high risk for falls. R7 at risk for falling r/t (related to) history of falls visual acuity impairments, decreased safety awareness, impulsiveness with attempts to stand or self-transfers without assistance from staff leaning forward in chair with attempts to pick up objects. On 09/17/24 I slid out of my wheelchair in the hallway. I did not hit my head, and I do not have any obvious injury. On 1/22/25 I was observed sitting on the floor beside my bed. I have no apparent injury. On 03/27/25 I rolled out of bed when sleeping. I had shoulder pain, but it went away. On 07/29/25 I slid off of a pillow that was in the seat of my w/c (wheelchair). No injury. On 11/02/25 I was attempting to move from my w/c to the bed and slid to the floor. Approaches for this problem include: Keep assistive devices at bedside. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation. A facility document titled Long-Term Care Facility and IID-Serious Injury Incident report documents under general information: Incident Date 01/05/2025 with a time of incident of 0630 and a report date of 01/05/25. Resident #1 involved in Incident: R7 listed as victim. Staff #1 involved in the incident: V13 position CNA (Certified Nursing Assistant) , retained no, suspended yes, terminated no. Witness Name V16 (former Assistant Director of Nursing) and V49 (CNA). Detailed Incident Summary (Who, What, When, Where, Why) Resident #1 (R7) is a 95 y.o (year old) Fw/PMH (Female with a Past Medical History): dementia, CAD (Coronary Artery Disease), HTN (Hypertension), anxiety, insomnia, depression. Per the facility protocol, an investigation was conducted in response to an allegation of abuse involving resident #1 (R7). Per interview conducted with witness #2 (R49), resident approached witness #2 and staff during a conversation. Witness #1 (V16) stated that resident #1 stated she needed to be careful with that man staff asked resident not to interrupt and took resident #1 (R7) to room. Per staff member resident #1 (R7) referred to him as a druggie, loser, and a fool He did ask her to stop and took her to her room. While in the room staff member states that resident slapped him and scratched his face. Resident #1 then through a water pitcher at staff member striking him in the back of the head. Staff member left the room with no further incident. Staff member stated that he went outside to take a break following the incident. Staff member states that he did rush his care with resident #1, but he was never aggressive with the resident #1. Staff member states that he was frustrated with the resident's behavior. Multiple staff members did hear about the incident second hand. The PCP (Primary Care Physician, Administrator, ADON (Assistant Director of Nursing) and family were notified of the incident. An interview was conducted with the resident with ADON present. A skin assessment was completed with no findings by the ADON. Law enforcement notified of incident and investigation is ongoing with no current concerns. Facility investigation unsubstantiated with no findings of abuse. Resident #1 had no recollection of event on follow up interview. Dated 02/28/25 by V1 (Administrator) at 12:00PM. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated one day V1's (Administrator) son V13 (CNA) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. At that time observed R7 trying to show she couldn't reach across her body with her right arm and when she moved her right arm across her body to her left, she grabbed her right shoulder and said ouch, it hurts when I do that. On 12/2/25 at 2:26 PM, V20 (CNA) stated R7 says V1's son V13 tells her all the time that V1's son V13 hurt her arms. V20 stated that R7 will roll to V1's office door at times and tell him his son hurt her. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who called him and asked him what happened. V13 stated he resigned from his position after all of this happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the incident with V13 and R7 and he was (in hall) because he had just come out from there passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 told R7 he would be right back and get her taken care of, he was taking his med cart back up to where it belongs and while he was taking his cart he started thinking that taking a wheelchair away was considered a restraint and he got worried so he went and got V31 (Registered Nurse) to ask for help with the situation. V14 stated he asked V31 if taking R7's wheelchair away was a restraint and V31 stated yes, that last time someone took her wheelchair away she fell and had to get staples. V14 stated he and V31 ran back to R7's room and when they walked in R7 was still visibly upset and was reaching for V31 to console her. V14 stated then R7 refused her medications with him because she was so upset but she ended up taking them for V31. V14 stated R7 is independent with getting herself from the wheelchair to the bed and back to her wheelchair. V14 stated V13 told him that R7 called him a druggy saying he will never make anything of himself and V14 told him it doesn't matter what a resident says to you, you cannot take away their wheelchair and shut them in their room. V14 stated he didn't report the incident because he didn't know he was supposed to. V14 stated V1 (Administrator) called him and asked what happened. V14 stated no one else from the facility contacted him regarding this incident. V14 stated the police never contacted him regarding this incident. V14 stated he doesn't remember talking to anyone from Illinois Department of Public Health prior to right now. V14 stated this incident bothered him for a long time because he just felt like it wasn't right and wondered what could have happened to R7 if no one was there. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. V49 said that V13 came back to the nurses station and told her that he threw R7 into bed and that R7 threw a water bottle at him and he threw it back at R7 then left the room. V49 stated she told V13 to not mess with R7 anymore or touch her that she was going to take care of her. V49 said that R7 was taken to the Suites unit (but she couldn't remember who took her) and R7 was put in a bed in an empty room to sleep the rest of the night. V49 said another CNA was working the suites and took care of R7 the rest of the night. V49 did not report it because she thought someone else did because V1 (Administrator) called her the next day to ask her what happened. V49 stated she told V1 the same thing she told this surveyor. On 12/4/25 at 2:57 PM, V22 (CNA) stated she took report from V13 on Saturday 2/22/25 in the morning and V13 told her that he and R7 weren't getting along during the night, and he said he tried to put R7 in bed and she would not let go of her wheelchair, so he dumped her into bed. V22 stated that during report on 2/23/25 V13 told her that he and R7 weren't getting along again so he took her wheelchair away from her and he told V22 that if she called him a druggie again, he would throw water in her face and make R7 eat a bar of soap. V22 stated that R7 mentions often that V13 grabbed her arms and was rough with her and hurt her. V22 stated when there are reports of abuse to administration, actions are never taken, and they treat the reporter different after that. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. V12 stated when she arrived to work that morning at 6:00 AM R7 was still on the rehab unit and would not come back to her unit because she was so upset. V12 stated she was finally able to get her to come back around 2PM or 3PM that day. V12 stated she did a body assessment after the police and V1 arrived at the facility. V12 said that the police officer and V1 were present as they looked at R7's arms and under her arms where R7 said she was hurting. V12 stated she did not see any markings. V12 stated anytime Illinois Department of Public Health came into the facility V2 (DON) would tell staff to keep their mouths shut about the alleged abuse of R7 by V13. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her, and she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/03/25 at 2:49PM, V31 (RN) said that he was working the night that the incident occurred with V13 and R7. V31 said that he was working a different hall and that V14 (LPN) came and got him. V31 said that V13 had taken R7 out of her wheelchair and put her in her bed and had the door shut and the wheelchair on the outside of R7's room. V31 said that R7 was in her room yelling and that he and V14 went in and got R7 back up out of bed and moved her to a different hall because V13 was still working on her hall. V31 said that R7 will usually transfer herself if she has her wheelchair next to her, but V13 moved her wheelchair away from her. On 12/08/25 at 11:28AM, V1 (Administrator) said that he doesn't think that V16 (Former ADON) was working the night that V13 and R7 had the alleged altercation. V1 said that he was not told about the incident between V13 and R7 until the next morning. V1 said that he talked to the officer and that he really doesn't know a lot about the abuse allegation that the police were doing their investigation into it. V1 said that he investigated the allegation of abuse between V13 and R7 and it was not substantiated. V1 said he had to investigate this with an unbiased mind because it was his son. V1 said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if a resident wanted their wheelchair to get out of bed and they were in bed and the wheelchair was taken away from them she would consider it abuse or seclusion and she stated that isn't right. Statements provided from the facility regarding the investigation present as follows:V22's (CNA) statement with no date documents, Saturday during report V13 mentioned him and R7 weren't getting along and attempted to put R7 in bed. R7 wouldn't let go of wheelchair so V13 stated he dumped her out of the wheelchair into bed. On Sunday 02/23/25 during report V13 mentioned that R7 and him weren't getting along again and he took her wheelchair and said to me and the nurse next time R7 is mean to him or calls him a Druggie he will throw water in her face or make her eat a bar of soap. A statement dated 02/23/25 with no staff name documents, Today when I arrived to work at 6AM got report. V14 asked me if taking a wheelchair is restraints, right? then told me V13 was being hateful to R7 and put her in bed and took her wheelchair from her. V22 then told me that she forgot to let me know but V13 said in report that he picked R7 up in the wheelchair and dumped her in the bed. R7 is stating that he kept pinching her on her arms and twisting the skin. I told V13 he cannot treat residents like that nor take the wheelchair from them. V13 told me I apologized for taking her wheelchair but next time she calls me a druggie I'm gonna throw water in her face or shove a bar of soap down her throat. V14, V22 and V31 were there for this happening. A statement that says interview with V31 (RN) heard about incident 2nd hand, V31 gave ger medication and took her to C-wing. R7 was upset at that time. Not an eyewitness to any proceeding events prior to taking R7 to C-wing. A statement that says interview with R7 dated 02/25/25 no clear recollection of events at time of interview. A statement that says interview with R7 no date documents. Beat the tar out of me. Stated individual beat her all over. States she screamed and hollered but no one came. Put arms around her and squeezed her. Stated he pinched her under right arm specifically. He hit her on shins as well. A typed statement by V13 dated 02/26/25 which documents R7 has a history of wandering the building. Normally there are no restrictions. (The facility) is currently under precautions due to respiratory illnesses. I try to encourage R7 to stay on her hallway due to infection risks. R7 does suffer from Alzheimer's dementia and does become agitated with restrictions despite repeated attempts to redirect her. R7 is a risk for falls and has poor safety awareness. At the time of this incident, I was talking with the other CNA on the hall. R7 came up to us and started calling me a druggy, loser, and fool. I asked R7 to stop and took her to her room. I asked R7 at that time to please stop calling me names. R7 proceeded to slap and scratch my face. I transferred R7 to her bed. As I was leaving the room, R7 threw a water pitcher at me that hit the back of my head. I quickly left the room with the wheelchair. I placed the wheelchair right outside the room. I told V49 (CNA) that I was going outside to have a cigarette. I was told after returning that the wheelchair was returned to R7 and that she went to another hallway where she remained for the rest of the night. I was frustrated when I gave the report the next morning, but I never was aggressive with R7 in any manner. My care may have been rushed but it was never aggressive. As I gave report, I did not use proper words. It was obvious that I was frustrated with the resident's behavior. A statement by V14 dated 02/24/25 documents, V13 put R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and R7 stated that CNA took w/c away. You talked to V31 and decided that w/c needed to be returned. V31 took resident to c-wing, did not see any interaction between V13 and R7, per V14 V31 was not on the hall at the time of the incident. V14 returned wheelchair immediately, R7 spent rest of night on the suites. An incident report from the local police department documents: Incident Assault, reported 02/23/25 at 4:16PM. Officer arrived at 02/23/25 at 3:34PM. Report of incident Assault: On 02/23/25 I (local officer) responded to (the facility) for a complaint of possible Elderly Abuse. Upon arrival I was met by two nurses that were witnesses to the complaint. I first spoke to V12. V12 stated that she is one of the head nurses at the business and was made aware of an incident that possibly took place the evening of 02/22/25 involving a male CNA and a resident. V12 stated when she arrived at work that a CNA V13 had taken a wheelchair from R7 which her means of getting around the facility. V12 then said that V22 (CNA) another nurse and complainant to this incident, advised her that V13 was telling her during report this morning that he picked R7 up in her wheelchair the night prior and dumped her into her bed. V12 said she confronted V13 about his behavior towards R7 to which he replied I apologized for taking her wheelchair, but next time she calls me a druggie I'm gonna throw water in her face and shove a bar of soap down her throat. V12 advised that R7 is stating that V13 was pinching her arms and twisting her skin during these events as well. V12 stated her and V22 then both went to their Administrator V1 and filed statements and formal complaints against V13 for his conduct. I did not speak to V22 specifically regarding the events due to her working with patient, but she provided her written statement about her involvement with V13. V12 and V22 both provided their written statements and are attached to (Local Police Department) complaint forms in file. I would like to note at this time that V13 is the son of V1, the administrator for the facility. I would also like to note that I was advised that R7 has serve dementia. I spoke with V1, V1 advised that he was made aware of the situation involving his son and resident the morning of 02/23/25 and soon came into work to start his investigation. V1 stated that his son V13 has been suspended from work pending the investigation into the allegations. He advised that he and nurses at the facility have observed R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with R7 while at the facility due to her medical state. V1 stated that a full investigation would be completed on the facilities behalf and reports would be available to investigation as requested. V1 stated that he would be in contact with R7's POA to advise them of the allegations. V1 also provided his bosses information if investigators were to need to contact her. The facility policy titled Abuse Prevention with a revision date of 07/2015 documents in part, This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.

Based on interview and record review the facility failed to ensure residents were free from involuntary seclusion for 1 of 7 residents (R7) reviewed for abuse and neglect in the sample of 44. This failure resulted in R7 experiencing feelings of emotional distress and acts of crying out in fear from being placed into her bed without her wheelchair nearby leaving her with no means of transferring out of bed or mobility safely. The findings include: R7's face sheet, dated 12/22/25 documents an admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem of Falls R7 is high risk for falls. R7 at risk for falling r/t (related to) history of falls visual acuity impairments, decreased safety awareness, impulsiveness with attempts to stand or self-transfers without assistance from staff leaning forward in chair with attempts to pick up objects. On 09/17/24 I slid out of my wheelchair in the hallway. I did not hit my head, and I do not have any obvious injury. On 1/22/25 I was observed sitting on the floor beside my bed. I have no apparent injury. On 03/27/25 I rolled out of bed when sleeping. I had shoulder pain, but it went away. On 07/29/25 I slid off of a pillow that was in the seat of my w/c (wheelchair). No injury. On 11/02/25 I was attempting to move from my w/c to the bed and slid to the floor. Approaches for this problem include: Keep assistive devices at bedside. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation. A facility document titled Long-Term Care Facility and IID-Serious Injury Incident report documents under general information: Incident Date 01/05/2025 with a time of incident of 0630 and a report date of 01/05/25. Resident #1 involved in Incident: R7 listed as victim. Staff #1 involved in the incident: V13 position CNA (Certified Nursing Assistant) , retained no, suspended yes, terminated no. Witness Name V16 (former Assistant Director of Nursing) and V49 (CNA). Detailed Incident Summary (Who, What, When, Where, Why) Resident #1 (R7) is a 95 y.o (year old) Fw/PMH (Female with a Past Medical History): dementia, CAD (Coronary Artery Disease), HTN (Hypertension), anxiety, insomnia, depression. Per the facility protocol, an investigation was conducted in response to an allegation of abuse involving resident #1 (R7). Per interview conducted with witness #2 (R49), resident approached witness #2 and staff during a conversation. Witness #1 (V16) stated that resident #1 stated she needed to be careful with that man staff asked resident not to interrupt and took resident #1 (R7) to room. Per staff member resident #1 (R7) referred to him as a druggie, loser, and a fool He did ask her to stop and took her to her room. While in the room staff member states that resident slapped him and scratched his face. Resident #1 then through a water pitcher at staff member striking him in the back of the head. Staff member left the room with no further incident. Staff member stated that he went outside to take a break following the incident. Staff member states that he did rush his care with resident #1, but he was never aggressive with the resident #1. Staff member states that he was frustrated with the resident's behavior. Multiple staff members did hear about the incident second hand. The PCP (Primary Care Physician, Administrator, ADON (Assistant Director of Nursing) and family were notified of the incident. An interview was conducted with the resident with ADON present. A skin assessment was completed with no findings by the ADON. Law enforcement notified of incident and investigation is ongoing with no current concerns. Facility investigation unsubstantiated with no findings of abuse. Resident #1 had no recollection of event on follow up interview. Dated 02/28/25 by V1 (Administrator) at 12:00PM. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated one day V1's (Administrator) son V13 (CNA) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. At that time observed R7 trying to show she couldn't reach across her body with her right arm and when she moved her right arm across her body to her left, she grabbed her right shoulder and said ouch, it hurts when I do that. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who called him and asked him what happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the incident with V13 and R7 and he was by (in hallway) because he had just come out from there passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 told R7 he would be right back and get her taken care of, he was taking his med cart back up to where it belongs and while he was taking his cart he started thinking that taking a wheelchair away was considered a restraint and he got worried so he went and got V31 (Registered Nurse) to ask for help with the situation. V14 stated he asked V31 if taking R7's wheelchair away was a restraint and V31 stated yes, that last time someone took her wheelchair away she fell and had to get staples. V14 stated he and V31 ran back to R7's room and when they walked in R7 was still visibly upset and was reaching for V31 to console her. V14 stated the R7 refused her medications with him because she was so upset but she ended up taking them for V31. V14 stated R7 is independent with getting herself from the wheelchair to the bed and back to her wheelchair. V14 stated V13 told him that R7 called him a druggy saying he will never make anything of himself and V14 told him it doesn't matter what a resident says to you, you cannot take away their wheelchair and shut them in their room. V14 stated he didn't report the incident because he didn't know he was supposed to. V14 stated V1 (Administrator) called him and asked what happened. V14 stated no one else from the facility contacted him regarding this incident. V14 stated the police never contacted him regarding this incident. V14 stated he doesn't remember talking to anyone from Illinois Department of Public Health prior to right now. V14 stated this incident bothered him for a long time because he just felt like it wasn't right and wondered what could have happened to R7 if no one was there. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. On 12/4/25 at 2:57 PM, V22 (CNA) stated she took report from V13 on Saturday 2/22/25 in the morning and V13 told her that he and R7 weren't getting along during the night and he said he tried to put R7 in bed and she would not let go of her wheelchair, so he dumped her into bed. V22 stated that during report on 2/23/25 V13 told her that he and R7 weren't getting along again so he took her wheelchair away from her and he told V22 that if she called him a druggie again, he would throw water in her face and make R7 eat a bar of soap. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. V12 stated when she arrived to work that morning at 6:00 AM R7 was still on the rehab unit and would not come back to her unit because she was so upset. V12 stated she was finally able to get her to come back around 2PM or 3PM that day. V12 stated she did a body assessment after the police and V1 arrived at the facility. V12 said that the police officer and V1 were present as they looked at R7's arms and under her arms where R7 said she was hurting. V12 stated she did not see any markings. V12 stated anytime Illinois Department of Public Health came into the facility V2 (DON) would tell staff to keep their mouths shut about the alleged abuse of R7 by V13. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her and she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/03/25 at 2:49PM, V31 (RN) said that he was working the night that the incident occurred with V13 and R7. V31 said that he was working a different hall and that V14 (LPN) came and got him. V31 said that V13 had taken R7's out of her wheelchair and put her in her bed and had the door shut and the wheelchair on the outside of R7' room. V31 said that R7 was in her room yelling and that he and V14 went in and got R7 back up out of bed and moved her to a different hall because V13 was still working on her hall. V31 said that R7 will usually transfer herself if she has her wheelchair next to her, but V13 moved her wheelchair away from her. On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if a resident wanted their wheelchair to get out of bed and they were in bed and the wheelchair was taken away from them she would consider it abuse or seclusion and she stated that isn't right. On 12/08/25 at 11:28AM, V1 (Administrator) said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. Statements provided from the facility regarding the investigation present as follows:V22's (CNA) statement with no date documents, Saturday during report V13 mentioned him and R7 weren't getting along and attempted to put R7 in bed. R7 wouldn't let go of wheelchair so V13 stated he dumped her out of the wheelchair into bed. On Sunday 02/23/25 during report V13 mentioned that R7 and him weren't getting along again and he took her wheelchair and said to me and the nurse next time R7 is mean to him or calls him a Druggie he will throw water in her face or make her eat a bar of soap. A statement dated 02/23/25 with no staff name documents, Today when I arrived to work at 6AM got report. V14 asked me if taking a wheelchair is restraints, right? then told me V13 was being hateful to R7 and put her in bed and took her wheelchair from her. V22 then told me that she forgot to let me know but V13 said in report that he picked R7 up in the wheelchair and dumped her in the bed. R7 is stating that he kept pinching her on her arms and twisting the skin. I told V13 he cannot treat residents like that nor take the wheelchair from them. V13 told me I apologized for taking her wheelchair but next time she calls me a druggie I'm gonna throw water in her face or shove a bar of soap down her throat. V14, V22 and V31 were there for this happening. A typed statement by V13 dated 02/26/25 which documents R7 has a history of wandering the building. Normally there are no restrictions. (The facility) is currently under precautions due to respiratory illnesses. I try to encourage R7 to stay on her hallway due to infection risks. R7 does suffer from Alzheimer's dementia and does become agitated with restrictions despite repeated attempts to redirect her. R7 is a risk for falls, and has poor safety awareness. At the time of this incident, I was talking with the other CNA on the hall. R7 came up to us and started calling me a druggy, loser, and fool. I asked R7 to stop and took her to her room. I asked R7 at that time to please stop calling me names. R7 proceeded to slap and scratch my face. I transferred R7 to her bed. As I was leaving the room, R7 threw a water pitcher at me that hit the back of my head. I quickly left the room with the wheelchair. I placed the wheelchair right outside the room. I told V49 (CNA) that I was going outside to have a cigarette. I was told after returning that the wheelchair was returned to R7 and that she went to another hallway where she remained for the rest of the night. I was frustrated when I gave the report the next morning, but I never was aggressive with R7 in any manner. My care may have been rushed but it was never aggressive. As I gave report, I did not use proper words. It was obvious that I was frustrated with the resident's behavior. A statement by V14 dated 02/24/25 documents, V13 put R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and R7 stated that CNA took w/c away. Talked to V31 and decided that w/c needed to be returned. V31 took resident to c-wing, did not see any interaction between V13 and R7, per V14 V31 was not on the hall at the time of the incident. V14 returned wheelchair immediately, R7 spent rest of night on the suites. An incident report from the local police department documents: Incident Assault, reported 02/23/25 at 4:16PM. Officer arrived at 02/23/25 at 3:34PM. Report of incident Assault: On 02/23/25 I (local officer) responded to (the facility) for a complaint of possible Elderly Abuse. Upon arrival I was met by two nurses that were witnesses to the complaint. I first spoke to V12. V12 stated that she is one of the head nurses at the business and was made aware of an incident that possibly took place the evening of 02/22/25 involving a male CNA and a resident. V12 stated when she arrived at work that a CNA V13 had taken a wheelchair from R7 which her means of getting around the facility. V12 then said that V22 (CNA) another nurse and complainant to this incident, advised her that V13 was telling her during report this morning that he picked R7 up in her wheelchair the night proper and dumped her into her bed. V12 said she confronted V13 about his behavior towards R7 to which he replied I apologized for taking her wheelchair, but next time she calls me a druggie I'm gonna throw water in her face and shove a bar of soap down her throat. V12 advised that R7 is stating that V13 was pinching her arms and twisting her skin during these events as well. V12 stated her and V22 then both went to their Administrator V1 and filed statements and formal complaints against V13 for his conduct. I did not speak to V22 specifically regarding the events due to her working with patient, but she provided her written statement about her involvement with V13. V12 and V22 both provided their written statements and are attached to (Local Police Department) complaint forms in file. I would like to note at this time that V13 is the son of V1, the administrator for the facility. I would also like to note that I was advised that R7 has serve dementia. I spoke with V1, V1 advised that he was made aware of the situation involving his son and resident the morning of 02/23/25 and soon came into work to start his investigation. V1 stated that his son V13 has been suspended from work pending the investigation into the allegations. He advised that he and nurses at the facility have observed R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with R7 while at the facility due to her medical state. V1 stated that a full investigation would be completed on the facilities behalf and reports would be available to investigation as requested. V1 stated that he would be in contact with R7's POA to advise them of the allegations. V1 also provided his bosses information if investigators were to need to contact her. The facility policy titled Abuse Prevention with a revision date of 07/2015 documents in part, This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.

Based on observation, interview, and record review, the facility failed to administer/apply pain medications as ordered for 1 of 3 residents (R19) reviewed for pain management in a sample of 44. This failure resulted in R19 experiencing pain with the treatment application to R19's leg wounds.The findings include: R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including: cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating R19 has severe cognitive impairment. Section J, Health Conditions, documents that R19 experiences pain or hurting frequently.R19's Care Plan documents that R19 has impaired skin integrity related to venous insufficiency and R19 has pain/risk for pain with a start date of 9/26/25 with documented interventions including administer medications, monitor and record effectiveness, and report adverse side effects.R19's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R19 has the following wounds: Venous wound of the right leg with a wound size of 13.6 cm (Centimeters) length x 16.8 cm width x 0.3cm depth , skin tear of the right dorsal foot wound size of 1.3 cm in length x 1.4 cm width x 0.5 cm in depth, arterial wound of the right ankle with a wound size of 2.7 cm length x 2.7 cm in width x 0.4 cm in depth, non-pressure wound of the right medial foot with a wound size of 1.3 cm length x 2.4 cm in width x 0.3 cm in depth, and skin tear to the right, posterior ankle with a wound size of 12 cm in length x 5 cm in width x 0.3 cm in depth.R19's Physician Order Report dated 11/15/2025-12/15/2025 documents and order for Lidocaine cream 4% topical, apply to right lower extremity wounds prior to wound care/treatment change once a day with a start date of 11/17/25 and an end dated labeled open ended, an order for pain assessment every shift with a start date of 10/06/25 with an end date labeled open ended, and an order for hydrocodone-acetaminophen tablet 5-325mg amt (Amount) 1 tablet twice a day PRN (as needed) with a start date of 09/26/25 and an end date labeled open ended. R19's Pain-MDS focused assessment dated [DATE] documents: Pain received schedule pain med regimen: No; Pain management: Received PRN (as needed) pain meds or offered and declined: Yes; Received non-medication interventions: Yes; Should pain assessment interview be conducted: Yes; Res (resident) have you had pain or hurting at any time in the last 5 days? Yes; Res (resident) How much of the time have you experienced pain or hurting over the last 5 days? Occasionally; Res (resident) Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Rarely or not at all; Res (resident) Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? Rarely or not at all; Resident Over the past 5 days, how often have you limited your day-to-day activities? Occasionally; and Resident please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine: 4.R19's Medication Administration Record (MAR) for December 2025 documents: Hydrocodone-Acetaminophen 5-325mg 1 tablet PRN (As Needed) twice a day. Administered on 12/02/25 at 8:45PM for pain, 12/04/25 at 12:28AM for pain, 12/04/25 at 9:40AM for pain, 12/05/25 at 10:52PM for pain, 12/08/25 12:44AM for pain, 12/08/25 10:29PM for pain, 12/09/25 10:31AM for pain, 12/09/25 11:11PM for pain, 12/10/25 10:31AM for pain, 12/10/25 7:40PM pain 4/10 RLE (Right Lower Extremity), 12/12/25 12:50AM for pain 7/10 for RLE, 12/12/25 7:34PM for pain, 12/13/25 7:33PM for pain, 12/15/25 12:54Am for pain, 12/17/25 at 9:47AM for pain 12/21/25 at 12:32AM for pain, 12/21/25 11:40PM for pain 4/10 RLE. The same MAR documents the order for Lidocaine cream 4% topical apply to right lower extremity wounds prior to wound care/treatment change from 6:30PM to 6:30AM was administered on the following dates: 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/26, 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, and 12/21/25. On 12/08/25 at 11:41 PM, V37 (License Practical Nurse) was observed providing wound treatment on R19 wounds of the right leg and foot. Observed old dressing which was saturated with large amounts of yellowish-green drainage to entire dressing. Topical lidocaine was not observed to be applied during this observation. R19 was observed multiple times throughout the procedure grimacing, grabbing her leg, and saying ouch. Wounds extend to most of R19 lower right leg from front to the back with what appears to be a depth of around 0.25 to 0.5 cm in depth. The area to the back of the right leg around the ankle/heel area looks to have a large amount of slough and possible muscle exposure.On 12/08/25 at 1:30 PM, R19 stated that there have been times when she has not gotten her treatment done to her right leg. R19 stated the nurses won't do it for a couple of days. R19 stated they have told her they have ran out of the medicine they put on her wounds on her right leg before. On 12/17/25 at 1:31PM, R19 stated that she doesn't know if they put the lidocaine on her leg during her treatment or not. R19 said that they just start working on her right leg and she doesn't' t know what all they are doing to her just that they are doing the treatment. R19 said that it always hurts when she gets her treatment done. R19 said that she usually will get a pain pill before her treatment if she requests it. R19 said that she is usually asleep when they come in to do her treatment, so she doesn't get a chance to request the pain pill prior to the treatment. On 12/17/25 at 1:40PM, V40 (Licensed Practical Nurse/LPN) stated that she looked in the treatment cart and she was unable to find any lidocaine gel for R19. V40 said that she found lidocaine gel for other resident, because each lidocaine gel is prescribed to each resident. V40 said that she looked in the medication cart as well and only found a lidocaine gel tube with no resident name on it and didn't know who's gel it was.On 12/03/25 at 2:19 PM, V21 (LPN) stated they run out of wound supplies like prescription creams and medication for wounds at times, and she will have to push off the wound care at nighttime until the next shift.On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if lidocaine is ordered for pain control to be applied prior to wound treatments it should be applied. V2 stated a residents lidocaine cream will have their name on it and come from their pharmacy, On 12/19/25 at 9:45AM, V48 (Physician) stated that he would expect any medication or treatment that is ordered to be administered as ordered. V48 said if R19 had an order for lidocaine gel to be applied to her right leg before doing the treatment then he would expect it to be applied. V48 said that the lidocaine gel being applied before the treatment performed was probably to help with pain from the treatment as a topical pain medication.The facility policy titled Pain Prevention and Treatment with an effective date of October 2017 documents Policy: To assess for, reduce the incidence of the severity of pain to help resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and non-pharmacological interventions to manage pain and/or try to prevent the pain consistent with the resident's goals. Definitions: Pain-an unpleasant sensory and emotional experience that can be acute, recurrent, or persistent.

Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 73 residents currently residing at the facility. Findings include:1. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment.R1's Physician Order Report dated 11/2/25-12/2/25 documents mechanical lift for transfers. R1's Care Plan documents R1 is dependent for transfers, R1 uses mechanical lift for all transfers. On 11/26/25 at 8:28 AM, R1 was lying in bed. R1 stated she wanted to get up for breakfast, but the CNA (Certified Nursing Assistant) told her she couldn't get her up because there wasn't anyone to help her since she was a mechanical lift. R1 stated she doesn't like eating in her bed, she likes going to the dining room for meals. R1 was orientated to person, place, time, and situation during interview. On 11/26/25 at 8:32 AM, V5 (CNA) stated she was told when she arrived at her shift at 8am that they didn't have enough staff to get R1 up since she was a mechanical lift. On 11/26/25 at 2:34 PM, V7 (CNA) stated night shift doesn't get any 2 person assist up in the morning and he is the only CNA on the floor from 6am-8am so he must find someone to help him get R1 up since she is a mechanical lift. V7 stated he didn't get R1 up today because she is a 2 person assist, and he would rather get up the other 13 residents that are a 1 assist then get up 1 resident that needs 2 staff to help. On 12/2/25 at 11:22 AM, V2 (Director of Nursing) stated no resident should be left in bed because they are a 2 person assist. V2 stated there are plenty of staff in the building to help, including herself. On 12/2/25 at 12:23 PM, V1 (Administrator) stated he is not aware of staff unable to get mechanical lift residents up due to not having enough staff to help, they should ask someone in the building to help. V1 stated there is always someone in the building to help. 2. R38's Face Sheet documents an admission date of 10/18/2023 with diagnoses including in part pain in right foot, hypertension, and tobacco use. R38's MDS dated [DATE] documents a BIMS of 15, indicating R28's cognition is intact.On 11/26/25 at 9:14 AM, R38 stated it can take 30 minutes or more to get his call light answered at times. 3. R27's Face Sheet documents an admission date of 10/17/2023 with diagnoses including in part generalized arthritis. R27's MDS dated [DATE] documents a BIMS of 10, indicating R27's cognition is moderately impaired.On 11/26/25 at 9:16 AM, R27 stated she feels like they could really use more staff, especially nighttime they need staff the most. 4. R30's Face Sheet documents an admission date of 9/30.2025 with diagnoses including in part pain in thoracic spine, nausea with vomiting, dizziness and giddiness, weakness, and other chronic pain. R30's MDS dated [DATE] documents a BIMS of 15, indicating R30's cognition is intact.On 11/26/25 at 9:30, AM, R30 stated she thinks they could use more help on all shifts. R30 stated sometimes when you need assistance you might have to wait a while for help. 5. R4's Face Sheet documents an admission date of 4/30/2024 with diagnoses including in part hypertension, type 2 diabetes, chronic kidney disease, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, acquired absence of left leg below knee, history of falling, pain in left shoulder, and other chronic pain. R4's MDS dated [DATE] documents a BIMS of 15, indicating R4's cognition is intactOn 11/26/25 at 9:45 AM, R4 stated his call light can be a long wait at times, sometimes up to an hour and it is usually worse on Saturdays and Sundays. R4 stated he asked for a cup of ice water one night recently and he waited about 4 hours before he got it. On 12/01/25 at 3:06 PM, V28 (Cook) stated he has seen the CNA's not getting all the residents up for meals. V8 stated a lot of times they don't have enough staff to be able to get all the resident up for meals. On 12/04/25 at 5:18 PM, V32 (License Practical Nurse) stated her last day was in October of 2025. V32 stated they were short of staff often. V32 stated they had times when there was only 2 CNA's in the entire building and management would get mad when we would tell them that we have no staff. V32 stated administration would send out a group text message trying to get someone in to work, they would offer bonus to try and get someone to come in but most of the time they weren't able to get anyone in to work. V32 stated a lot of the time they didn't have any management come in to help, they would just work short. On 12/03/25 at 2:19 PM, V21 (Licensed Practical Nurse) stated she has witnessed where they couldn't get all the residents up or put them back in bed because they only had 1 CNA and 1 nurse on the unit. V21 stated the nurse was busy doing medication pass and couldn't help the CNA out to lay down the residents or get them up. On 12/08/25 at 10:32 AM, V21 stated one nurse went home this morning and now it is only her and one other nurse taking care of all the residents. V21 stated she and the other nurse have 38 residents each to care for. V21 stated if we have an admission or an emergency it can be difficult to get all the resident care completed. V21 stated back on the suites it is very hard because they are higher levels of care. V21 stated she has been yelled at by V2 (Director of Nursing) as she was doing resident care, she was yelling at her to get off the clock and clock out while she was in a residents room. V21 stated a couple of dressing changes have been missed because they didn't have enough staff, and it was too busy. V21 stated she has been in trouble by V1 (Administrator) and V2 when she was trying to get a dressing change completed and V1 was telling her to get off the clock, and she told him that she didn't get a dressing change completed. V1 told her that she needs to pass it on to the next shift. V21 stated V1 has told her that cooperate doesn't want us to stay on the clock and we need to just pass on whatever is not completed. V21 stated she has had to report off to the next shift that she did not get a dressing change or two completed and she doesn't not know if the dressing got done. V21 stated she would feel better about it if she knew it was completed. V21 stated a couple of weeks ago she didn't get R1's wound dressing complete and she had to report it off to another nurse and she doesn't know if it got done. V21 stated she isn't saying it didn't get done but she just doesn't know if it was completed on the next shift or not. V21 stated she doesn't see long call light wait times very often but sometimes the CNAs are busy with another resident, and it may take them longer to get to that call light. On 12/08/25 at 10:55PM, V35 (CNA) stated she usually works 6p-6A on night shift. V35 stated they usually have 6 CNA's and 2 Nurses at night shift to the whole building. V35 stated they are supposed to have 6 CNA's every night but that doesn't always happen. V35 stated they do have call ins sometimes and management will call other CNAs to see if they can get someone to cover. V35 stated at times they end up with just one CNA on each unit and they will have them come to help the other units with resident care. V35 stated when they only have 4 CNAs for the whole building, she doesn't think the residents get proper care. On 12/17/25 at 10:04 AM, V20 (CNA) stated they had a call in today and they didn't know that a staff called off and she was on transportation for the day and didn't have any appointments, so they pulled her to the floor. V20 said management doesn't come in and cover the floor when the CNAs have a call off. V20 said they just have to make it work and cover the halls the best they can. V20 said when they come to work in the morning at 6AM that most of the night shift CNA are already gone.On 12/17/25 at 10:07 AM, V7 (CNA) said that when they come in the morning, most of the 6p to 6am staff are gone and there might be one CNA and 2 nurses in the building when they get here at 6AM. V7 said the 6p to 6a CNAs will just leave and not give any kind of report or anything. V7 said he had a resident that fell the other night, and he didn't know that they were on neuro checks and needed vitals done until the nurse told him, because the night shift staff was gone and didn't tell him anything. On 12/17/25 at 10:10 AM, V30 (CNA) stated that no management will cover the floor when they have a call in and can't find anyone to cover the floor. V30 said that management will not work the floor as a CNA. V30 said that they just try to make it work with as many staff as they have. V30 said that when they work short, they always make sure the resident care is done the best they can. V30 said that the resident care will always come first. V30 said that sometimes they don't have anyone one up and it is 7:30AM.On 12/17/25 at 11:30AM, V1 stated he has heard something about night shift CNAs leaving before day shift CNAs get into the building. V1 said that he heard that the nurses and a CNA were in the building still, he said that he should have investigated it. V1 said that he hasn't looked into it. V1 stated he does not get to the facility until around 8:00AM so he doesn't know if they did really leave. V1 said that he thinks it would be ok for 15-20 minutes if there were just the 2 nurses and 1 CNA in the building until the day shift staff come in. V1 said that they have nurse managers that are on call weekly. V1 said that he knows if they have a call off, they call or text the nurse managers. V1 said that he does know that staff has had problems with getting a hold of the nurse managers. V1 said that he did talk to V3 (Assistant Director of Nursing), V17 (MDS Coordinator) and V2 (Director of Nursing) about making sure that they are available. V1 said if the staff call off, he expects the nurse managers to come in to work the floor as a nurse or a CNA if they are short.6. The Resident Council Minutes from 11/10/25 documents under New Business: Nursing: urinals, shower waits, and call light waits.The Facility Resident Council Referral Form dated 11/10/25 documents specific preferences/problems/concerns identified during the resident council meeting: urinals not getting emptied at night, call light wait times, and shower waits. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility.

Based on interview and record review the facility failed to ensure that all staff have the appropriate competencies and skill sets to provide care and meet the residents' needs. This failure has the potential to effect all 73 residents living in the facility.The findings include: On [DATE] at 9:45 AM, V20 (Certified Nurse Assistant/CNA) stated this past weekend there was a CNA that was not certified working as a CNA, and she was let go on Monday by V1 (Administrator).On [DATE] at 10:06 AM, V1 (Administrator/ADM) stated the BOM (Business Office Manager) checks the CNA registry for their credentials prior to them working. V1 stated V46 (Nurse Assistant/NA) was hired and worked as a CNA but they later found out she never showed up for her certification test, so she is not a Certified Nursing Assistant. V1 stated they have a NA policy, but he is unsure what job duties she actually performed while on the job. V1 stated V46 was hired on [DATE].On [DATE] at 11:30AM, V1 said that they did have a CNA (V46) that was working at the facility he thought she was a CNA. V1 said that they did check the CNA registry, and it said that V46 was eligible for hire, and he said that it wasn't until recently he checked the registry and saw that under her test it said NS. V1 said that he didn't know what NS meant so he emailed the registry to ask them what the NS meant next to testing. V1 said that the CNA registry emailed him back and told him that the NS meant that V46 was a no show to take the CNA exam. V1 said that she had 120 days to take her test and work as a NA with another CNA. V1 said that he thinks the 120 days was up around [DATE]. V1 said that he doesn't know if she worked outside of her qualifications. V1 said they did a lot of hiring at the facility recently. V1 said that she no longer works at the facility now.On [DATE] at 10:10AM, V30 (CNA) stated they had a CNA V46 who was working on night shift who was not certified.On [DATE] at 09:13 AM, V1 provided hire date of [DATE] and a termination date of [DATE] for V46.On [DATE] at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated V46 (NA) worked primarily on the ARCH unit but she floated so probably would have worked on all hallways in the whole building. V3 stated she heard a rumor that V46 didn't have an active CNA certification, so she went straight to V1 and told him, and she did not work again after they found out she didn't have a current certification. V3 stated V46 was hired as a CNA so she could have provided care as a CNA outside of the NA policy, but she doesn't know for sure because she worked midnights, and she wasn't ever in the building when she was working.On [DATE] at 9:56 AM, V46 (NA) stated she started at the facility the week prior to Thanksgiving this year and she worked as a full CNA. V46 stated when she was hired V2 (DON) knew she hadn't tested yet. V46 stated V2 told her to schedule it as soon as she could. V46 stated she finished CNA school in May of 2025 and her test is scheduled for [DATE]. V46 stated when she interviewed with V2 (DON) she told her she hadn't taken her certification test yet but she really wanted the job. V46 stated V2 hired her on the spot during her interview with the intention she would take her test as soon as she could. V46 stated V2 told her she was okay with her working without her certification for a little while until she could take her test. V46 stated she worked all over the building, she would go where she was needed.The facility document titled Certified Nursing Assistant Job Description documents job summary as The overall purpose of the Certified Nursing Assistant position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the residents' plan of care. Education and Experience Requirements: The Certified Nursing Assistant must have the following: State certification as a Certified Nursing Assistant, CPR (Cardiopulmonary Resuscitation) Certification preferred, ability to read, write, and speak the English language, no disqualifying criminal offenses as defined by regulatory guidelines.The midnight census report dated [DATE] documents there are 73 residents living in the facility.

Based on observation, interview, and record review the facility failed to use accurately labeled medication/cream, use cream that was not expired, and lock the medication and wound treatment carts. This failure has the ability to affect all 73 residents in the facility. Findings include:1. R17's Face Sheet documents an admission date of [DATE] with diagnoses including: Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility and R17 has pain/risk for pain with a start date of [DATE].R17's Physician Order Report dated [DATE]-[DATE] documents orders for silver sulfadiazine cream topical and clotrimazole cream topical, special instructions: Cleanse the wound to the right abdomen with normal saline or wound cleanser, apply silver sulfadiazine cream, clotrimazole, collagen powder, calcium alginate, and dry dressing daily, once a day, 06:30 PM - 06:30 AM with a start date of [DATE] and an end date labeled open ended, Metronidazole tablet 500 mg and betadine solution topical, special instructions: cleanse the wound to the right third toe with wound cleanser or normal saline, apply betadine, crushed metronidazole, calcium alginate, and dry dressing daily with a start date of [DATE] and an end date labeled open ended, and Povidone-iodine solution topical, special instructions: start betadine, calcium alginate and gauze wrap for the whole foot daily, once a day, 07:00 PM - 10:00 PM with a start date of [DATE] and an end date labeled open ended. On [DATE] at 12:09 AM, wound care for R17 was observed. V25 (Registered Nurse/RN) had to go to another unit to find collagen. V25 mixed collagen and silver sulfadiazine cream together. The tub of silver sulfadiazine cream did not have a name on it, V25 stated she didn't know who it belonged to because it doesn't have a name on it, but she doesn't know where her cream is, so she is going to use it.2. R3's Face Sheet documents an admission date of [DATE] with diagnose including: Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3's cognition is intact.R3's Care Plan documents a problem category of pressure ulcer/injury. Impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of [DATE].R3's Physician Order Report dated [DATE]-[DATE] documents an order for silver sulfadiazine cream topical, cleanse the area to the left upper buttock with wound cleanser or normal saline, apply Silvadene cream, collagen powder, calcium alginate, and dry dressing daily with a start date of [DATE].On [DATE] at 11:45 PM, wound treatment for R3 was observed. V25 (Registered Nurse/RN) mixed collagen and silver sulfadiazine cream that had another resident's name on it and had an expiration date of [DATE]. This surveyor asked V25 if the cream belonged to R3, and she stated she doesn't know where his is, so she is going to use the cream that belongs to a different resident since she doesn't use it anymore. This surveyor asked V25 what the expiration date of the silver sulfadiazine cream is, and she stated [DATE]. On [DATE] at 12:33 AM, V25 stated sometimes she will use other residents supplies if she can't find the correct supplies. V25 stated she probably shouldn't have used expired silver sulfadiazine cream on R3.On [DATE] at 10:55 PM, a cup of white cream with a spoon on top of the treatment cart for A Wing, Long Hall was observed. A tube of Nystatin on top of treatment cart was also observed with no nurse in the area. The treatment cart was unlocked.On [DATE] at 10:58 PM, the medication cart for A Wing, Long Hall was observed and was unlocked with the top drawer open slightly, with no nurse in the area. 2 Certified Nursing Assistants were observed working on the hall where the treatment cart was located. On [DATE] at 11:09 PM, the medication cart for A Wing, Short Hall was observed to be unlocked, with no nurse observed on the hallway. There were 2 CNA's observed working on the hallway where the medication cart was observed.On [DATE] at 11:10 PM, the medication cart for C Wing, East Hall was observed to be unlocked with no nurse around. There were 2 CNA's observed working on the hallway where the medication cart was observed.On [DATE] at 12:33 AM, V25 (RN) stated she usually doesn't leave the medication cart unlocked when she isn't around it but sometimes, she forgets to lock it.On [DATE] at 9:10 AM, V2 (Director of Nursing) stated medication and treatments carts should be locked when the nurse is not around the cart and there should not be any medications or creams sitting on top of the carts not locked up unless the nurse is with it. V2 stated you should not borrow medications or creams from other residents. V2 stated any medication/cream that is expired should not be used.A pharmacy policy titled Medication Administration dated [DATE] documents under B. Administration, 16) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.A pharmacy policy titled Medication Labels dated [DATE] documents under procedures: B. Each prescription medication label or package includes: 1) Resident's name. 8) Beyond use (or expiration date of medication on the package.The facility Midnight Census Report dated [DATE] documents that 73 residents reside in the facility.

Based on observation, interview, and record review the facility failed to follow the approved menu by not providing the approved protein and not serving the correct portion sizes. This failure has the ability to affect all 73 residents residing at the facility. Findings include:The facility Fall/Winter 2025 menu documents on 12/1/25 breakfast: choice of cereal, biscuits and gravy, margarine, orange, apple, or cranberry juice, milk, coffee/tea. The menu documented lunch: country chicken breast, garlic mashed potatoes, California vegetable blend, cornbread, chef's choice of dessert, gravy, margarine, milk, coffee/tea. 1. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. On 12/1/25 at 8:26 AM, R3 was in bed eating breakfast. Observed R3 was served scrambled eggs, hot cereal, toast, coffee, and water. R3 stated he hasn't had meat with his breakfast for a while and he likes having meat with his breakfast because he is supposed to have double protein, and the eggs aren't good and are usually cold. R3 stated they have eggs all pretty much every morning. R3 stated on his meal ticket he is supposed to get double protein and milk, and he doesn't get double protein very often and he hasn't had his milk in a long time because one of his special cups started leaking so they had to throw it away and they haven't replaced it. On 12/1/25 at 8:34 AM, R8 was served scrambled eggs, cereal, and toast. R8 who was alert and oriented stated they haven't had breakfast meat with their breakfast in a week or 2 and he likes having meat with his breakfast. On 12/1/25 at 8:34 AM, R9 was served scrambled eggs, cereal, and toast. R9 who was alert and oriented stated they haven't had meat with their breakfast in a week or 2 and she likes having meat with her breakfast. On 12/1/25 at 8:35 AM, R10 was served scrambled eggs, cereal, and toast. R10 who was alert and oriented stated they haven't had meat with their breakfast in a while and she likes having meat with her breakfast. On 12/1/25 at 8:41 AM, V10 (Certified Nursing Assistant/CNA) stated the residents were served scrambled eggs, hot cereal, and toast for breakfast this morning and no meat. On 11/26/25 at 9:39 AM, R2 who was alert and oriented stated they haven't served meat for breakfast for several days, then stated, I told you that the food is terrible. On 12/1/25 at 9:17 AM, V11 (Cook) stated she didn't make meat with breakfast because they do not have any. V11 stated they haven't had meat for breakfast for about a week. V11 stated they did not have what was on the menu for breakfast because she made biscuits and gravy over the weekend, so she didn't have the ingredients to make them today, so she made scrambled eggs, cereal, and toast for today. V11 stated she decided on the menu for today, and did not consult the dietitian. V11 stated she didn't give R3 milk today because he only has 2 cups, so she gave water and coffee. V11 stated R3 needs a 3rd cup ordered and she doesn't know who orders the cups. V11 stated she worked at the facility a while back and R3 had 3 cups at that time but since she's been back this time (about 2-3 months) he has only had 2 cups. V11 stated they are supposed to have chicken for lunch today, but they do not have any, so she decided to serve Salisbury steak, mashed potatoes, and green beans. On 12/1/25 at 9:29 AM, V4 (Dietary Manager) stated they won't get their next food truck until Thursday of this week. V4 stated she was not aware they were out of breakfast meat. V4 stated they are out of chicken for lunch today as well so V1 subbed Salisbury steak. V4 stated she ordered for 2 weeks on her last truck instead of 1 week due to the Thanksgiving holiday falling on the day they normally get their food truck, but she must have not ordered enough. On 12/1/25 at 3:06 PM, V28 (Cook) stated they didn't have any breakfast meats this past week for breakfast. V28 stated he did let V4 (Dietary Manager) know that we were out of breakfast meat. V28 stated he thinks the reason they ran out of the breakfast meat was because of the holiday and V4 had to double order back to back. On 12/2/25 at 3:18 PM, V19 (CNA) stated she saw there wasn't any meat served with breakfast for a couple of days, and she stated there were several residents that complained to her, R3 and R4 are the 2 she can remember off the top of her head. 2. The facility Fall/Winter 2025 menu documents on 12/3/25 dinner: smoked sausage, sauerkraut, sweet peas, fruit cocktail, milk, coffee/tea. On 12/3/25 at 4:50 PM, observed dinner meal on the rehab unit. Bite size hot dog/sausage pieces were served. Each resident was served 4 bite size pieces of hot dog/sausage. The hot dog/sausage was thin and small/thin in size. On 12/17/25 at 2:05 PM, V47 (Cook) stated he usually works for lunch and dinner service. V47 stated he has served cut up sausage and sauerkraut before. V47 stated they cook the sausage whole then cut them into bite size pieces. V47 stated when the sausage is cut up, they are cut up into about 9 or so pieces per sausage. V47 stated 4 pieces of sausage is not a whole sausage. On 12/17/25 at 3:50 PM, V4 (Dietary Manager) stated she looked the at the recipe for the sausage and sauerkraut that was served on 12/3/25 for dinner and it did call for a whole sausage. V4 stated the residents were probably not served the correct portion size due to them being cut up and only served 4 pieces. The facility dietary recipe for Sausage Smoked documents a single serving size of one 4 oz smoked sausage. 3. The Resident Council Minutes from 11/10/25 documents menu is not getting done. The Facility Resident Council Referral Form dated 11/10/25 documents specific preferences/problems/concerns identified during the resident council meeting: menu not getting updated was referred to V4. The Resident Council Minutes from 9/9/25 documents menus not always being updated. The Facility Resident Council Referral Form dated 9/9/25 documents specific preferences/problems/concerns identified during the resident council meeting: menus not being updated was referred to V4. A facility policy titled Meal Substitutions dated December 2016 documents under Purpose: To ensure residents receive adequate nutrition and hydration and to ensure resident preferences are honored and monitored. A facility policy titled Menus dated December 2016 documents under Policy menus shall be followed which have been written, reviewed for nutritional adequacy and approved by a Registered, Licensed Dietitian in compliance with Federal and State Regulations and consistent with Standards of Practice on nutritional care. In the same document it documents Changes following the implementation of the menu shall be reviewed and revised, as necessary, by the Registered, Licensed Dietitian. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility.

Based on observation, interview, and record review the facility failed to discard food items in the refrigerator and dry storage that were past the used by/expiration dates. This has the potential to affect all 73 residents living in the facility Findings include:On 11/25/25 at 12:10 PM, observations of the kitchen began. In the reach in freezer there was an unopened bag of crumbled sausage that had an expiration date of 11/9/25. On the storage rack there was an unopened container of strawberry glaze that had an expiration date of 10/25/25. On the storage rack there was an opened bottle of chocolate fudge that had 5/23 on it as the open date and had an expiration date of 11/13/25 on it. There were 2 unopened bags and 1 open bag of cookie pieces that had an expiration date of 11/23/25. There were 2 unopened boxes of cornstarch on the storage rack that had an expiration date of 8/28/23. There was a bag of opened tortilla chips on the storage rack that had an expiration date of 9/17/25 and no open date. V4 (Dietary Manager) was shown the expired food and stated they were no good anymore and she threw them all out. V4 stated expired food should never been kept, it should be thrown out. On 11/25/25 at 12:20 PM, observed refrigerator in kitchen and noted six cartons of eggs, five cartons had an expiration date of 11/17/25 and one had an expiration date of 11/14/25. On 11/25/25 at 12:40PM, V4 stated that she was going to throw away the eggs in the refrigerator that she said she brought the eggs a little while back and was going to cook out on the grill and make some hard fried eggs for some of the residents. She said that she never had a chance to make the eggs, and she was just going to get rid of them. On 11/25/25 at 1:05 PM, a container that had a sauce-like substance in it had a label that was marked Manwich with no date of when placed in the refrigerator or opened. Observed 2 large open containers in the refrigerator, one was coleslaw dressing and one was Italian dressing both dressings were half empty and did not have an open date on either one. A facility policy titled Dry Storage Areas dated January 2012 documents under Procedure: 9. Cans and dried goods will be dated with the date they were received and date they were opened. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility.

Based on interview, observation, and record review the facility failure to ensure that all licensed staff had a current license while working at the facility. This failure has the potential effect all 73 residents living at the facility.The findings include: On [DATE] at 9:45AM, V20 (Certified Nurse Assistant/CNA) stated that V21 (Licensed Practical Nurse/LPN) is not working at the facility anymore due to the fact that her LPN license was not active. V20 stated she had been working in the facility as and LPN while it was expired. On [DATE] at 10:06AM, V1 (Administrator/ADM) stated the BOM (Business Office Manager) or corporate checks staff nursing licenses. V1 stated V21's license expired at the beginning of the year but he thinks she might have gotten an extension on it but he isn't sure. V1 stated V21 did work as a nurse with an inactive license and passed medications and performed nursing duties during that time. V1 stated V21's LPN license became active again on [DATE]. On [DATE] at 11:30AM, V1 (ADM) said that he suspended V21 (LPN) on [DATE] because she didn't have an active nursing license. On [DATE] at 9:10AM, V2 (Director of Nursing/DON) stated she was not aware V21 did not have an active license. V2 said that typically corporate checks licenses at hire and then when it is renewal time. V2 stated she will have the nurses bring her proof that they renewed their license, but she doesn't keep that proof because she doesn't want to be responsible for that. V2 stated she doesn't remember if V21 provided anything or not. She stated this year things have gotten past her. V2 stated she doesn't know when V21's license expired or how long she worked without and expired license she just knows she did work some without an active license. V2 stated she heard about a CNA working without a certificate, but she doesn't remember who told her and she thinks V1 handled it. V2 stated corporate does the checks on the nurses' license prior to starting to work.On [DATE] at 9:32AM, V3 (Assistant Director of Nursing/ADON) stated she wasn't aware that V21 didn't have an active nursing license until after she was suspended. V3 stated V21 floated around when she worked so she could have worked on all the floors in the whole buildingOn [DATE] at 8:32AM observed V21 administering medications to R10 at the facility. On [DATE] at 8:45AM observed V21 administering medications to R28 at the facility.On [DATE] at 2:19PM observed V21 working on A hall and suites at the facility as an LPN.On [DATE] at 10:32AM observed V21 working C hall at the facility as an LPN. A document titled Licensed Practical Nurse Job description undated, documents Job summary as: The overall purpose of the Licensed Practical Nurse (LPN) position is to perform practical nursing work under the general supervision of a registered nurse. The LPN participates in the assurance of the provision of resident care services consistent with accepted standards of care and assigns duties to C.N.A's (Certified Nurse Assistant's) as appropriate. Essential Duties and Responsibilities: Performs duties and responsibilities with assigned functional area within a nursing home facility which may include, but are not limited to, any combination of the following task: Dedicated to delivering a high level of customer service, Consistent and regular attendance, provided resident care in accordance with accepted standards of practice and within the score of the LPN license, observes and reports on resident's conditions/changes and then documents in accordance with facility policies and as required by regulations, administer medication/treatment as prescribed within the LPN scope of practice, receives, transcribed and executes physician orders, implements and evaluates resident's plan of care, identifies and secures equipment and supplies. Notifies supervisor when supplies are needed, informs subordinate staff about the condition of residents and expectations/needs for the shift assigned at the beginning of each shift and receives report form subordinates throughout and at the end of each shift regarding resident's conditions, directs CNA's to assure care provided according to standards of practice and according to facility policies and regulations, rounds with CNA's prior to end of shift to assure unit is in proper order, communicates appropriate and thorough information to oncoming licensed staff so that continuity of care is provided from shift to shift, completes nursing documentation as indicated, i.e, admission paperwork, ongoing pain, documentation, etc., assures residents are as free from pain as possible and advocates for residents with physicians as needed, assures that resident's accident or incident is fully documented, investigated and reported in accordance with facility policies and per regulations, assures that each resident' attending physician and family/responsible party is promptly is notified of any significant changes in the resident's health condition, performs incidental housekeeping or maintenance tasks as may be required to maintain a clean, hazard-free environment for resident's, visitors, and staff, assists in the evaluation of subordinate staff and any necessary counsel /discipline in accordance with facility policies, ensure a safe environment is maintained in accordance with policies and regulations, performs frequent rounds throughout facility to assure that the facility is orderly, odor-free and clean, functions as a team leader/role model, has reviewed the facility abuse policy and understands employer's responsibility to enforce it, and performs other duties as assigned. Education and Experience Requirements: The Licensed Practical Nurse must have the following: A current, valid Illinois Licensed Practical Nurse licensed is required.The midnight census report dated [DATE] documents the facility has 73 residents at the facility.

Based on observation, interview, and record review the facility failed to supply linens (washcloths) and ensure the call lights were within reach for 6 of 6 residents (R1, R3, R4, R7, R22, R35) reviewed for accommodation of needs in a sample of 44. Findings include:1. On 11/26/25 at 2:34 PM, V7 (Certified Nursing Assistant/CNA) stated he ran out of washcloths about 2 weeks ago and had to use a pillowcase as a washcloth. On 11/26/25 at 3:03 PM, V5 (CNA) stated they ran out of washcloths the prior week and she had to cut up a towel to use as a washcloth. On 11/26/25 at 3:24PM observed on C hall cart there was only 1 washcloth noted along with no towels. The cart on long A hall had only 1 washcloth.On 11/26/25 at 3:27PM there were no washcloths noted in the linen cart on the short A hall linen cart.On 11/26/25 at 3:33PM the shower room on A hall did not have any washcloths.On 11/26/25 at 3:41 PM, V9 (CNA) stated he has run out washcloths before and when they don't have washcloths, he will use a towel, or he will buy wipes with his own money and use those. On 12/1/25 at 11:34 AM, V6 (CNA) stated they sometimes run short on washcloths so he buys wipes himself and will use them to clean residents. On 12/02/25 at 10:44AM, V5 (CNA) stated that they are out of washcloths and towels and R35 was wanting a washcloth to be able to shave. V5 went outside to the laundry room to look for towels and washcloths. V5 said that she also went to the other halls to look for wash cloths and towels and couldn't find any washcloths at either place.On 12/02/25 at 10:50AM, R35 stated that he was just wanting a washcloth so he could shave. R35 stated that they weren't able to find a washcloth or a towel for him to be able to shave. R35 stated that he just wouldn't be able to shave now. R35's Face Sheet documents an admission date of 7/17/2025 with diagnoses including in part encounter for other orthopedic aftercare, wedge compression fracture of first lumbar vertebra, heart failure, chronic kidney disease, unspecified fall, difficulty in walking, displaced fracture of medial malleolus of left tibia, and pain. R35's MDS dated [DATE] document a BIMS of 15, indicating R35's cognition is intact. On 12/2/25 at 12:23 PM, V1 (Administrator) stated he has heard about supply issues but as soon as he hears about it, he will go to the store and buy what is needed. V1 stated linens are washed at an off-site facility and they are delivered every morning. V1 stated linens are delivered to the laundry house behind the facility and there is no formal process to get the linens to the floor for staff to use and it isn't any one person's responsibility to restock linen carts or the linen room after delivery. V1 stated he agrees there should be a process on who brings the laundry in, but anyone can get them as they need them. V1 stated he has extra towels and washcloths locked up that anyone can get from him at any time. V1 stated he has to lock up the extra towels and washcloths because if he doesn't the staff will hide them. V1 stated if a resident needs a washcloth, then it should be available. On 12/2/25 at 3:18 PM, V19 (CNA) stated she doesn't have any issues with supplies but sometimes will run out of washcloths. V19 stated that V1 just told her today that he had extra washcloths locked up and if she ran out again, she needed to let him know and he would get her some. 2. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue. R1's Minimum Data Set, dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1's Care Plan documents R1 is at risk for falling. On 11/26/25 at 9:02 AM, R1 was lying in bed, and her call light was not in reach. One call light was on the wheelchair across the room, and the other call light was lying on the floor. R1 stated her call light is often out of reach. R1 was orientated to person, place, time, and situation during the interview. 3. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. R3's Care Plan documents R3 is at risk for falls. On 11/25/25 at 2:41 PM, R3 was laying in his bed and stated he uses his call light when he can reach it. The call light was observed lying on the floor out of reach. R3 stated sometimes different workers move his call light away from him where he can't reach it when he needs it. On 11/25/25 at 4:14 PM, observed R3 lying in bed and his call light was on the floor out of reach. 4. R4's Face Sheet documents an admission date of 4/30/2024 with diagnoses including in part hypertension, type 2 diabetes, chronic kidney disease, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, acquired absence of left leg below knee, history of falling, pain in left shoulder, and other chronic pain. R4's MDS dated [DATE] documents a BIMS of 15, indicating R4's cognition is intact. R4's Care Plan documents R4 is at risk for falls. On 11/26/25 at 9:45 AM, observed one of R4's call lights clipped up high on the room divider curtain and the other was clipped to the call light wall box, both call lights were out of reach for R4. R4 stated sometimes they clip it up high on the curtain and he has to stand up and reach it and he is afraid he is going to fall trying to get to it. 5. R7's Face Sheet documents an admission date of 4/29/2021 with diagnoses including in part dementia, primary generalized arthritis, malignant neoplasm of unspecified site of left female breast, anxiety disorder, primary insomnia, neuromuscular dysfunction of bladder, overactive bladder, history of falling, and pain. R7's MDS dated [DATE] documents a BIMS of 8, indicating R7's cognition is moderately impaired. On 11/25/25 at 10:44 AM, R7 was lying in bed and the two call lights in her room were clipped to the upper part of the room divider curtain out of reach for the resident. This surveyor asked R7 if she uses her call light and she stated, the girls make me so mad because they always hang the call light up high on the curtain where I can't reach it so when I need it I can't use it. On 12/1/25 at 8:22 AM, R7 was in bed and her call light was out of reach. One call light was clipped up high on the room divider curtain and the other was laying on the empty bed on the other side of the room, both call lights were out of reach. 6. R22's Face Sheet documents an admission date of 11/17/25 with diagnoses including in part wedge compression fracture of second lumbar vertebra, chronic kidney disease stage 3, chronic and pain. On 11/25/25 at 4:23 PM, R22 was sitting in his wheelchair in his room and one call light was wrapped around the light fixture on the wall and the other was clipped to the wall box where the call light inserts into the wall. Both call lights were out of reach. R22 who was alert and oriented stated he can't reach the call light because they are too high.On 12/18/25 at 9:10 AM, V2 (Director of Nursing) stated call lights should be within reach for residents when they are in their room. On 11/25/25 at 4:17 PM, V1 (Administrator) stated call lights should always be in reach for the resident when they are in the room. V1 stated staff should be doing checks on residents every 2 hours to make sure they have the call light in reach and don't need anything. A facility policy titled Answering the Call Light dated July 2014 documents under General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review the facility failed to acquire medication from the pharmacy and administer and document medications as ordered for 4 of 13 residents (R2, R3, R17, R19) reviewed for pharmacy services in a sample of 44.Findings include:1. R3's Face Sheet documents an admission date of 8/22/2018 with diagnoses including: Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R3's cognition is intact.R3's Care Plan documents a problem category of pressure ulcer/injury. Impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of 2/12/25.R3's Physician Order Report dated 11/2/25-12/2/25 documents an order to place on enhanced barrier precautions per guidelines with a start date of 4/1/24. Same report documents an order for silver sulfadiazine cream topical, cleanse the area to the left upper buttock with wound cleanser or normal saline, apply Silvadene cream, collagen powder, calcium alginate, and dry dressing daily with a start date of 11/5/25.On 12/8/25 at 11:45 PM, wound treatment for R3 was observed. V25 (Registered Nurse/RN) mixed collagen and silver sulfadiazine cream that had another resident's name on it and had an expiration date of 9/30/2025. This surveyor asked V25 if the cream belonged to R3, and she stated she doesn't know where his is, so she is going to use the cream that belongs to a different resident since she doesn't use it anymore.2. R17's Face Sheet documents an admission date of 10/16/2023 with diagnoses including: Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's MDS dated [DATE] documents a BIMS score of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility and R17 has pain/risk for pain with a start date of 11/24/23.R17's Physician Order Report dated 11/15/2025-12/15/2025 documents orders for silver sulfadiazine cream topical and clotrimazole cream topical, special instructions: Cleanse the wound to the right abdomen with normal saline or wound cleanser, apply silver sulfadiazine cream, clotrimazole, collagen powder, calcium alginate, and dry dressing daily, once a day, 06:30 PM - 06:30 AM with a start date of 9/17/2025 and an end date labeled open ended, Metronidazole tablet 500 mg and betadine solution topical, special instructions: cleanse the wound to the right third toe with wound cleanser or normal saline, apply betadine, crushed metronidazole, calcium alginate, and dry dressing daily with a start date of 11/3/2025 and an end date labeled open ended, and Povidone-iodine solution topical, special instructions: start betadine, calcium alginate and gauze wrap for the whole foot daily, once a day, 07:00 PM - 10:00 PM with a start date of 12/7/2025 and an end date labeled open ended.On 12/9/25 at 12:09 AM, wound care for R17 was observed. V25 (Registered Nurse/RN) had to go to another unit to find collagen. V25 mixed collagen and silver sulfadiazine cream together. The tub of silver sulfadiazine cream did not have a name on it, V25 stated she didn't know who it belonged to because it doesn't have a name on it, but she doesn't know where R17's cream is, so she is going to use it.3. R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including: cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's MDS dated [DATE] documents a BIMS score of 07, indicating R19 has severe cognitive impairment.R19's Care Plan documents R19 has impaired skin integrity related to venous insufficiency with a start date of 9/26/25.R19's Physician Order Report dated 11/15/2025-12/15/2025 documents orders for silver sulfadiazine cream topical, cleanse the wound to the right medial foot, top of right foot, right leg, right posterior leg, and right ankle with normal saline or wound cleanser, apply silver sulfadiazine cream, collagen powder, calcium alginate, gauze roll and secure with tape with a start date of 10/30/2025 and an end date labeled open ended and Lidocaine cream 4% topical, apply to right lower extremity wounds prior to wound care/treatment change once a day with a start date of 11/17/25 and an end dated labeled open ended.On 12/08/25 at 1:30 PM, R19 stated that there have been times when she has not gotten her treatment done to her right leg. R19 stated the nurses won't do it for a couple of days. R19 stated they have told her they have ran out of the medicine they put on her wounds on her right leg before. R19 stated she couldn't remember how many times they have ran out of treatment supplies for her right leg.On 12/03/25 at 2:19 PM, V21 (LPN) stated they run out of wound supplies like prescription creams and medication for wounds at times, and she will have to push off the wound care at nighttime until the next shift. V21 stated she does do wound care, but it might just be on the other shift. V21 stated she has had to borrow wound care supplies from one resident's supplies to use on another resident and then when they get those supplies back in, she will re-supply the resident that she borrowed from with what she borrowed.On 12/9/25 at 12:33 AM, V25 stated sometimes she will use other residents supplies if she can't find the correct supplies.On 12/18/25 at 9:10 AM, V2 (Director of Nursing/DON) stated residents should not run out of medication from the pharmacy, all they need to do it tell her and she will get it ordered.4. R2's Face Sheet documents an admission date of 12/23/24 with diagnoses including: spina bifida, anemia, paraplegia, pressure ulcer of sacral region stage 4, and pressure ulcer of right buttock stage 4.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2's cognition is intact.R2's Physician Order Report dated 11/2/25-12/2/25 documents an order for oxybutynin chloride 5 mg, 1 tablet three times a day with a start date of 1/14/25 and an end date labeled open ended.R2's December 2025 MAR dated 12/1/25 documents oxybutynin chloride scheduled for 7:00 AM-10:00 AM was not administered due to R2 refused the medication.On 12/01/25 at 11:51 AM, V15 (License Practical Nurse) was passing medication this surveyor observed some of R2's medications were red on the computer in R2's electronic medical record. V15 said that she might have missed his morning medications. V15 said that she did forget to give him his morning medications now that she thinks about it, but she said that she was going to call the nurse practitioner to make sure it was ok to give the medication now.On 12/01/25 at 12:01 PM, V15 called V50 (Nurse Practitioner) observed phone call and V15 told V50 that she just missed R2 and that she didn't give him his morning medications and she asked if she could give the medications now. V15 said that V50 said it was ok to give morning medications now.On 12/01/25 at 12:04 PM, V15 was observed popping out R2's medications from the medication cards. V15 was observed popping out the following medications: multivitamin with iron 1 tablet, arginaid 1 packet in water, vitamin C 500mg 1 tablet, glyburide 2.5mg 1 tablet, senna 8.6mg 1 tablet, oxybutynin 5mg 1 tablet, and Xarelto 10mg 1 tablet.On 12/01/25 at 12:10 PM, V15 took the medications into R2's room. R2 refused to take all the medications. R2 said that it was too late to take his blood glucose check now because he had already eaten. R2 said that he would go ahead and take the oxybutynin 5mg tablet.On 12/1/25 at 12:30 PM, V15 was observed documenting in the Electronic Health Record (EHR) that R2 refused the medications. When V15 went back to look to make sure that all the medication had been marked refused except for oxybutynin she noticed that the oxybutynin was also marked as refused. V15 stated that she did not know how to unmark the refusal on the oxybutynin. V15 said that she doesn't know how to change or edit when refused is marked. V15 stated that R2 had an oxybutynin due again at 1:00 PM-3:00 PM.On 12/02/25 at 2:10 PM, V15 stated she did not call the physician or the physician assistant and tell them R2 refused his medications. V15 stated she did call and tell the Nurse Practitioner that she missed giving R2's morning medications and she told her to go ahead and give them now. V15 stated R2 refused all the morning medications but the oxybutynin but when she went to sign out that R2 refused all the other medications it showed he refused the oxybutynin as well and she couldn't change it. V15 stated R2 had another oxybutynin due at 1:00 PM so she signed that she gave the 1:00 PM dose so he missed getting the morning dose. V15 stated she normally will make a progress note when a resident refuses or they get their medications late, but she forgot this time.On 12/19/25 at 9:45 PM, V48 (Physician) stated he expects that he or his Nurse Practitioner would be notified if any resident missed any medications or treatments. V48 stated that he would expect any medication or treatment that is ordered to be administered as ordered.On 12/18/25 at 9:10 AM, V2 (Director of Nursing) stated all residents should get their medications when they are ordered.A pharmacy policy titled Medication Administration dated 10/25/2014 documents under Procedures, B. Administration, 2) Medications are administered in accordance with the written orders of the prescriber. 15) Medications supplied for one resident are never used for another resident. Under D. Documentation, 4.) The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided.A pharmacy policy titled Ordering and Receiving Non-Controlled medications from the Dispensing Pharmacy dated 10/25/14 documents under Procedures: 2) Refills are ordered by peeling the reorder tab from the prescription label and placing it in the appropriate area on the reorder form provided by the pharmacy for that purpose and include: a. Date ordered, b. Facility name and nursing station, c. Nurse first and last name.

Based on observation, interview, and record review the facility failed to maintain food items served to residents at palatable/hot temperatures for 4 of 4 residents (R1, R2, R3, R14) reviewed for food preferences in the sample of 44. Findings include:On 11/26/25 at 7:00 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. 1. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, unspecified protein-calorie malnutrition, non-pressure chronic ulcer of left heel and midfoot with unspecified severity, vitamin B12 deficiency anemia, nutritional anemia, and weakness. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1's Care Plan documents a problem category of nutritional status, documenting R1 is at risk for impaired nutrition and hydration. R1's Physician Order Report dated 11/2/25-12/2/25 documents R1 is on a regular diet with regular consistency and thin/regular liquids. On 11/26/25 at 8:00 AM there was a plate of untouched food sitting at the table in the dining room with no cover on it and no resident was near it. This surveyor asked V7 (Certified Nursing Assistant/CNA) whose food it was, and he stated it was R1's but she wasn't out of bed yet because he needed help to get her up and they hadn't had time yet. On 11/26/25 at 8:25 AM, V5 (Certified Nursing Assistant/CNA) put a cover on the food that was sitting at the table for R1, took the tray from the table and took it to R1's room to assist her with eating. V5 poured milk into her cold cereal then this surveyor asked V5 to see if she could get another tray for R1. V5 went to the kitchen and brought back a new tray for R1. The 1st tray was temped at 8:28 AM, the biscuits and gravy were 94.8 degrees Fahrenheit, the scrambled eggs were 93.6 degrees Fahrenheit, and the milk in the cold cereal was 61.3 degrees Fahrenheit. V5 stated she usually microwaves the food if she thinks it is cold. On 11/26/25 at 8:28 AM, R1 stated she gets cold food often. R1 was orientated to person, place, time, and situation during interview. 2. R2's Face Sheet documents an admission date of 12/23/24 with diagnoses including in part spina bifida, anemia, paraplegia, pressure ulcer of sacral region stage 4, and pressure ulcer of right buttock stage 4.R2's MDS dated [DATE] documents a BIMS of 15, indicating R2's cognition is intact.On 11/26/25 at 9:39AM, R2 stated the food is terrible, and it is always cold when he gets it. 3. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. On 12/1/25 at 8:26 AM, R3 stated he hasn't had meat with his breakfast for a while and he likes having meat with his breakfast because the eggs aren't good and are usually cold. R3 stated today the eggs were cold so he couldn't eat them. 4. R14's Face Sheet documents an admission date of 8/22/2025 with diagnoses including in part malignant neoplasm of colon, depression, other symptoms and signs concerning food and fluid intake, nausea with vomiting, secondary malignant neoplasm of large intestine and rectum, and generalized anxiety disorder. R14's MDS dated [DATE] documents a BIMS of 14, indicating R14's cognition is intact. On 12/3/25 at 2:38 PM, R14 stated the food is cold all the time and breakfast is always cold. R14 stated lunch and dinner are cold some days and some days it is okay. On 11/26/25 at 3:03, V5 (CNA) stated she has received complaints from residents about cold food before and she will tell kitchen and warm the food up if they tell her before they eat it. On 12/1/25 at 3:27 PM, V10 (CNA) stated she has had residents complain about cold food and usually its breakfast food. On 12/2/25 at 2:26 PM, V20 (CNA) V20 stated she receives resident complaints a lot about their food being cold. On 12/03/25 at 2:19 PM, V21 (License Practical Nurse) stated the residents get served cold food daily. V21 stated she would take and heat it up or give them a new tray, but they often don't let her know that the food is cold until after they eat it. On 12/2/25 at 12:23 PM, V1 (Administrator) stated if food is cold, it should not be served to the resident, it should be reheated. V1 stated food should go from the steam table to the resident and not sit on the table if they are not in the dining room at the table ready to eat. The Facility's Cooking Foods- Internal Temperatures policy dated January 2012 documents, Temperature Guidelines: Food- Hot at Point of Service, 120 degrees or higher. Food- Cold at Point of Service, 50 degrees or lower.

Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions while providing wound care for 5 of 5 residents (R15, R3, R17, R19, and R1) observed for wound care in a sample of 44.The findings include:1. R15's Face Sheet documents an admission date of 3/17/25 with diagnoses including in part pain, type 2 diabetes, primary hypertension, and venous insufficiency.R15's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 13, indicating R15's cognition is intact.R15's Care Plan documents R15 was admitted with skin ulcer/lesion and is at risk for further skin impairment with a start date of 3/17/25 and R15 requires antibiotic therapy for wound infection with a start date of 3/18/25 with interventions including provide meds as ordered and use good infection control measure with resident.R15's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R15 has the following wounds: diabetic wound of the right calf, diabetic wound to the left calf, and a stage 4 pressure ulcer of the right heel.R15's Physician's Order Report dated 11/15/25-12/15/15 did not document an order for Enhanced Barrier Precautions.On 12/8/25 at 11:14 PM, observed V25 (Registered Nurse/RN) perform wound treatments on R15. An enhanced barrier sign was observed on the wall next to R15's door. V25 pushed the wound treatment cart into R15's room then applied gloves and was observed not wearing a gown, removed the wound dressing to right heel, then cleansed the wound with normal saline wound wash. V25 changed gloves without performing hand hygiene. V25 applied the treatment to the right heel. V25 then removed the old dressing to right calf wound and cleaned wound with normal saline wound cleanser. V25 then changed gloves without preforming hand hygiene. V25 applied the treatment on right calf and applied calcium alginate over the cream mixture. V25 then wrapped with gauze. V25 removed the wound dressing to the left calf then cleansed the wound with normal saline wound cleanser. V25 changed gloves without preforming hand hygiene. There was some bleeding from R15's left calf wound so V25 dabbed it with some gauze. Without removing gloves V25 then opened a drawer on the treatment cart and pulled out the jar of silver sulfadiazine cream. V25 didn't have a spoon to get the silver sulfadiazine cream out with so she left the room to get one with her gloves on, walked down the hall to the medication cart and got a spoon from the medication cart then returned to the room with the same gloves on. V25 then opened all 4 drawers and went through the supplies in each drawer with her gloves on looking for collagen. V25 could not find collagen so she removed her gloves, did not perform hand hygiene, and went to another unit to find collagen. V25 then returned and applied gloves then applied the treatment to the wound on R15's left calf. V25 then threw away supplies and placed the jar of silver sulfadiazine cream in drawer then removed gloves. V25 then pushed the cart out of the room back to the nurse's station. V25 did not perform hand hygiene at any time after leaving R15's room. V25 immediately starting prepping wound supplies for the next resident.2. R3's Face Sheet documents an admission date of 8/22/2018 with diagnoses including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact.R3's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R3 has the following wound: Skin tear to the left, lateral, upper buttock.R3's Care Plan documents a problem category of impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of 2/12/25.R3's Physician Order Report dated 11/2/25-12/2/25 documents an order to place on enhanced barrier precautions per guidelines with a start date of 4/1/24 and an end date of open ended.On 12/8/25 at 11:45 PM, observed wound treatment for R3, this was a continuous observation from the previous wound treatment. R3 had a droplet and contact precautions sign on his door. V25 did not perform hand hygiene between the last resident and R3. V26 (Certified Nursing Assistant) and V25 donned gloves and a mask and V25 stated R3 is on isolation for Rhino virus so you only need to wear gloves and a mask. V26 and V25 was observed not donning a gown prior to entering R3's room. V26 and V25 then entered R3's room and V25 pushed the treatment cart into the room. V26 rolled R3 and there was no dressing on the left upper buttocks wound. V25 cleansed the wound with normal saline wound cleanser then changed gloves without performing hand hygiene. V25 applied the silver sulfadiazine cream and collagen mixture to wound, applied calcium alginate over cream mixture, then placed a dry dressing over wound. V25 then removed gloves and pushed the treatment cart out of the room. V25 then performed hand hygiene with hand sanitizer.3. R17's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's MDS dated [DATE] documents a BIMS of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility with a start date of 11/24/23.R17's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R17 has the following wounds: post-surgical wound of the right lower abdomen, arterial wound of the right 2nd toe, and skin tear wound to the right 3rd toe.R17 Physician Order Report dated 11/15/2025-12/15/2025 documents the following orders: Place on Enhanced Barrier Precautions per guidelines prn with a start date of 4/1/24 and an end date labeled open ended.On 12/9/25 at 12:09 AM, observed wound care for R17. R17 did not have an enhanced barrier sign on the door. V25 entered R17's room and took the treatment cart into the room with her then applied gloves, removed the old bandage, then cleansed wound with normal saline wound cleanser. V25 then changed gloves without performing hand hygiene. V25 applied the treatment to the wound on right side of torso. V25 removed the old bandage on right foot/toe area and cleansed with normal saline wound cleanser then reached into a multi-use gauze pack and removed some gauze squares with dirty gloves on. V25 then applied the treatment to the right foot/toe. V25 then removed gloves and pushed treatment cart out of room to the hallway. V25 was observed not wearing a gown during this observation. V25 did not perform hand hygiene after leaving the room.On 12/9/25 at 12:33 AM, V25 stated when a resident has a wound and they are on enhanced barrier precautions anyone providing care should wear a gown and gloves. V25 stated she forgot to put a gown on when she did wound treatments on R3, R15, and R17, V25 stated she should have worn a gown with each treatment. V25 stated sometimes she uses hand sanitizer between glove changes and sometimes she forgets. V25 stated she should use hand sanitizer between glove changes, before donning gloves, and after removing gloves but she doesn't always think about it and forgets. V25 stated she should have taken her dirty gloves off to go through the supplies in the drawers on the treatment cart. V25 stated she usually takes the cart into the rooms with her when she does wound treatments but will usually clean it with bleach wipes after she leaves the room, but she forgot to do that tonight.4. R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including in part cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's MDS dated [DATE] documents a BIMS of 07, indicating R19 has severe cognitive impairment.R19's Care plan documents that R19 has impaired skin integrity related to venous insufficiency and R19 has pain/risk for pain with a start date of 9/26/25 with documented interventions including administer medications, monitor and record effectiveness and report adverse side effects.R19's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R19 has the following wounds: Venous wound of the right leg, skin tear of the right dorsal foot, arterial wound of the right ankle, non-pressure wound of the right medial foot, and skin tear to the right, posterior ankle.R19's Physician Order Report dated 11/15/2025-12/15/2025 did not document an order for Enhanced Barrier Precautions.On 12/08/25 at 11:41 PM, observed V37 (License Practical Nurse) going to do wound treatment on R19. There was no enhanced barrier sign observed on R19's door and no personal protective equipment observed outside of R19's door. V37 stated that she didn't have all the treatment supplies she needed to perform R19's treatment. V37 stated she needed some wound cleanser and had to try to find some collagen powder for the treatment. At 11:48PM V37 knocked on R19's door and R19 was asleep in her bed, she woke R19 up and told her she was going to do her treatment. V37 took her treatment cart into the room. V37 performed hand hygiene and then donned gloves. V37 then placed a bed pad under R19's right leg. V37 then took a pair of scissors and started to cut the bandage off the right leg which had large amount of drainage coming through the dressing, this surveyor did not observe V37 clean scissors prior to use. V37 placed the scissors on the bed pad next to the right foot as she removed the bandage. V37 removed all the bandage which had a large amount of drainage to the entire bandage which she placed in the trash bag, she removed her gloves and performed hand hygiene, and then she picked up the scissors and placed them on the top of the treatment cart. V37 never cleaned the scissors. V37 then performed the treatments to R19's wounds. While applying the treatment to R19's wounds, V37 then took her scissors which had not been cleaned and started to cut the rope (Fiber) calcium alginate with the dirty scissor then placing the fibers to the wound bed on the right foot and the back of the ankle area and to the top of lower leg below the knee. V37 was observed not wearing a gown for this observation.On 12/08/25 at 12:20AM V37 (License Practical Nurse/LPN) stated R19 should be on enhanced barrier precautions because she has a large wound to her right leg. V37 stated R19 does not have a sign or PPE outside of her door saying that she is on enhanced barrier precautions, and she did not perform treatment like R19 was on enhanced barrier precautions because there was no sign on her door.5. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue.R1's Minimum Data Set, dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1 was orientated to person, place, time, and situation during interview.On 12/17/25 at 1:28 PM, observed V39 (Certified Nursing Assistant/CNA) and V5 (CNA) perform incontinent care on R1. V39 and V5 removed R1's (incontinent brief) and cleaned her buttocks with wipes then performed incontinent care using warm water, soap, and washcloths. V39 and V5 were observed not wearing a gown during care. There was an enhanced barrier sign on R1's door. V39 and V5 both stated they didn't know they needed to wear a gown when providing care. V39 and V5 stated they didn't know what enhanced barrier precautions meant, they didn't realize it was to protect the resident.A facility policy titled Isolation Precautions/Enhanced Barrier Precautions (EBP) dated April 1, 2024, documents under Policy: It is the policy of (name of facility) to make every effort to prevent the spread of infection in the facility. Enhanced Barrier Precautions are used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The same policy documents under Procedure: 1. EBP will be used for any resident who meets the following criteria: Chronic wounds, such as, pressure ulcer, venous stasis ulcers, diabetic ulcers, unhealed surgical wounds. 2. Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: dressing, providing hygiene, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, indwelling medical devices care, chronic wound care. 3. Place EBP sign at entrance to the room for the resident who meet the criteria. Staff will clean their hands before entering and when leaving the room. Staff will wear gloves and a gown for High-Contact Resident Care Activities. Do not wear the same gloves and gown for the care of more than one person. If only one resident in the room requires EBP, place an EBP sign above the bed of the resident who meets the criteria as well as the entrance to the room.A facility policy titled Wound Management Program dated 1/20/2023 documents under Policy: It is the policy of (name of facility) to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions.A facility policy titled Dressings, Dry/Clean dated January 2018 documents in part; Verify that there is a physician's order for this procedure, review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs, and check the treatment record. The same document under Procedure it documents 1. Adjust bedside stand to waist level. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or open on the bed. 7. Wash and dry your hands thoroughly. 8. Put on clean gloves. Loosen tape and remove soiled dressing. 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 18. Apply the ordered dressing and secure with tape.

Based on interview and record review the facility failed to transport a resident in the appropriate wheelchair to prevent an accident for 1 (R1) of 3 residents reviewed for accidents in a sample of 10. This failure resulted in R1 falling face first into the dining room floor resulting in a left nasal bone deformity and both ulnar and olecranon fracture of the left upper extremity. The findings include: R1's Face Sheet documented an admission date to the facility of 2/09/25 with diagnoses including cerebral palsy, weakness, anxiety, and type 2 diabetes mellitus with diabetic neuropathy.R1's MDS (Minimum Data Set) dated 9/23/25 documents in Section C that R1 has a BIMS (Brief Interview of Mental Status) score of 15 indicating R1 is cognitively intact. The same MDS section GG-Mobility documents that R1 needed substantial/maximal assistance (helper does more than half the effort-helper lifts or holds trunk or limbs and provides more than half the effort) and uses a manual wheelchair for mobility.R1's Care Plan documents that R1 is totally dependent on nursing for all aspects of care related to Cerebral Palsy with interventions including Ensure proper body alignment when in bed or chair with a start date of 10/10/25. R1's Care Plan also documented an update on 10/18/2025 with a category of pain: resident is at risk for pain related to: fracture resulting from fall on 10/18/25.On 10/22/2025 at 12:12 PM, R1 stated she did fall out of a wheelchair in the dining room on 10/18/2025. R1 stated she had been in a different wheelchair then her usual wheelchair. R1 stated the wheelchair she had been transferred to on 10/18/2025 was a high back wheelchair and she uses a standard wheelchair with no high back. R1 stated V11 (Certified Nurse Assistant/CNA) was moving her from the dining room table when she fell forward into the floor hitting her face and left arm.On 10/23/2025 at 11:00 AM, R1 further explained that she does use footrests with her normal wheelchair and stated her legs were too short to reach the footrests on the high back wheelchair that she was in when she fell on [DATE].On 10/22/2025 at 1:37 PM, V8 (CNA) stated that he did transfer R1 from her bed using a mechanical lift to a high back wheelchair on 10/18/2025. V8 stated at the time he thought it was her wheelchair, however he learned later that it was another resident's wheelchair.On 10/23/2025 at 6:20 AM, V4 (CNA) stated he had been in assisting R1 from the dining room table when she fell the evening of 10/18/2025. V4 stated he went to assist R1 by pulling her wheelchair back from the dining room table and he made it about a foot when R1 fell forward hitting her face on the floor. V4 stated R1 had been in a high back wheelchair with no footrest at the time of the incident, and this is not her regular wheelchair.On 10/24/2025 at 8:25 AM, V17 (Occupational Therapist/OT) stated with R1's decrease in core strength, maximum assistance with mobility and her body size, R1 would appropriately fit the standard mechanical wheelchair that comes up to the base of her neck with foot pedals. V17 stated with a high-back wheelchair, the high-back part of the chair would be pushing on the back of R1's head and forcing her forward out of the wheelchair. V17 stated R1 would not be able to support herself while leaning forward and unable to reposition on her own. On 10/24/2025 at 9:40 AM, V9 (Registered Nurse/RN) stated she did assess R1 after her fall event in the dining room on 10/18/2025. V9 stated R1 had been sitting in a high back wheelchair when she had fallen face forward on the dining room floor. V9 stated R1 had been sitting in a high back wheelchair and is not appropriate for her, because the high back wheelchair sits to high up for her and R1 had no core muscle control and is unable to reposition or balance herself.R1's Occupational Therapy Evaluation dated 10/12/2025 documented under Reason for Therapy: Clinical Impressions/Reasons for skilled services, R1 presents with impairment in balance, fine motor coordination, gross motor coordination, mobility and strength. Under Initial Assessment/Current Level of Function, Other System/Condition Assessment, Balance: Patient sits unsupported x 30 seconds with feet flat on floor and no back support? No; Amount of assist needed to sit at edge of bed is Moderate Assistance; Time patient can sit unsupported is 5 seconds.R1's local emergency room notes by V19 (Emergency Physician) documented under ED (Emergency Department) Course on 10/18/2025 that R1 had imaging of facial bones showing evidence of left nasal bone deformity and both ulnar and olecranon fracture of the left upper extremity.R1's Serious Injury Incident Report final report received on 10/24/25 documents under Detailed Incident Summary see attached. The attached document titled Final Reportable to IDPH - Fall with Fracture documents under Conclusion based on the investigation, the facility concludes the fall was accidental and related to forward momentum during wheelchair movement.The facility policy titled Falls Management (revision date July 2017) documents It is the policy of (name of facility) to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.

Based on interviews and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors in sample of 13. This failure resulted in R1 receiving another resident's medication and being hospitalized for hypoglycemia.Findings Include:R1's Face Sheet shows documents an admission date of 10/16/2023 and includes diagnoses of Type 2 diabetes mellitus without complications, Alzheimer's Disease, Iron Deficiency, Cholecystitis, Renal Insufficiency, and Diaphragmatic Hernia without Obstruction. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, documents a Brief Interview for Mental Status (BIMS) score of 5, indicating R1 has severe cognition impairment. R1's Progress Note dated 8/30/2025 at 8:46AM, documents Asked patient (R1) her name she said it was other residents name gave her that residents meds. BG (blood glucose) was 44 so gave orange juice with sugar to raise BG to 77. Notified ADN (V3 Assistant Director of Nursing), called ambulance, notified provider (name of provider).R1's Progress Note dated 8/30/25 at 10:35PM documents that the local hospital was contacted for an update and R1 was admitted for Hypoglycemia.On 9/5/2025 at 3:16PM, V9 (Licensed Practical Nurse/LPN) stated she was the nurse that accidentally gave R1 the wrong medications. V9 said prior to administering the wrong medications to R1, she saw R1 while R1 was in R1's room lying in bed. V9 stated when she checked R1's blood sugar, R1's blood sugar was 44. V9 said she provided R1 with some orange juice. V9 said after R1 drank the orange juice V9 rechecked R1's blood glucose and it had come up to 77. V9 said later in V9's shift (during morning medication pass) R1 was sitting in the dining room and when V9 asked R1 her name, R1 gave V9 the wrong name and gave the medications of the name (the name of R6) R1 gave her. V9 stated after she gave R1 the medications, a CNA stated, that is R1 not R6. V9 stated that is when she knew she made a medication error. V9 stated she could not remember what the medications were that she administered to R1 but they were R6's morning meds. V9 said when she realized the medication error had occurred, she reported this to V2 (Director of Nursing/DON) and then she sent the resident to the Emergency Room. V9 stated she does not work very often because she is in school, so she is not real familiar with some of the residents. V9 stated she also had called the physician and the Power of Attorney about the incident. V9 stated she had not administered R1's medications that were prescribed for that morning ordered for 7:00 AM to 10:00 AM after realizing her error. V9 stated she just received education from V2 on the date the medication error occurred (8/30/2025), on Medication Administration.R6's Medication Administration Record shows the AM (7:00AM-10:00AM) medications ordered for R6 that was given to R1 were Colace 100mg capsule, Ferrous Sulfate 325mg tablet, Furosemide 20mg tablet, Gabapentin 100mg capsule, Januvia 100mg tablet, Levothyroxine 125 mcg tablet, Lisinopril 20mg tablet, Magnesium Oxide 400mg tablet, Metformin 500mg tablet plus 250 mg tablet to equal 750 mg total, and Vitamin D3 50mcg capsule. R1's Physician Order Sheet documents an order for Lantus Solostar Insulin of 15 units subcutaneous once a day with an order date of 10/16/2023 and an order for BS checks dated 10/16/2023 for three times a day 7AM-10AM, 11AM-1PM, and 3PM- 6PM with sliding scale Regular Insulin per results.R1's Medication Administration Record dated 8/1/2025-8/31/2025 at 4:00AM-6:00AM documents R1 received Lantus Solostar Insulin 15 units subcutaneous and documents that it was administered by V19 (Registered Nurse). On 8/30/2025 at 7:00AM-10:00AM R1's blood sugar is documented as Low. On 9/5/2025 at 11:05AM, V2 stated she was made aware of the medication error and R1 was sent to the emergency room and was admitted for Hypoglycemia. V2 stated an investigation was initiated. V2 stated that V9 was educated on Medication Administration.R1's Event Summary Report dated 8/30/2025 at 8:42AM documents the medication error under event details and the type of error as incorrect medication. This report documents under Interventions that V2 (Assistant Director of Nursing) was notified and R1's blood glucose level dropped to 44 and R1 was given orange juice with sugar raising R1 blood glucose to 77 after 20 minutes. Report shows Physician was notified on 8/30/2025 at 9:00AM, Family was notified at 9:00AM, and Care Plan was reviewed at 9:00AM. Evaluation: Sent to emergency room for evaluation and treatment.On 9/5/2025 at 7:15AM, V17 (Emergency Medical Technician/EMT) stated he has gone to the facility twice to pick up R1. V17 said one time was to transport R1 to the hospital due to R1 receiving the wrong medications that were actually for another resident. V17 stated the medications that were accidently given to R1 was documented on the run report. R1's (Emergency Medical Service) Report from the local EMS agency dated 8/30/2025 documents a chief medical complaint of Accidental Medication Administration Multiple and a secondary complaint of hypoglycemia. The report documents On arrival to scene, crew received a brief verbal report from the patients nurse. Nurse reported the following; medications were administered at approx. 08:05 today, 20mg Furosemide (diuretic), Aspirin 81mg, Colace 100mg, Ferrow [SIC] Sulfate 325mg, Gabapentin 100mg, Januvia 100mg (antidiabetic), Metformin 750mg (antidiabetic), Fish oil & Vit (vitamin) D3. They noted patient appeared lethargic and more confused to baseline, noted BGL (blood glucose level) 40s, administered oral glucose/glucagon prior to EMS arrival. Patient is baseline confused due to Alzheimer's. discharged from (name of local hospital) last week for infection of wound site on antibiotics.R1's records from the local hospital document an admission date of 8/30/25 and a discharge date of 8/31/25. R1's Hospital Discharge Summary under Details of Hospital Stay documents (R1) is a [AGE] year-old woman with diabetes who lives in a group home. She was inadvertently given another resident's medications, including diabetes medications. She became hypoglycemic and was brought to the emergency room. She was given intravenous dextrose, oral nutrition and monitored with frequent AccuCheks. Her blood sugars normalized, and then she was discharged back to her nursing facility where she will resume her own previous medications.The facility policy titled Medication Administration (undated) documents under Procedures, Five Rights- Right resident, right drug, right dose, right route, and right time are applied to each medication being administered. A triple check of these 5 rights is recommended in the process of preparation of a medication for administration: 1) when the medication is selected, 2) when the dose is removed from the container, and finally 3) just after the dose is prepared and the medication put away.On 9/5/2024 at 3:10PM attempted to call V18 (Physician) but did not receive a call back.A facility policy for Medication Errors was requested from V2 on 9/5/2025 at 11:05AM. V2 stated she would see if they had one, but she was not sure. There was no policy provide by the end of survey on 9/12/25.

Based on observation, interview and record review, the facility failed to provide behavioral health services for residents with mental illness, and to maintain/improve resident's psychosocial well-being for 1 of 3 residents (R1) reviewed for behavioral services in a sample of 9. This failure resulted in R1 voicing feelings of isolation, suicidal ideations with a plan of strangulation, and engaging in self-injurious behaviors.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/14/25 when the facility failed to implement increased monitoring for R1, remove hazardous objects from R1's room, and refer R1 for recommended counseling services. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 8/22/2025 at 9:03 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 8/22/2025, but the noncompliance remains at Level Two due to additional time to evaluate implementation and effectiveness of training.The findings include:R1's Face Sheet documents an admission date of 4/3/2025 and includes diagnoses of Bipolar Disorder, Depression, Generalized Anxiety Disorder, Personality Disorder, Suicidal Ideations, Poisoning by unspecified drugs medicaments and biological substances, intentional self-harm, subsequent encounter, and Genetic related Intellectual Disability. R1's MDS (Minimum Data Set) dated 7/10/025 includes a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. Section GG- Functional Abilities documents R1 is independent for ADL's (Activities of Daily Living). Section D -Mood documents R1 has frequent symptoms of feeling down, depressed or hopeless. Section E-Behavior documents Behavior Symptoms documents 'Behavior not exhibited for Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)A document in R1's medical record titled Crisis Intervention Clinical Assessment dated 3/22/2025 (prior to R1's admission) from a Psychiatric Consultant group documents R1 had suicidal ideation for 2-3 days, and 2 months ago tried strangling herself with a bed sheet but stopped herself. The document showed R1 had a suicidal plan, and the plan was to wrap cord or string around her neck. R1's Care Plan documents a Problem area of Behavioral Symptoms; R1 has episodes of yelling and screaming, refusing and resisting care. Agitation and angry outburst dated 8/15/2025 with a goal of R1 will not hurt self or others during episodes of aggressive behaviors and will receive adequate care by next review dated 6/30/2025. Documented interventions include meds as ordered, notify MD (Medical Doctor) as needed, observe for changes in mood/cognition and behavior, psych consult (5/14/2025) as ordered and as needed, redirect R1 as needed, and remove R1 as needed to prevent harm to self or others. R1's Care Plan also documents a Problem area of Mood State: R1 with diagnosis of Bipolar/suicide ideations, start date of 4/22/2025 and edit date of 8/15/2025. The Goal documented is R1 will voice whenever she is feeling down and depressed or anxious (suicide ideations), edit date 6/30/2025. Documented interventions include: 1. Listen to R1 and validate feelings. 2. 1:1 given weekly with social services. 3. Let Psych Nurse Practitioner know of any issues. 4. Give Medications as ordered. 5. If R1 talks of suicide ideations will follow directions as given by Nurse Practitioner or Medical Doctor, created date of 4/25/2025. R1's Care Plan also documents a Problem area of R1 will punch self in face causing self-harm with a start date of 4/25/25 and edit date of 8/15/25. The Goal documented is R1 will not cause harm to self /others when becomes upset. Documented interventions for this Problem area include: 1) listen to resident and validate feelings 2) remind resident punching self doesn't solve anything 3) try to get resident to talk through her feelings 4) remind resident we are here to help 5) give medications as ordered 6) psych Nurse Practitioner made aware of situation ASAP for direction if needed with a start date of 4/25/25 and edit date of 5/1/25.R1's Progress Notes document the following:4/14/2025: R1 sent to ER for stating she had bad thoughts, were very strong, wanting to strangle herself and began punching self in her face. Resident returned on 4/14/2025 with a recommendation to refer R1 to (Name of Counseling Service) for counseling. 4/15/2025: R1 continued to have suicidal ideations and asked to be sent to hospital stating she was going to hurt herself when staff leaves room. Resident placed on 1:1. R1 called 911 herself for transfer to local hospital. R1 was transferred to local hospital and the local hospital transferred R1 to another hospital. R1 returned to facility on 4/21/2025 with medication changes. 4/21/2025: R1 was sent back out to the local hospital for suicidal behaviors/ideations, screaming, crying out, punching self in the face and bouncing head off of the headboard. R1 returned to facility on 4/22/2024 at 4:13AM. 4/24/2025: R1 sent to ER for suicidal behaviors/ideations, hyperventilating, screaming and crying out, punching self in face, and bouncing head off of headboard. R1 called 911 herself. Transferred out of facility via ambulance. R1 returned to the facility on 4/25/2025 at 10:07AM shows R1 returned to facility shortly after leaving facility.4/27/2025: R1 was sent to ER due to R1 stating she was thinking about harming herself and reported having suicidal thoughts. Call back was received from the local hospital and R1 was being placed in a psych facility to be determined.4/29/2025: At 12:30AM R1 returned to facility. R1 was placed on 1:1 with a CNA on 4/29/25 at 11:58PM.5/23/2025: At 5:47AM R1 called 911 twice verbalizing she does not feel safe and wants to strangle herself. R1 taken to local hospital. On 5/23/2025 at 7:12AM the note documents that R1 planned to return to the facility. 6/10/2025: At 10:09PM R1 was screaming and bouncing her head off the wall. R1 was sent to the local hospital for altered mental status/ suicidal ideations/aggressive behavior toward self. On 6/11/2025 at 1:53AM R1 returned to facility and stated she wanted to strangle herself. R1 called 911 herself. 6/11/2025: At 7:24PM R1 was transferred to a behavioral health facility. On 6/17/2025 at 3:29PM R1 returned to facility with an increase in antidepressant medication. 6/24/2025: At 9:40PM R1 was screaming, moaning, beating head off the doorway and punching herself in the face. R1 transferred to the local ER. There was no note of time or date of return. 6/27/2025: At 3:39AM R1 was in her room and staff heard R1 hitting herself. R1, stated she wanted to hurt herself, then R1 started banging her head on the door frame violently. R1 stated I would rather kill myself than go to the hospital, I'm going to hang myself. R1 was sent to the hospital and returned at 4:30AM and R1 had 1:1 with a CNA. On 6/27/2025 at 5:22PM R1 transferred to local hospital for suicidal thoughts. R1 returned at 11:12PM. 7/26/2025: At 1:54PM R1 screaming and cursing at other residents, screaming and banging her head off her walls saying she was going to kill herself. R1 sent to ER at 2:17PM and returned at 5:46PM. On 7/26/2025 at 9:55PM R1 called 911 due to suicidal thoughts, R1 transferred out to local hospital. 7/27/2025: At 8:22AM R1 returns from local hospital where she was seen by a counselor. Once R1 was in her room, R1 starts screaming I'm gonna kill myself, I'm gonna hurt myself, room completely stripped to include fitted sheet. On 7/27/2025 at 8:43AM R1 loud again and attempting to strangle herself with a fitted sheet and the use of her hands, refuses out of her room to be monitored and not enough staff for 1:1. On 7/27/2025 at 9:52AM R1was sent back out to ER. R1 returned at 7:42PM.7/28/2025: At 10:55AM R1 has 1:1 monitoring.8/6/2025: At 11:09AM R1 was aggressive, disruptive behaviors, screaming and cussing and making threats that she wants to strangle herself with a sheet. R1 stated she was going to barricade herself in her room and kill herself. R1 unable to be redirected or consoled, all items (sheets, cords, blankets, pillowcases, clothes ) removed from room. R1 began gently headbutting her door frame and stating that she wants to go to the hospital. (R1) was disturbing other residents on the hall and when they yelled from their room for her to be quiet, resident threatened 2 different female residents that she 'will punch them in their faces' and called them 'f****ing b******.' (R1) yelled out to staff 'I am going to barricade myself in the room and kill myself.' Staff prevented (R1) moving furniture to barricade door. (R1) held a fist up and threatened a CNA when taking her vitals, staff rotated someone monitoring behaviors for 2 hours, resident realized that her (small, baby-sized) [NAME] blanket was removed from her room and began screaming at staff to give her things back. This writer explained to (R1) that it's protocol to remove all items when someone is threatening suicidal plans. (R1) began screaming at staff that she 'will call the cops on us for stealing if we did not give the [NAME] blanket back.' (V20-RN) was able to console resident and resident stated 'I won't try to kill myself if I can have [NAME] back. [NAME] blanket returned to (R1) and no more behaviors observed at this time. (V3-Assistant Director of Nursing/ADON) called and currently in room with resident.8/9/2025: At 8:50PM R1 was screaming and banging her head forcefully on the wall, choking self and strangling self with a blanket. R1 sent to ER and returned on 8/10/2025 at 5:32AM. 8/11/2025: At 9:03PM R1 was 1:1 at nurses' station and wanted to go to bed so R1 went to her room and started beating her head on the wall. R1 was sent to the ER for evaluation. R1 returned to facility on 8/15/2025 at 1:18AM.8/18/2025 (documented as a late entry on 8/25/25 at 9:46AM) Sweep made of (R1's) room. All Hazards removed and cords secured. Daily audit sheet completed to ensure no further hazards in room authored by V1 (Administrator).R1's Behavior Tracking Logs dated 6/20/2025 - 8/20/2025 were reviewed and document the following:6/27/25 at 2:18AM: R1 had disruptive sounds behavior with interventions, behaviors documented was disruptive sounds with interventions of redirecting, 1:1, offering food/fluids, toileting, and positioning and was ineffective. 6/30/2025 at 10:05P: R1 stated she was having bad thoughts and was biting her fingers. R1 was also punching herself in the face. Interventions of 1:1, offer food/fluids and calm environment was ineffective. No other behaviors were documented for June 2025. 7/1/2025 at 8:22AM: R1 had 1:1 that was effective for hearing or seeing things not there. 7/1/2025 at 9:05PM: R1 was yelling and crying in her room when staff checks on her, she is saying she is having racing thoughts, providing a calm environment was not effective.7/30/2025 at 9:04PM: R1 was hitting self and interventions to redirect and 1:1 was ineffective. No other behaviors were documented for July 2025.8/6/2026 at 11:37PM: R1 had behaviors of cursing at others, with redirection ineffective nor was 1:1 effective. No other behaviors documented for August 2025. R1's Physician Orders documents an order for 15-minute checks once a day and as needed for diagnosis of bipolar disorder with a start date of 4/3/25. There were no other orders documented in R1's Physician's Orders for increased monitoring.On 8/29/2025 at 4:00PM, V1 (Administrator) stated he was unsure of who took out the call light out of R1's room or when this occurred. V1 was unsure about the 15-minute checks as well.On 8/29/2025 at 4:30PM, V2 (Director of Nursing/DON) stated she didn't know about the 15-minute checks for R1 but may have a few somewhere. V2 stated she didn't know when 15-minute checks started or when they ended. V2 referred this surveyor to V3 for the 15-minute checks. V2 stated she doesn't think she has any of the 15-minute check sheets.On 8/29/2025 at 5:35PM, V3 (Assistant Director of Nursing) stated when R1 returned to the facility on 6/27/2025 she instructed the staff to move R1 to another room and to remove all items that R1 could be used to harm herself. V3 stated they removed the call light at that time. V3 stated she did not direct them to remove the call light in the bathroom because R1 shared a bathroom with another resident. V3 stated she didn't think about the remote cord or other cords left in the room. V3 stated she did know that at one time R1 was on 15-minute checks but she didn't know when they started or how long they were for.On 8/29/2025 at 4:30PM, V9 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated R1 was in a private room prior to 6/27/2025. On 6/27/2025 R1 was returning from a hospital stay and the staff felt it would be safer for R1 to be in a room that was more visible so they moved her to another hall. V9 stated this is when they removed the call light, when R1 was placed in the different room. V9 didn't know of any other items removed but she does know they would not let R1 take any personal items that could be used to harm herself. V9 stated she did not have any 15-minute check sheets and she was not sure where they would be.On 8/29/2025 at 6:55PM, V20 (Licensed Practical Nurse/LPN) stated she doesn't recall R1 being on 15-minute checks.R1's Psychiatric Notes and Evaluations document the following:4/4/2025: R1 was seen by V21 (Master of Social Work/Licensed Clinical Social Worker) documents writer will meet with R1 on a weekly to biweekly basis for 6 months.4/7/2025: R1 was seen by V12 (Psychiatric Nurse Practitioner) and documents continue medication and treatment plan, staff to report any behavioral changes to provider. 4/21/25: Psych note documents R1 is to follow up with (Name of Counseling Service) for counseling and send to ER (Emergency Room) immediately if R1 expresses Suicidal Ideations and or exhibits self-harm behaviors/threats.6/23/3035: documents R1 was readmitted to the facility on [DATE] from a Psychiatric/Behavioral Health Facility for wanting to strangle herself and in-house Psych visits to increase to weekly.Visits by Psychiatric group for in-house visits shows no changes in plan of care for 6/28/2025, 6/30/2025, 7/7/2025 and 7/12/2025. On 7/14/2025 and 7/21/2025 medication changes were ordered by V12. 7/28/2025: V12 documents, the provider recommends facility to find proper placement for resident where needs can by appropriately met at appropriate level of care.8/4/25: R1 was seen by V12 and documents facility currently awaiting referral responses for placement Client to continue to meet with Social Worker.8/11/25: R1 was seen by V12 with no changes in plan of care. On 8/20/2025 at 9:30AM, R1 was observed in her room resting in her bed. Observation was made of the following items present in R1's room: R1 had a large blanket on her with a medium size thin blanket lying beside her, a cord attached to the bed remote occupied by R1 and the same cord on the unoccupied bed in the room. There were two Walmart bags present on bedside table. There were cords noted to the TV and air conditioner and hanging freely. R1's bathroom had an approximately 4-foot call light cord noted and a utility pipe coming out of the wall approximately 6 inches from the ceiling. There was a folded chair leaned up against the wall in R1's room. R1 was sleeping at this time. There were no staff observed with R1 or present outside of R1's room at this time.On 8/20/2025 at 10:15AM, V4 (Licensed Practical Nurse/LPN) stated she takes care of R1 on some of her shifts. V4 stated she caught R1 with a fitted sheet wrapped around her neck. V4 stated she got the sheet removed and stated she told R1 that she would pass out before she died doing that. V4 stated she could not remember exactly when this incident occurred. V4 stated R1 has good days and bad days. V4 stated R1 is suicidal at times.On 8/20/2025 at 10:18AM, V1 (Administrator) stated R1 was admitted from a behavioral facility up North that closed. R1 stated they do 1:1 off and on, according to R1's behaviors. V1 stated he told R1 that if she tried to strangulate herself then she would pass out before she died. This interview took place outside of R1's room. R1 was observed getting up from her bed and went into her bathroom and closed the door. On 8/20/2025 at 11:25AM, R1 stated she wants to be in a place where people are more her age. R1 stated she frequently has bad thoughts. R1 was asked to explain what she meant by bad thoughts, R1 stated, I frequently have thoughts of suicide, and the thoughts are coming more frequently now. R1 was asked if she had a plan, R1 stated, I will strangle myself. R1 stated, They took my fitted sheet and call light. R1 then started laughing. R1 stated, They caught me with the sheet around my neck and they stopped me, I was trying to do it. R1 then stated, The thought of suicide is really frequently lately. R1 was asked if there were ever staff that stayed in her room with her, R1 stated No, they never stay. R1 stated, I have good days and bad days; the bad days are really bad. R1 stated, I usually eat in my room by myself. R1 was asked what she does when she needs help. R1 stated, I am independent so I don't ask for help.On 8/20/2025 at 11:40AM, V6 (Licensed Practical Nurse) stated she does take care of R1 when she works. V6 stated, I have seen behaviors out of R1 like banging her head against the wall. V6 stated, I have never seen her try suicide. V6 stated R1 can be verbally aggressive to other residents especially R3. V6 stated R3 is confused but she will argue back at R1. V6 stated she was not aware of ever having 1:1 monitoring for R1.On 8/20/2025 at 11:58AM, V7 (Physician) was asked if he was familiar with R1, V7 stated Oh my God, please help with her, she is violent. V7 then stated, Is she still at the facility? V7 was asked if he was unaware of her return from the hospital and V7 stated, She has been sent out so many times I can't keep track. V7 stated she needs to be placed somewhere more fitting for her. V7 stated he gave the facility several facilities to send referrals to but evidently nobody will take her. V7 was asked if he felt like R1 was a threat to herself and others. V7 stated, Yes she is a threat to herself and to others, she hurt a staff member there by giving the staff member a head concussion. V7 was asked if he felt like R1 could possibly harm or kill herself and V7 stated, Oh, yes and I believe she tried but they caught her. V7 was asked if he felt like a call light in the bathroom and cords like remotes to the bed could be hazards for a resident with suicidal ideation. V7 stated, Of course they can, and I know they took away the sheets and I don't know that they can take everything away, but something needs to be done to assure safety for (R1), but they mainly need to get her placed somewhere more fitting and a place where she can be monitored closely. V7 stated R1 beats her head against the wall too and she could get a serious injury from that.On 8/20/2025 at 12:54PM, V8 (Licensed Practical Nurse) stated R1 used to be on the hall that she works but has since moved to the other hall. V8 was asked why R1 moved and V8 stated, I am not sure. When I came back to work after a couple of days off, (R1) had been moved. V8 was asked if she has ever seen behaviors with R1 while R1 resided on her hall, V8 stated she had seen behaviors like R1 banging her head against the walls. V8 stated, One time I heard R1 state she was going to kill herself, so we sent her to the hospital. V8 stated she has never seen R1 have any behaviors with other residents.On 8/20/2025 at 1:00PM, V2 (DON) came into V1's office where this surveyor was discussing R1's statement that she had frequent thoughts of suicide and had a plan of strangulation. V2 spoke up and said, I have never heard her mention that. V2 then left the room and yelled back that she was going to have R1 go to her office and sit with her. V2 then shortly came back to V1's office and summoned this surveyor to R1's room and stated that R1 stated she didn't say that. At 1:05PM, this surveyor entered the room, R1 was observed to be crying and when this surveyor asked her again about what she had said about wanting to kill herself, R1 stated she did say that. V2 and this surveyor stepped out of R1's room and V2 was asked if she felt the room of R1 was safe for someone that plans on strangulation. V2 went back into the room and looked around and noted the cords and stated, No but we did take away her sheets and call light. V2 was asked if R1 was ambulatory and V2 stated yes. V2 was then asked if R1 took herself to the bathroom independently and V2 stated yes, she does. This surveyor asked V2 to go look at R1's bathroom and see if she sees any hazards there. V2 came out of the bathroom and stated she wasn't aware there was a call light pull cord in the bathroom. V2 stated, I will cut that down right now and V2 left to go get scissors. V2 then went in the bathroom and cut the call cord. V1 then came to the hallway outside of R1's room and V2 reported that there was a call cord in the bathroom, and she cut it down. V1 stated he was unaware there was a cord in there as well. V1 stated to V2, (R1) has to be on constant 1:1 until we get her placed somewhere else, we have to for her safety. V2 stated, We will have to have department heads to take turns with her until I can get staff assigned to sit with her at all times. V1 and V2 were shown the thick metal pipe in the bathroom wall at the top above the toilet. V2 stated, Oh my I hadn't noticed that either. V2 stated, Well that is the sprinkler, and I can't do anything about that so there is that. At this time, this surveyor requested documentation of staff education for Suicidal Plan and/or Behavioral Health Care and V2 stated she has never done that type of training since she has been the Director of Nursing. V2 stated she has never trained the staff on Suicidal Plan/Threat or Behavioral Health Care. V2 stated she did not have training materials or policies on these topics and will have to get that information from corporate.On 8/20/2025 at 1:30PM, V1 requested this surveyor come to R1's room and stated, We have secured down all the cords and have taken off the remotes with cords on R1's bed and we have secured all the cords on the other bed in R1's room. All cords observed in R1's room were secured to the walls with plastic and screws. The folding chair was also removed. A staff member was observed sitting outside R1's door for 1:1 monitoring.On 8/27/2025 at 2:00PM, V1 presented an untitled document with V1's signature, a list of items and date of 8/20/2025, documenting items removed from R1's room. These items included, cords secured to wall, call cords removed from bathroom, folding chair removed, sharp objects removed, Walmart bags removed, and other hazardous items removed.On 8/20/2025 at 1:37PM, V9 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated she is involved with R1's care. V9 stated, She is something else. V9 stated, (R1) can be really good and then gets a trigger. V9 was asked what she meant by that, V9 stated, Anytime she doesn't get her way or what she wants. V9 stated the behaviors that she had mostly heard of was R1 banging her head hard against the wall. V9 stated that they took her sheets away because she said she was going to put the sheet around her neck and kill herself and V9 could not recall the date that this occurred. V9 stated she does work on care plans and some of R1's interventions were put in the wrong place on R1's Care Plan for the suicide interventions, but the interventions are 1. Listen to resident to validate comments. 2. Weekly 1:1 session with Social Services. 3. Let Psych know of issues. 4. Administer medications as ordered. 5. If resident talks of suicide, notify psych NP or MD for directions. V9 stated there was a period after a hospital return (unsure of which hospital return) when we had her on 1:1 but that was lifted by the Nurse Practitioner. V9 stated R1 has harmed a staff member and from what she heard the staff member turned around to leave R1's room and R1 slammed the door hitting the staff member in the back of their head causing a concussion. V9 stated some other behaviors are yelling, cursing, and disruptive to other residents. V9 states sometimes R1 states she has bad thoughts and R1 is encouraged to call the crisis hotline for psych but R1 refuses to call.On 8/20/2025 at 3:30PM, V3 (Assistant Director of Nursing) stated R1 has quite a bit of behaviors and must be sent to the emergency room as directed by V12 (Psychiatric Mental Health Nurse Practitioner). V3 was asked to describe such behaviors and V3 explained behaviors as yelling, screaming, temper tantrum for lack of words, and banging her head against the wall. V3 stated R1's triggers are when R1's sister or dad do not come to the facility when she wants them to. V3 stated she has heard R1 say she has bad thoughts, and some days are bad days. V3 stated that staff reported to her that R1 stated she was going to strangle herself, so she reported this to V1 and V2. V3 stated we usually send R1 to the Emergency Room, but they send R1 right back. V3 was asked if a resident had suicidal thoughts and specifically strangulation, what are some items that should not be in the room, V3 stated any kind of cords, sheets and things of that nature. V3 stated she was not aware that R1's bathroom had a call light cord present and was unaware of the television cords. V3 stated she was unsure about the air conditioner cord or if it could be detached. V3 stated R1 has a blanket that she likes, and it is thin, but it does bring R1 comfort, so we left it with her. V3 was asked about plastic bags and V3 stated, those must have been brought in yesterday and they shouldn't be in there as she could harm herself with those. V3 stated R1 had gone shopping with her sister yesterday and that must be where those came from. V3 stated, I take suicide thoughts and attempts very seriously because you never know when they are going to do it. V3 stated R1 can go from being fine to behaviors escalating quickly but we usually know when she is escalating by the yelling and screaming. V3 stated she doesn't schedule extra staff for 1:1 but if the need arises, she calls people in to try to cover the 1:1. V3 was asked if she has had behavior training, V3 stated she has in the past but has not received training since she has been employed at this facility. V3 stated she is unaware of any behavior training in the facility.On 8/20/2025 at 3:50PM, V1 approached surveyor and said, Well we sent R1 out because of what she reported to you, and they are sending her right back. V1 was asked what his plans were for R1 when she arrives back to the facility. V1 stated, Nothing really, I am not going to do the 1:1 thing because that is what she wants and that is rewarding her behavior to me. V1 stated he must find a way to get her placed. V1 stated, I don't think (R1) is strong enough to hang herself. V1 was asked to explain what he meant by R1 not being strong enough, V1 stated I mean physically strong enough to do that. On 8/21/2025 at 9:00AM, R1 was observed resting in bed with a blanket. A staff member was observed sitting outside R1's door monitoring R1.On 8/21/2025 at 9:15AM, V10 (Social Service Director/SSD) stated she does frequent 1:1 session with R1. V10 stated I talk to her every day. V10 was asked what prompted the weekly 1:1 session with R1 and V10 stated, Mainly her diagnoses. V10 stated R1 has told her before she is having strong thoughts/bad feelings several times but always denies hearing voices. V10 said that she asked R1 what bad thoughts meant and R1 did not explain what the thoughts were. V10 stated she has tried very hard to get R1 into a better suited facility for her but continues to get denials. V10 stated she had gotten accepted into a facility and then R1 was sent to the hospital and then that facility denied her. V10 stated she was going to keep trying as R1 needs to be at a behavioral facility and with other residents her age. V10 stated she has sent out several referrals and has followed up with many, but nobody will accept R1. V10 stated she is still trying to place R1 in another facility.On 8/21/2025 at 9:33AM, V2 stated the plan for R1 was to continue to see the Psych Nurse Practitioner and send to the emergency room when behaviors arise and continue Suicide Watch. V2 stated she understood that some of the items that were in R1's room are considered a risk but V2 stated this is her home and we must follow Long Term Care Regulations. V2 stated we try to keep it like home. V2 stated we had R1 in a nice Suite but due to behaviors starting in June we had to move her to a different room for better visual checks on R1. V2 stated, We are not a behavioral facility. V2 stated I will keep R1 with 1:1 at all times until R1 is placed in a facility that is more equipped to handle a behavior resident. V2 was asked if she has done any type of training to the nursing department related to Behaviors, or Suicidal Residents and how to handle the situation if behaviors arise. V2 stated, I had training years ago, but I have never done any type of training to the staff here at the facility. I will get with Corporate and see what types of training they want me to do. V2 stated (R1) has been on 1:1 since yesterday. V2 stated she feels like R1 is manipulating the staff with her behaviors but said we still must deal with that type of behaviors as well.On 9/2/2025 at 11:52AM, V1 was asked if he knew if the referral was ever made for R1 with (Name of Counseling Center) that was recommended in the Progress Note on 4/14/25 by the hospital, V1 stated the facility does not do that and those types of referrals have to go through the hospital. V1 was asked if (Name of Counseling Center) ever comes to the facility to make visits with R1 and V1 stated no but she does have the hotline to call if ever she needs to call. V1 was asked if he knew why R1 sometimes would call 911 on her own when she is having behaviors, V1 stated she does that on her own before the nurse gets to call for help. V1 stated R1 has a phone and has the right to call the hotline as well as 911 when she wants to.On 8/22/2025 at 12:50PM, V12 (Psychiatric Mental Health Nurse Practitioner) stated she visits R1 on a weekly basis and visits are held in R1's room. V12 stated, This facility is not the right placement for this type of resident with her mental health issues. V12 stated the services that R1 needs are not available here, R1 needs to be in a Psychiatric facility with clients more her age. V12 stated she was unaware of a call light cord present in R1's bathroom. V12 also stated she didn't notice all the cords present in R1's room such as cords to bed remotes, television cords, or a chair present in the room. V12 was asked if she felt those types of objects could be used to cause harm or have a successful attempt at suicide. V12 stated, Yes, they really could, and they do not need to be present in her room at all. V12 stated, Anytime someone makes the statement that they want to commit suicide and especially with a plan, should be taken very serious. V12 stated R1 has an excessive manipulatory behavior. V12 stated, I have always told the facility if (R1) ever makes the statement that she wants to die or wants to kill herself, they are to send (R1) straight to the Emergency Room. V12 stated, The facility should have never accepted this resident as she requires more services than the facility can accommodate. V12 stated R1 has behaviors if she doesn't get her way. V12 stated she is unsure what the facility will do as they have tried to place her several places, but everyone denies her. V12 stated she was not sure what the plan is for R1 at this point, but she does feel R1 has to have 1:1 at all times due to her being ambulatory and could retrieve harmful items from another resident's room. V12 stated there is a risk that R1 would harm herself if given the opportunity especially when her behaviors escalate.The facility policy titled Suicidal Threats dated [NAME][TRUNCATED]

Based on interview and record review, the facility failed to ensure necessary supervision was provided to prevent a fall with injury for 1 (R1) of 3 residents reviewed for accidents and supervision. This failure resulted in R1 being found in the floor resulting in mildly displaced left lateral sixth and seventh rib fractures and an acute, mildly displaced, and angulated fracture of the left femoral neck. Findings include: R1's Admission Record documents an admitted to the facility of 3/16/25 with diagnoses including displaced intertrochanteric fracture of right femur, altered mental status, unspecified, alzheimer's disease, unspecified and dementia in other diseases classified. R1's Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 had severe cognitive impairment. The same MDS section GG documents that R1 has impairment in both sides of upper extremities (shoulder, elbow, wrist, hand) and impairment on one side for lower extremity (hip, knee, ankle foot) and uses a wheelchair as a mobility device. R1's Care Plan documented a focus area of R1 at risk for falling related to alzheimers disease/dementia, with interventions including observe frequently and place in supervised area when out of bed. On 5/2/25 at 9:40 AM, V3 (Family) stated R1 had been transferred to this facility for rehabilitation after a fracture to her right femur. V3 stated R1 had 4 falls within one month time frame that she had been in the facility. V3 stated R1 had been significantly injured in two of the falls that included a laceration to the lip and fracture to the left hip. V3 stated he did not receive any communication from the facility on R1's fall on 4/4/2025 when she had been transported to the local hospital. On 5/2/25 at 10:49 AM, V11 (Certified Nurse Assistant/CNA) stated she was familiar with R1 and has cared for her. V11 stated R1 did have multiple falls while in the facility. V11 stated R1 did have a habit of trying to get up from her wheelchair without assistance. On 5/2/25 at 10:58 AM, V5 (Registered Nurse/RN) stated he was familiar with R1 and has cared for her. V5 stated R1 had a habit of trying to stand up from her wheelchair and had been at risk for falls. V5 stated R1 should not be out of staff's line of sight because of her impulsive behavior of trying to stand without assistance anytime she was in her wheelchair. V5 stated nurses are to report to another nurse when they are leaving the unit floor and CNA staff are to report to the nurse when they are leaving the unit floor so there is coverage. V5 stated, he had never had 2 staff members off the unit floor together, it should always be a rotation. On 5/2/25 at 10:59 AM, V9 (Nurse Practitioner/NP) stated, she did have direct patient care with R1. V9 stated R1 was confused and always trying to stand up from her wheelchair without assistance. V9 stated, that R1 needed constant care and if you took your eyes off of her, she would attempt to get up out of her wheelchair. V9 stated she had observed multiple times staff redirecting R1 when she would try to stand without assistance. On 5/2/25 at 11:20 AM, V8 (Physical Therapy Assistant/PTA) stated, she did have direct care with R1. V8 stated she provided services to R1 that included ambulation, balance, walking and strengthening. V8 stated R1 was very confused most of the time and did attempt to stand on her own frequently from her wheelchair. V8 stated R1 did have mulitple falls while in the facility. V8 stated R1 needed a lot of verbal cues during therapy, but would respond to them. V8 stated R1 was a fall risk and should not have been out of staff sight. V8 stated, on 4/4/2025, V6 (CNA) came to the physical therapy room to ask her to stay with R1 who had fallen in the dining room. On 5/2/25 at 12:07 PM, V7 (CNA) stated he didn't normally work with R1 and had been pulled from his usual unit to work R1's unit/hall on 4/4/2025 when R1 had been found in the dining room floor. V7 stated V4 (Licensed Practical Nurse/LPN) had left R1's unit/hall (where she was assigned) to go to a different hall in the facility for a few minutes sometime after 1:00 PM. V7 stated R1 had been sitting at the dining room table with another resident when he also left the unit to go to his car outside the building to get his vital sign equipment and was gone for about 5 minutes. V7 stated he did not notify anyone that he had left the hall to go outside. V7 stated it is the facility process for CNA's to notify the nurse when leaving the floor to help make sure the floor has coverage. V7 stated there was no staff member in the dining room with R1 when he left. V7 stated when he was walking back down the hallway with V4 (LPN) around 1:14 PM when V6 (CNA) notified them that R1 had been found in the dining room floor. On 5/2/25 at 12:13 PM, V6 (CNA) stated, on 4/4/25 she had been working on R1's unit. V6 stated she had been pulled to work R1's hall that day, however, does not normally work there. V6 stated she had been in another resident's room when she heard yelling help, help, help around 1:14 PM. V6 stated when she went out to the dining room, R1 was lying on the floor and no other staff was present. V6 stated she asked V8 (Physical Therapy Assistant/PTA) to stay with R1 while she notified V4 (LPN). V6 stated she had not been aware that V4 and V7 were off the floor. V6 stated it is the facility process for nurses to notify another nurse and CNA's to notify the nurse when leaving the floor to help with coverage on the unit. On 5/2/25 at 12:55 PM, V4 (LPN) stated she had been working R1's unit hall on 4/4/2025. V4 stated R1 was at risk for falls and did attempt to stand without assistance, frequently. V4 stated she did leave the unit floor sometime after 1:00PM to get keys from another unit floor nurse. V4 stated she had not been aware that V7 (CNA) had left the unit floor after she had. V4 stated on her way back to the unit floor around 1:14 PM, she bumped into V7 heading back to the unit floor at the same time. V4 stated V6 (CNA) notified her that R1 had been found lying on the dining room floor. On 5/2/25 at 2:25 PM, V2 (Director of Nursing/DON) stated R1 had been admitted to the facility as a fall risk. V2 stated there should be 1 nurse and 2 CNA's working each unit. V2 stated, if a nurse is leaving their unit floor they should notify another nurse in the building for coverage. V2 stated, if a CNA is leaving their unit floor then they should notify their nurse for coverage. V2 stated her expectation for staff is to follow facility process of notifying another team member for coverage when they leave the unit floor. V2 stated there should not be 2 teammates off the floor together. On 5/6/25 at 9:02 AM, V13 (Assistant DON/ADON) stated the facility will have 2 CNA's and one nurse to each unit and then a float CNA for the building. V13 stated it is the process of all staff members to notify another teammate when leaving the unit floor for coverage. V13 stated there should not be 2 teammates off the floor at the same time. R1's Fall Risk assessments dated 3/16/25, 3/17/25, 3/25/25, 3/27/25 and 4/5/25 all documented R1 was a high fall risk. R1's Progress Note dated 3/25/25 at 2:17 PM documented At 1310 (1:10 PM), this resident fell in the dining room. She was trying to get up and walk, lost her balance and fell . I and the CNA were not able to catch her. She hit her right arm with no injuries and good ROM (range of motion). Landed on her back. No injuries noted. Paperwork being done and notifications made. R1's Progress Note dated 3/27/25 at 5:50 AM documented Resident was sitting in a wheelchair at the sink in her bathroom brushing her teeth when she attempted to stand without assist. Resident was found in the floor, laying on her left side. No shortening or rotation to BLE (bilateral extremeties). Hematoma noted above the left eye. No other injuries observed. Resident placed back in wheelchair with assist x (times) 2. Spoke to (name of V9/NP). No new orders received at this time. She will be in this morning to assess Resident. Detailed message left with (name of V3/POA). Message sent through (name of messaging app) to notify Administration. Neuro's started. Fall report complete. Resident currently sitting in dining room watching television. R1's Progress Note dated 3/31/25 at 11:00 AM documented the resident was sitting in her wheelchair in her room prior to lunch. (Name) with activities witnessed the fall, she stated the resident stood up and fell face first hitting her head off the floor. Assessed resident no rom (range of motion) or shortening of extremities noted. She has a laceration to her top lip. Vitals are 146/78, P98, temp 98.3, R 20, o2 975 room air. She is stating that she is dizzy . The progress note also documented a fall mat was placed in the resident room and bed in lowest position. R1's Progress Note dated 04/04/25 at 1:31 PM documented it was recorded as a Late Entry on 4/4/25 at 4:01 PM by V4 (LPN). The progress note documented Called to dining room at approx. 1:14 PM by CNA. Resident found to be laying in floor. Resident c/o (complained of) left hip pain. (Name of ambulance company) called to transport resident to (name of local hospital) for further evaluation. R1's Progress Note dated 04/04/25 at 4:01 PM documented Called (name of local hospital) to follow up on resident. Nurse states patient will be admitted for fx (fracture) left hip. Nurse will call back with further details. The facility incident report dated 04/04/25 documented V4 (LPN) had found R1 lying on the floor in the dining room. R1 had been identified of having poor safety awareness. The resident had been sitting at the table prior to fall with brakes to wheelchair locked. V4 stated wheelchair had been found with brakes unlocked and sitting behind resident. Local hospital History of Present Illness (HPI) dated 04/04/25 at 2:16 PM documented under Chief Complaint: Patient presents with fall. This is reported to be (R1's) 3rd fall in 1 month. R1 had an unwitnessed fall. Two weeks ago, she fell and broke her proximal femur in right side. Then she fell and hit her face with sutures in the lips and third is left leg. This same document on page 8 documented a computed tomography scan dated 04/04/25 with results of mildly displaced left lateral sixth and seventh rib fractures and on page 9 under electromagnetic waves (X-ray) of the hip left included pelvis results of acute, mildly displaced, and angulated fracture of the left femoral neck. The facility Falls Management (revised 4/21/2022) documented under Policy it is the policy of (facility name) to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. The facility staffing policy (revised 1/2023) documented under Policy, The facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements (CMS, IDPH). Under Procedure, 1. Our facility maintains adequate staffing on each shift to ensure that that our resident's needs and services are met and schedules adequate staff to meet or exceed individual state requirement. 2. Licensed registered nurse and licensed nursing staff are available to provide and monitor the delivery of resident care services 3. Certified Nursing Assistants are available each shift to provide and monitor the delivery of resident care services of each resident as outlined on the resident's comprehensive care plan.

Based on interview and record review the facility failed to follow orders by placing a resident on hospice and failed to get a timely X-ray for a Covid positive resident having respiratory distress for 2 of 2 residents (R80 and R81) reviewed for quality of care in a sample of 39. This failure resulted in R80 being admitted to the hospital for 5 days with hypoxemic respiratory failure. Findings include: 1. R80's face sheet documents an admitted [DATE] with diagnoses including: cerebral infarction, acute kidney failure, 2019-nCoV acute respiratory disease, chronic kidney disease stage 3, dementia, and atrial fibrillation. R80's Care Plan documents in part, Problem Start date 9/6/24, Category: Disease Process. (R80) has tested positive for Covid-19. This places resident at higher risk for severe illness to include: Acute respiratory distress and secondary infections such as pnuemonia or bronchitis: increased risk for fluid volume deficit . The following clinical symptoms have been exhibited: Cough and Maliaise/lethargy are marked. Under Approach: Start date 9/6/24. Labs per healthcare provider orders . Nursing to assess respiratory status and observe for signs and symptoms of pneumonia or acute respiratory distress such as: productive cough, elevated temperature, abnormal respiratory status, cyanosis, shortness of breath, diaphoresis. Notify healthcare provider is occurs . Vitals (to include temperature, heart rate, respirations, pulse oximetry, blood pressure) per CDC guidelines R80's physician notes document a progress note by V24 (Nurse Practitioner/NP) documenting a visit date of 09/10/24 and a subject area of: subjective HPI (history of present illness) documenting: R80 is a [AGE] year old female seen today for Covid. (R80) reports shortness of breath at times. (R80) currently has oxygen on. Chest x-ray was ordered yesterday (10/09/24) but has not been done yet. R80 denies cough, headache, fever and sore throat. The subject area listed as 'Plan:' lists: covid: acute, cxr (chest x-ray) pending, nursing staff will monitor temp (temperature) and O2 (oxygen) sat (saturation) each shift and prn (as needed), and supportive therapy, will monitor for worsening systemic infection. R80's radiology (X-ray) order by V24 documents the order was sent in verbally on 9/10/24 at 6:40 am for a PA (posteroanterior) chest, LAT (lateral) chest, and OBL (oblique) chest. Frequency: once-one time 6:30am-6:30pm. This order also documents that the order was discontinued on 9/11/24 at 9:18am based on census discharge event. This order also documents a transmission status: New order fax error during attempt to send. R80's progress note dated 9/6/24 at 9:14am documents R80's lungs sounds were diminished. There were no additional progress notes assessing R80's respiratory status until V24's physician notes documented on 9/10/24 found in R80's Clinical Record. R80's progress notes documents: On 09/11/2024 at 8:58 AM This resident (R80) was taken by family members to ED (emergency department) for decline in condition and pneumonia work-up because they are concerned for her. She has had some decline in ability to feed herself. Family of R80 stated: I took two days off work to wait for a chest x-ray and one was never done. On 11/25/24 at 10:38 AM, V26 (family) stated R80 was at the facility for rehab and contracted Covid-19 while at the facility. They went in to see her and R80 kept coughing and having a hard time breathing. She told the staff R80 was coughing, having a hard time breathing and declining and R80 kept laying there coughing and losing her breath. They stated, they would get her an order for a chest x-ray to make sure it was not pneumonia. The x-ray never happened and she became concerned and took her out and took her to the emergency room . R80 was admitted to the hospital for about 5 days. V26 stated she does not remember if she actually had a diagnosis of pneumonia or if she had an accumulation of fluid causing her not to breathe, either way, she could not breathe well. So R80 did not get her rehab while she was at the facility, they did not have enough staff while she was there they had a bunch of Covid in the building and R80 was in her room with the door shut because of the covid and she has dementia, she did not get a chest x-ray when she needed one, therefore she was not taking her back there, she went to another nursing facility after she was discharged from the hospital and it was much better. R80's hospital records document a visit date of 09/11/24 at 9:19 AM with the heading of Subjective patient (R80) with family members after she apparently was supposed to have a chest x-ray 3 days ago and did not get a chest x-ray. Patient (R80) has a history of testing positive for COVID-19 8 days ago. Patient (R80) has no specific complaints but states I am a little short of breath positive cough that sounds productive. The section titled, Narrative documents: patient (R80) is an [AGE] year old female admitted to acute with SOB (shortness of breath) and hypoxia. Patient (R80) recently tested positive for COVID-19. Upon arrival to ER (emergency room ), patient (R80) was hypoxic with O2 saturation at 83% on RA (room air). The section titled, Assessment and Plan document: acute hypoxemic respiratory failure, likely secondary to COVID, chest x-ray reviewed significant edema bilaterally. IV (intravenous) Lasix 40 mg (milligrams) IV daily x 3 days. The section titled, COVID19 infection documents in part: dexamethasone started 6mg (milligrams) po (per oral) daily x 5 days. Hospital records document a discharge date of [DATE]. On 11/21//24 at 12:10 PM, V1 (Administrator) stated, he does not have a document showing when that order came through for R80's X-ray or exactly when V24 called and gave the order for the chest x-ray. He stated he sees the note from V24 about the order but does not know when she verbally put it in. V1 stated, sometimes x-rays can take awhile to get here. V1 confirmed that R80 did not receive an X-ray prior to leaving the facility on 9/11/24. On 11/21/24 at 12:10 PM when asked what the fax error on R80's order meant V1 (Administrator) stated, when the transmission status of a fax error occurs a notification would be sent to three different computers and the order would be automatically resent. On 11/21/24 at 12:07 PM, 12:19 PM, 3:59 PM ,V24 (NP) was attempted to be reached at both numbers listed for her, with messages left. V24 never returned a call back. On 11/22/24 at 11:14 AM, V23 (Medical Director) stated he did not have much information about R80. V23 stated he would not have any information of when V24 ordered the chest x-ray, she is not his nurse practitioner, she is the nurse practitioner for the facility. Therefore she or the facility would have that information. On 11/25/24 at 1:17 PM, V24 was attempted to be reached. V24 never returned a call back. 2. R81's face sheet documents an admitted [DATE] with diagnoses including: Iron deficiency anemia, malignant neoplasm of liver, hypertension, pulmonary embolism without acute cor pulmonale, gastrointestinal (GI) hemorrhage, and type 2 diabetes mellitus. R81's hospital records fax transmission dated 11/15/24 documents: subject: patient referral with a comment of: referral for services. This document contains progress notes dated 11/15/24 with a section titled, plan for today awaiting appropriate placement with hospice input after discussion with V19 (family) on 11/14 oncology consult with physician was finally canceled after reassessing goals of care with V19 (family) over discussion on 11/14. These documents contains an acute care surgery consult note dated 11/12/24 at 10:47 AM documents: R81 is an 82 y. o. (year old) male with a history of insulin dependent diabetes mellitus type 2, prior CVA (cerebrovascular accident) on Eliquis, history of GIB s/p APC of AVM ([NAME] plasma coagulation for gastrointestinal bleed caused by arteriovenous malformations) in the 2nd portion of duodenum 6/24/24 who presented to (acute hospital) with complaints of progressive weakness and fatigue. R81 was found to be anemic with a hemoglobin of 5.9 requiring blood transfusion with stabilization of H/H (hemoglobin and hematocrit). GI was consulted and performed a colonoscopy on 11/11 which revealed a large nearly obstructing fungating mass in proximal ascending colon. MRI (magnetic resonance imaging) of the abdomen obtained and revealed a probable primary adenocarcinoma at the cecum/ascending colon with probable metastatic lesions at the pancreatic uncinate process, 2 hepatic lesions, pulmonary nodules, and metastatic lymph nodes in the right lower quadrant mesentery and second portion of the duodenum. R81 seen and evaluated at bedside. (R81) is tolerating FLD (fluid diet). R81 reports RLQ (right lower quadrant) abdominal pain. These documents contain a progress note dated 11/15/24 at 7:53 AM with a section titled, consults/procedures/tests documenting in part: Oncology 11/14 was canceled on 11/14 since after long discussion with V19 she elects hospice/comfort care (evidence of brain metastatic disease on CT (computed tomography) brain w (with) iv (intravenous) contrast). R81's hospital notes contains a document dated 11/14/24 titled, Registered Dietitian Note which documents in part: assessment comment(s): per MD (medical doctor) note, imaging showed cecal mass with metastatic disease in the mesenteric and retroperitoneal lymph nodes and distal SBO (small bowel obstruction). MD notes also state that pt (patient) family has decided in favor of hospice care. On 11/19/24 at 3:19 PM, V19 (family) stated she was under the impression R81 was already on hospice care. She thought he was coming to this facility on hospice care. On 11/19/24 at 4:55 PM, V1 (Administrator) stated R81 is not on hospice care, he talked with V19 today and he will look into getting a hospice consult for R81 set up. On 11/22/24 at 11:14 AM, V23 (Medical Doctor) stated, he has not received a message from the facility about a consult for R81 to be admitted to hospice care. He will contact the facility and check into that. R81's physician order report documents an order with a start date of 11/19/24 documenting: code status DNR (do not resuscitate) comfort measures. R81's physician order report documents an order with a start date of 11/21/2024 documenting: admit to hospice care Dx (diagnosis) malignant neoplasm of liver. The facility policy dated 07/14 titled, Obtaining and Following Physicians orders documents: it is the policy of (this facility) that physician orders will be obtained by licensed personnel and followed.

Based on interview and record review, the facility failed to ensure safe resident transfers were provided to prevent accidents for 2 (R1 and R2) of 3 residents reviewed for accidents and supervision in the sample of 4. This failure resulted in R1 sustaining a laceration to the right foot requiring sutures and R2 sustaining a fibula fracture. Findings include: 1. R1's face sheet documented an admitted [DATE], a discharge date of [DATE], and diagnoses including: urinary tract infection, laceration without foreign body of unspecified toe without damage to nail, metabolic encephalopathy, paraplegia, lymphedema, anemia, type 2 diabetes mellitus. On 4/11/24 at 1:31 PM, V4 (Licensed Practical Nurse/LPN) stated she was called to R1's room on 4/8/24 to help transfer R1 onto his motorized wheelchair. V4 said while R1 was in the mechanical lift sling the wheelchair moved causing R1's foot to be lacerated by the bedframe. V4 said she applied pressure to R1's laceration to slow the bleeding and called for emergency services to transfer R1 to the hospital. V4 said R1's laceration looked pretty deep. On 4/12/24 at 9:57 AM, V10 (CNA) said she was assisting R1 to transfer to his motorized wheelchair on 4/8/24. V10 said that R1's motorized wheelchair was sitting parallel with the bed when R1 was transferred onto it with a mechanical lift. V10 said while staff were trying to position R1, R1 hit the controls on the motorized wheelchair causing the wheelchair to turn and R1's foot to be cut by the bedframe. V10 said once staff got R1's foot out from under the bedframe a laceration was seen with heavy bleeding. V10 said staff assisted R1 back to the bed and R1 was sent to the hospital for further treatment. On 4/12/24 at 10:16 AM, V9 (CNA) stated that on 4/8/24 she was assisting R1 to get cleaned up for the day and get R1 in his motorized wheelchair. V9 said staff used a mechanical lift to get R1 out of bed and onto the motorized wheelchair. V9 said as staff were attempting to move R1 back into the seat for better positioning the motorized wheelchair came on and moved causing R1's foot to be sent under the bedframe. V9 said once R1's foot was under the bedframe staff used the joystick control on the motorized wheelchair to move the chair back. V9 said this caused a laceration to R1's foot that was bleeding heavily. On 4/12/24 at 11:28 AM, V7 (Therapy Director) said all residents who wish to use a motorized wheelchair must be assessed by therapy for safety. V7 said R1 had not been assessed for motorized wheelchair safety when the 4/8/24 incident happened. V7 said she was not made aware R1 had a motorized wheelchair until after the 4/8/24 incident. V7 said staff should ensure the motorized wheelchair is off prior to transferring someone onto it. On 4/12/24 at 11:59 AM, V2 (Director of Nursing/ DON) said she expected staff to notify her of a family bringing in a motorized wheelchair as the resident would need to wait to use it until therapy could assess the resident for safety. V2 said she expected staff to notify her if any resident family brings Durable Medical Equipment (DME) into the facility. On 4/12/24 at 1:05 PM, V8 (Certified Nursing Assistant/CNA) said R1's family brought R1's motorized wheelchair into the facility on [DATE] at approximately 10:30 AM. R1's progress note dated 4/8/24 at 12:08 PM documented in part .Between 11:15 and 11:20 AM, during a transfer from his bed to his chair using a hoyer lift, this resident sustained a deep laceration to his right 4th metatarsal. Towels were applied to his right foot to staunch the flow of blood. 911 was called for transfer to a hospital. After the bleeding slowed down to a slower continuous bleeding a pressure dressing of 4 X 4s and an abdominal pad were applied to the area. This dressing was then reinforced with tape . R1's progress note dated 4/8/24 at 5:35 PM documented in part . (Nurse Practitioner) at facility and made aware of incident. Facility notified by family that resident will require sutures. (V1 Administrator) notified. Awaiting resident return . R1's progress note dated 4/8/24 at 6:42 PM documented in part .(R1) returned from the (Hospital) about 5:30 pm, after having his right 4th metatarsal stitched with 7 internal and 7 external stitches. He is doing okay. The foot has a dressing that is intact, but since the doctor left a small opening for drainage, there is some blood coming out. This is expected, so blood won't build up under the skin or around the toe . R1's 4/8/24 hospital medical record documented in part . right foot with starburst pattern laceration overlying the 5th MCP (metacarpophalangeal) joint. 2 cm (centimeters) in diameter with approximately 3 cm length of affected skin. Laceration affects underlying facia with approximately 0.7 cm deep puncture wound just proximal to the web between fourth and fifth toes. (R1) with complete loss of feeling in both feet at his baseline .seven 4 - 0 running Vicyl internal sutures and 7 interrupted 4 - 0 nylon external sutures . The facility's June 2013 Motorized Mobility Aides in the LTC (Long Term Care) Residence- Policy Considerations documented in part .housing providers must also permit manually operated wheelchairs and other manually operated assistive devices without exception. Housing providers must also permit individuals who use power- driven mobility devices to utilize same, unless it can be shown by the housing provider that an individual's use fundamentally alters its programs, services, activities, or creates a direct threat, and/or safety hazard . 2. R2's face sheet documented an admitted [DATE] and diagnoses including: dementia, atherosclerotic heart disease, hypertension, anxiety disorder, contusion of right ankle. R2's 1/23/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R2 is severely cognitively impaired. R2's progress note dated 3/13/2024 at 7:00 PM documented in part . (V11, Wound Physician) in facility to round on wound to left foot at approximately (7:00 PM). Continue treatment per eTar (Electronic Treatment Administration Record). Right foot currently bruised with no swelling observed. Both (V11) and (V12 LPN) palpated foot with no observed (signs or symptoms) of pain. No complaints of pain. No new orders. (V2 DON) notified. Resident had previous fall with eye currently bruised purplish red as well . R2's progress note dated 3/14/2024 at 05:34 PM documented in part .(R2) in bed was seen by (V11) yesterday- right foot swollen, bruised and painful. Unsure of his orders. Did call (V13, Nurse Practitioner) (new order) received for a right foot and ankle x-ray. Did make POA (Power of Attorney) aware and x-ray set up for tonight . R2's 3/14/24 Patient Report of the right ankle x-ray documented in part . an oblique fracture is noted involving the distal fibula . R2's 3/14/24 incident investigation contained a note from V7 (Therapy Director/Family Member) and documented in part . I have transferred (R2) multiple times . there have been several instances where she is unable to assist with the pivot portion of a transfer. I have noticed that when she cannot assist with the pivot, her feet do get caught up in the wheels of her (wheelchair). This has happened during our transfers a few times . R2's 3/19/24 Detailed Incident Summary by V1 (Administrator) documented in part .Per the facility protocol an investigation was completed to identify the cause of the fractured extremity. It was found that the resident's (R2's) feet would become entangled in the wheelchair foot rests during transfers, and cause a twisting of the ankle . On 4/12/24 at 9:14 AM, V16 (LPN) said she was caring for R2 on 3/13/24 during the day shift. V16 said she did not see any bruising or swelling of R2's ankle during her shift. V16 said no staff reported any new injuries to R2 during her shift. On 4/12/24 at 9:39 AM, V15 (CNA) said she was caring for R2 on 3/14/24 during the dayshift. V15 said when she assisted R2 back to bed after the noontime meal she noticed bruising to R2's right ankle. V15 said when R2's ankle was moved R2 complained of pain. V15 said she reported R2's right ankle bruise and complaints of pain to V4 (LPN) immediately. On 4/12/24 at 10:07 AM, V14 (CNA) said she was caring for R2 on 3/13/24 during the dayshift. V14 said she did not see any bruising to R2 right ankle. V14 said R2 did not complain of any pain to her right ankle during transfers on 3/13/24. V14 said if she had noticed any bruising to R2's ankle she would have reported it to the nurse. On 4/12/24 at 10:43 AM, V12 (LPN) said she arrived at the facility to start her shift at 6:00 PM on 3/13/24. V12 said as she was administering medications to residents, V11 (Wound Physician) had alerted her R2 had a bruise to her right ankle. V12 said she went to assess R2 and R2's right ankle was bruised. V12 said R2's right ankle was not swollen and R2 did not complain of any pain with palpation. V12 said she notified V2 (DON) of R2's bruise and was told R2 had previously fallen, and the bruising was known about. V12 said she did not work on R2's hall often and was not aware the bruise to the right ankle was a new injury. On 4/12/24 at 11:28 AM, V7 (Therapy Director/Family Member) said she was very familiar with R2. V7 said she had transferred R2 several times. V7 said there are times R2 will not follow queuing to move R2's feet during a transfer and R2's feet will get caught up on the wheelchair. V7 said she was not sure how R2's fibula sustained a fracture. V7 said it was possible R2's foot got caught under the wheelchair pedal and R2 moved the wheelchair causing the fracture. On 4/12/24 at 11:59 AM, V2 (DON) said she did not recall V12 (LPN) notifying her of any new bruise to R2's ankle on 3/13/24. V2 said if she had been notified, she would have instructed V12 no notify V13 (Nurse Practitioner). On 4/12/24 at 1:31 PM, V4 (LPN) said on 3/14/24 staff reported to her R2 had some bruising on her right ankle. V4 said after she assessed R2 she contacted V13 (Nurse Practitioner) to obtain an order for an x-ray of R2's ankle. V4 said R2 complained of pain when the right foot was moved left and right. On 4/15/24 at 10:42 AM, V1 (Administrator) said V7 (Therapy Director) had told him of R2's feet getting tangled in the footrests on R2's wheelchair at times. V1 said in the course of his investigation of the 3/14/24 incident, no other staff had told him of R2's feet getting tangled on the footrests of her wheelchair during transfers. V1 said it was an assumption that R2's foot got entangled in R2's wheelchair's footrests causing R2's fibula to become fractured. V1 said he was not sure exactly how R2's fibula sustained a fracture. On 4/15/24 at 12:36 PM, V13 (Nurse Practitioner) said she would expect staff to notify her of any new bruises or injuries to residents. V13 said she was not notified of R2's right ankle bruise until 3/14/24 when she ordered an x-ray. The facility's February 2012 Change in Condition policy documented in part . 1. The staff person who first notices the change reports resident change in condition immediately to the licensed nurse. 2. The licensed nurse assesses the resident . signs, symptoms and any physical and/ or mental changes in condition. 3 . sign, symptoms and any physical and/ or mental changes in condition are documented in the resident's medical record. 4. The resident's primary physician or designated alternate will be notified immediately of any change in a resident's physical or medical condition, this includes: b. Deterioration in health, mental, or psychosocial status. C. Need to alter treatment .

Based on observation, interview, and record review the facility failed to ensure catheter care was provided per current standards of practice for 2 of 8 (R25 and R34) residents reviewed for catheter care in the sample of 45. This failure resulted in R34 developing a urinary tract infection that required hospitalization on [DATE]. Findings Include: 1. R34's undated Resident Face Sheet documents R34 was admitted to the facility on [DATE] with diagnoses that include spinal stenosis, diabetes, acute kidney failure, urinary tract infection, muscle wasting, atrophy, dependence on supplemental oxygen, and hypertension. R34's MDS (Minimum Data Set) dated 9/14/23 documents R34 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R34 is cognitively intact. This same MDS documents under Section I, R34 has neurogenic bladder and obstructive uropathy. R34's Physician Order Report dated 12/14/23 to 12/21/23 documents a physician order to provide foley catheter care each shift. R34's local hospital record with an admitted [DATE] documents R34 was admitted to the hospital with diagnoses that included acute encephalopathy, acute kidney injury, and urinary tract infection with hematuria. On 12/21/23 at 1:23 PM, V8 (Certified Nursing Assistant/CNA) stated R34 was recently transferred to the hospital, and she worked the day after R34 returned to the facility. V8 stated R34 reported to her that he had not received peri care from the time he arrived back to the facility until she returned to work the next day. V8 stated R34 told her a few days later that he had not received catheter care again. On 12/21/23 at 1:28 PM, R34 stated he was in the hospital recently and diagnosed with a severe urinary tract infection. R34 stated he returned to the facility from the hospital a week ago today (12/14/23) around supper time. R34 stated they have enough staff most of the time. R34 stated when they don't have enough staff peri care/catheter care doesn't get provided. R34 stated he thought catheter care was supposed to be provided each shift and it didn't get done. R34 stated it starts stinking because the facility staff doesn't clean it. This surveyor didn't observe R34's catheter bag hanging on the bedside and clarified with R34 that he did in fact have a urinary catheter. R34 stated he did, and it should be hanging on the bed. This surveyor asked V12 (Licensed Practical Nurse/LPN) to assist in finding R34's catheter bag. V12 pulled R34's blanket back and the catheter bag was observed laying on/near R34's abdomen. V12 (LPN) stated it should have been hanging on the side of the bed. V12 stated staff had assisted R34 to reposition and had forgotten to reattach the catheter bag after they assisted him. On 12/21/23 at 3:52 PM, V8 (CNA) was observed providing catheter care to R34. V8 used a washcloth with no rinse soap and wiped both sides of the penis in circular motion and outward away from the catheter insertion site. V8 then used a separate washcloth and began wiping the catheter tubing beginning at the insertion site and going downward. V8 then used the same washcloth and wiped up and down the tubing toward and away from the insertion site. On 12/21/23 at 3:50 PM, V4 (Director of Nurses/DON) stated catheter care should be provided each shift. V4 reviewed R34's treatment administration record and stated the nursing staff have signed off that catheter care is provided each shift. When asked if the licensed nurses performed catheter care, V4 stated sometimes they do and other times they oversee the certified nursing staff to ensure they provide the catheter care. After reviewing the observation of catheter care provided to R34 by V8, V4 stated she would expect staff to wipe down the catheter tube away from the meatus (insertion site). V4 stated R34 gets frequent urinary tract infections and is followed by an Infectious Disease Specialist due to the frequency of infections. On 12/22/23 at 9:15 AM, V18 (Nurse Practitioner/NP) stated that he would expect staff to follow current policies and standards of care when providing catheter care. V18 stated that improper technique when providing catheter care can contribute to urinary tract infections. The facility Catheter Care, Urinary dated 2/2012 documents, The purpose of this procedure is to prevent catheter-associated urinary tract infections. This same policy documents under Maintaining Unobstructed Urine Flow, .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Under Steps in Procedure the policy documents, .16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward . 32619 2. R25's Face Sheet documented an admitted [DATE] and listed diagnoses including Type 2 Diabetes and Chronic Kidney Disease (CKD). R25's Care Plan dated 11/29/23 documented problem areas, Requires contact isolation for ESBL (Extended-spectrum beta-lactamases), and (R25) has CKD and is frequently incontinent of bowel and bladder. R25's Minimum Data Set, dated dated dated [DATE] documented that R25 requires partial/moderate assistance for toileting and is always incontinent of bowel and bladder. R25's Nursing Progress Note dated 12/17/23 documented, Resident lying in bed with head of bed elevated. New order received for Macrobid 100 milligrams one tablet twice daily for seven days for ESBL in urine. On 12/20/23 at 01:45pm, V9 (CNA), was observed providing incontinence care for R25. R25 was awake and alert only to herself. With R25 lying in bed, V9 donned gloves and removed R25's incontinence brief which was soiled with urine and feces. V9 rolled R25 to the side and wiped off some of the feces from the buttocks. Without changing gloves, V9 repositioned R25 onto her back and, using washcloths with perineal cleansing spray, wiped the perineal area three times from back to front. Again, without changing gloves, V9 touched the perineal spray bottle and a clean towel with which the perineal area was dried. V9 placed the contaminated spray bottle into R25's nightstand. At the conclusion of the procedure, V9 acknowledged she should have changed gloves after they came in contact with feces, and the perineal area should have been wiped front to back. On 12/22/23 at 08:54am, V4 (DON) stated all CNA's will be re-educated on the proper infection control techniques for incontinence care. A Perineal Care Policy dated July 2017 stated, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. 9. For a female resident, wet washcloth and apply soap or a skin cleansing agent. wash perineal area, wiping front to back.

Based on interview and record review the facility failed to assess for the safety of a personal rocking chair and cushion for 1 (R3) of 3 residents reviewed for an accident in a sample of 9. This failure resulted in R3 falling from the rocking chair sustaining a laceration to the forehead and a fracture of the C2 vertebra requiring local hospitalization and subsequent transfer to an out of state hospital. The findings include: R3's Face Sheet documents he admitted to this facility on 08/26/22 with diagnoses to include - diabetes mellitus II (DMII), atrial fibrillation, COPD (Chronic Obstructive Pulmonary Disease), urinary incontinence, with additional diagnosis of repeated falls dated 10/26/22. R3's admission MDS (Minimum Data Set) dated 09/18/22, section C (Cognitive Patterns) documents a BIMS (Brief Interview for Mental Status) of 14, indicating R3 was cognitively intact. Section G (Functional Status) documents R3 required extensive assistance with two or more persons for transfers. R3's balance between transitions and walking was assessed as not steady, only able to stabilize with staff assistance. R3's Care Plan documents Problem Start Date: 08/26/2022; Category: Falls. Resident is at risk for injuries r/t (related to): Hx (history) of falls, Edited: 12/05/2022; Long Term Goal Target Date: 1/25/2022. Resident will be free of fall related injuries by next review date. Created: 9/28/2022. R3's Care Plan also documents Approach Start Date: 08/31/2022. Approach End Date: 11/25/2022. Remind (R3) not to lean forward when sitting in wheelchair. Approach Start Date: 10/24/2022 Ensure b/l (bilateral) leg rest on w/c (wheelchair) for transporting. Created: 10/24/2022. Approach Start Date: 2/02/2022 Enc (encouraged) resident not to sit in rocker in room due to safety concerns of his falling. Created: 12/05/2022. R3's admission Fall Risk assessment dated [DATE] documents a score of 7, indicating R3 is at moderate risk for falls. (Scoring: 0-5 Total Points = Low Fall Risk, 6-13 Total Points = Moderate Fall Risk, >13 Total Points = High Fall Risk). R3's Transfer Assessment observation details dated 08/26/22 documents Is the resident independent in transfers and ambulation? No, Is resident able to bear weight well during transfers, do they have history of being able to bear weight? No, and Is resident predictable, cooperative, and able to follow directions? Yes, Use gait belt with 2 assists during all transfers. R3's progress note dated 08/31/22 at 2:30 PM, documents R3 experienced an unwitnessed fall in his bathroom to include - . upon entering room nurse witness patient lying on left side on floor. Patients' wheelchair was in bathroom facing as if patient was coming out of bathroom. When nurse was performing head-toe assessment, nurse asked patient how he fell . Patient stated, 'he was trying to pick up a piece of garbage off floor and took a tumble.' Nurse note patient had small abrasion to left side of forehead with some dried blood coming from scratch. Nurse asked patient is he was having any other pain, and patient stated 'No'. Nurse had patient perform active range of motion to upper and lower extremities, patient could only perform to normal self, nurse noted no inward rotation or deformities to hips/legs, so nurse perform passive range of motion to make sure he was not hurting in joints . R3's Event Report dated 08/31/22 includes in house treatment of a 1 cm (centimeter) abrasion to the forehead with a root cause for fall described as, confusion, and weakness. Patient trying to use restroom and too weak to stand. The post fall intervention documented on R3's Event Report dated 08/31/22 was to educate resident to use call light and check on resident. R3's Transfer assessment dated [DATE] includes Is resident predictable, cooperative, and able to follow directions? No; Mechanical lift stand assist with all transfers; Use full body/mechanical lift for all transfers . R3's Fall Risk assessment dated [DATE] documents a score of 21 points indicating R3 is a high risk for falls. R3's progress note dated 10/24/22 documents While being taken to dining room for dinner via wheelchair, resident had his feet up. He suddenly put them down. Wearing soft soled shoes which caused him to suddenly go forward falling on the carpet. Sustained a hematoma and 2 cm laceration to right forehead. Also, a 2 cm laceration to bridge of nose. The skin on nose has carpet burn. Left hand with a 7 cm laceration to posterior hand. Steri-strips applied. A 2.5 cm laceration to left ring finger and a 1 cm laceration below that one. A 2 cm laceration to tip of left ring finger. Wedding ring removed and placed in narcotic drawer. Ice applied to right forehead and nose. Call placed to nurse practitioner who ordered x-rays of facial area and nose .will ensure leg rest are intact when resident in wheelchair. Will continue to monitor. R3's Event Report dated 10/24/22 documents Conclusion with root cause: Being t/p (transferred/pushed) without leg rest on bl (bilateral). Rubber soled shoes on. Had his legs up initially, but then put them down causing him to tumble forward to the carpet. Will ensure he is t/p with bl leg rest intact. R3's Fall Risk assessment dated [DATE] documents a score of 13, indicating R3 remains at high risk for falls. R3's progress notes dated 12/02/2022 at 10:05 AM documents guest observed on floor in room, lying on stomach with forehead on feet of bedside table, lying in puddle of blood. This nurse rolled guest off bedside table and assessed forehead, had a 4 cm by 2 cm laceration to R (right) forehead above eyebrow. Guest (R3) told this nurse the year, day of week, and who the president of the US (United States) is, he also stated, 'I was sitting in rocking chair and fell asleep that's when I was on the floor, pressure applied to forehead to stop bleeding then ice was applied. (V2 - Director of Nursing - DON) called ambulance services for transportation to hospital for eval (evaluation). R3's Initial Incident Report dated 12/03/22 at 12:45 PM includes: . STATUS: On 12/2/22 Resident (R3) Dx (diagnosis) of COPD (Chronic Obstructive Pulmonary Disease), acute kidney failure, cognitive communication deficit. Was observed by Nurse in the floor of his room. Resident stated he fell asleep in his rocking chair and fell forward. Nurse assessed resident. Resident had laceration to area above right eyebrow. Resident sent to hospital for evaluation. At hospital resident received x-ray of neck. On 12-3-22 facility received notification of x-ray findings of an odontoid fracture of cervical spine C2 vertebrae .Investigation started. R3's Final Incident Report dated 12/03/22 at 12:45 PM includes: .Type of Occurrence: Serious Injury . On 12-3-22 Nurse heard resident calling from room. Nurse got to resident room and observed resident (R3) laying on floor on stomach with head against base of bedside table. Nurse immediately began to assess and tend to resident. Resident stated he was in his rocking chair, fell asleep, and had fallen forward out of rocking chair. Resident had 4 cm by 2 cm laceration to right forehead above eyebrow. Nurse applied pressure. Called ambulance. Resident sent to hospital for evaluation. All staff statements find that resident was heard calling out and was observed on floor in front of rocking chair. Resident statement tells that resident was in rocking chair prior to fall and fell asleep 'that is when I was going to the floor' per resident. Rocking chair has been removed from resident room with approval from family and resident. Spoke to family about replacing chair with recliner .This is the final report. On 02/15/23 at 9:42 AM, V6 (CNA - Certified Nursing Assistant) stated he remembered the incident on 12/02/22 when R3 fell and was working that day. V6 stated R3 had fallen from his rocker and the lift aid cushion was in the seat of the rocker at the time of R3's fall. V6 stated the facility did an investigation and took statements. V6's written statement dated 12/02/22 documents the following - V6 last provided care to R3 at 9:30 AM; R3 found on floor for unwitnessed fall; R3 was not usually assigned to V6; R3 was assigned to V6 at time of incident; and R3 was dry at time of incident. V6's written statement further documents Resident (R3) was placed in his rocking chair that had a cushion from the family that resident was sitting on. Assisted with transfer. Bedside table was placed in front of resident. Resident was asked if he needed anything else, he didn't, so left the room. After leaving resident approximately 30 minutes later (activities) found resident on floor. On 02/15/23 at 11:59 AM, V19 (Rehab Director/Occupational Therapist) stated she evaluated (R3) on 08/30/22. I assessed transfers and self-care. (R3) did fine transferring with one person, he was able to get up on his own. Then, (R3) went out to the hospital and came back on 09/11/22. (R3) required 2 plus (person) assist at that time. V19 stated she recommended the sit-to-stand device which was safer for nursing/CNA's and R3 loved this. V19 stated progress was very slow and due to Medicare rules of non-progression and plateau he was discharged from therapy on 10/27/22. V19 verified R3 did have a wooden rocking chair from his home with a cushion. V19 said the cushion was removable and the family moved it around. V19 said the cushion was spring loaded as a sort of assist when standing from a sitting position. V19 stated a cushion like that would never be recommended by therapy. V19 said that the family requested a Care Plan meeting and they had one on 11/30/22. V19 said that R3 wanted to stay up in his rocker all day long, but the family was complaining about wounds, so V19 recommended R3 use a recliner, which the family was going to bring in a lift recliner. V19 said that they recommended on 11/30/22 that the family remove the rocker. V19 said it was not a safety suggestion, it was more for the elevation of the legs and compliance with that which would have been accomplished with the lift chair. V19 said the rocker was more for the family when they visited. V19 stated the sit-to-stand device would have been appropriate to transfer to and from his rocking chair. V19 confirmed R3's rocking chair was not assessed for safety during his stay. On 02/15/23 at 11:47 AM, V1 (Administrator) stated that two days prior to R3's fall, the facility held a Care Plan meeting on 11/30/22 that included V28 (Family Member/POA - Power of Attorney). V1 said that R3 did have a wooden rocking chair with a cushion that the family brought to the facility for R3 to use. V1 said the cushion was not a normal cushion, it was a type of lift assist cushion to help with getting up from the rocking chair. V1 stated that V28 was told during the Care Plan meeting that they did not recommend R3 to continue using this cushion and it was not good for R3 to use the cushion in the rocking chair. V1 said that they asked the family to please take the cushion and chair home. A printed description of the lift assist cushion was provided by the facility and describes the cushion as a Portable self-powered seat lifts to help you out of any chair. Easily transition from sitting to standing with the aid of this self-powered lift assist cushion. Simple hydraulic mechanisms gently lifts you as you stand. On 02/15/23 at 10:24 AM, V28 (Family Member/POA - Power of Attorney) said The day we had planned to move him . was the day they called and said he fell out of his rocker, and they sent him out. When I was waiting with him in the ER (emergency room ), the doctor came in and told me his neck was broken. (Local hospital) was going to transfer him to (out of state hospital) for treatment. He was transported by ambulance.

Based on interview and record review, the facility failed to ensure necessary reporting of a fall was completed in order to immediately assess for resident injury and evaluate potential causal factors leading to the fall for one of 3 residents (R3) reviewed for quality of care in the sample of 4. This failure resulted in an immediate jeopardy, which was identified to have begun on [DATE] when the facility to failed to accurately report a fall in order to seek timely medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 (Administrator) and V29 (Regional Director of Operations & Clinical Services) were notified of the Immediate Jeopardy on [DATE] at 2:00PM. The surveyor confirmed by observations, record review, and interview, that the Immediate Jeopardy was removed on [DATE]. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff as needed and evaluate the effectiveness of their interventions. The findings include: R3's resident face sheet documents R3's date of birth was [DATE] with an admitted to the facility of [DATE]. R3's face sheet also listed the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's most recent fall risk assessment tool was completed on [DATE] and documents a total fall risk score of 7, which falls into the moderate fall risk category. R3's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C, documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R3 is cognitively intact. This same MDS documents in Section G that R3 requires extensive assist (of two plus person physical assist) for the following: bed mobility (how a resident moves to and from lying position, turns side to side, and position body while in bed or alternate sleep furniture), transfer (how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off unit locations like dining room, activities and treatment areas), dressing (how a resident puts on, fastens and takes off all clothing items), toilet use, and personal hygiene. This same section of the MDS also indicates that R3 did not walk in room or corridor during the look back period of this assessment. Section G0300 indicates that R3 needed staff to assist in stabilizing when moving from seated to standing position, while moving off and on the toilet, and when moving from surface to surface. G0600 indicates that a wheelchair was normally used as a mobility device. Section H of this MDS indicates that R3 was occasionally incontinent of urine and bowel and was not on a toileting program. Section J1800 is coded for R3 to have not experienced any falls since admission/entry or re-entry to facility. Section O indicates that R3 received active range of motion 7 days a week and received bed mobility training and skill practice for 7 days a week during that 7 day look back period. Section P indicates that R3 has no restraints or alarms. R3's care plan has a problem area with a start date of [DATE] documenting a potential for complications related to anticoagulant therapy. The goal is to have no active bleeding and the approaches include: administer medications, monitor lab work, monitor vital signs, and observe for active bleeding. A problem area dated [DATE] under category disease process lists resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal with a target date of [DATE] is that R3 will be free of complications (injuries from shuffling gait). The approaches to this problem area include: activities as tolerated by choice, call light within reach, clutter free environment, encourage family involvement, notify MD (medical doctor) of changes, observe for safety, therapy evaluation as ordered, provide assist for daily care and mobility, provide medications as ordered and monitor effectiveness. A problem area with a start date of [DATE] includes R3 is unable to participate in activities of daily living (ADL) secondary to weakness. The goal date of [DATE] documents R3 will have met all ADL needs until next review date. The approaches include: call light within reach while in room and remind resident to call for assistance, explain all procedures to resident, meet grooming needs/hygiene/nails/skin, provide care for resident and provide privacy for care. Problem category with start date of [DATE] for Falls documents R3 is at risk for falls. Goal is for R3 to be free from falls. Approaches to this problem are to: assess and treat postural/[CONDITION(S)], implement exercise program that targets strength, gait and balance, increased staff supervision with intensity based on resident need, medication review to reduce fall risk, and provide individualized toileting interventions based on needs/patterns. R3's nursing progress notes in the medical record have no entries from [DATE] through [DATE]. The last note entered was [DATE] at 2:23 AM regarding R3's skin condition, and there is nothing else entered until a late entry recorded on [DATE] at 3:21 PM by V14 (former Licensed Practical Nurse/LPN) documenting that on [DATE] at 8:00 AM during morning med pass, R3 was noted to be sleeping soundly. Upon administering morning medication through feeding tube, resident awoke and talked briefly to the nurse. When this nurse went in the room again approximately 30 minutes later to change feeding tube dressing, a small amount of emesis was noted on beard. Staff notified and cleaned resident. Feeding tube stopped for 2 hours due to emesis and head of bed stayed at 90 degrees due to aspiration precaution. There are no further progress notes found in the medical record documenting R3's tube feeding being restarted, vitals being taken, or notes on R3's condition until he is found unresponsive at 4:20PM. On [DATE] at 4:20 PM, V2 (Director of Nursing/DON) documents in nursing progress notes arrival to guest room to assess patient. Guest (R3) found with snoring respirations and gurgling. Guest suctioned no response. Small amount of thick yellow sputum removed. Respirations sound improved. Sternal rub performed and guest unresponsive. Left pupil 1 millimeter and right pupil 4 millimeters and responsive to light. No response to commands. Nurse practitioner notified and guest sent out. On [DATE] at 4:29 PM, EMS (Emergency Medical Services) called to transport guest. On [DATE] at 4:43 PM, V14 (LPN) documented that during evening medication pass resident noted unresponsive. Upon assessment audible gurgling noted. V2 notified and assisted nurse. R3 was suctioned. Gurgling continued after suction. R3 was non-responsive to a sternal rub. Vitals were as follows: ,d+[DATE] blood pressure, temperature 98.4, Oxygen saturation 75 percent on 5 Liters of oxygen, pulse 63 and respirations 22. Physician notified, ambulance called, local hospital called, and report given. Ambulance arrives and transports R3 at this time. On [DATE] at 4:47 PM, V14 attempts to call family to notify of R3 being transferred to local emergency department. On [DATE] at 5:41 PM, V14 documents that local hospital emergency department nurse called and asks nurse several questions regarding R3. Hospital nurse states that R3 has a brain bleed and was asking if he had any recent falls. V14 stated that no falls were noted. Hospital nurse then asks how R3 was today and V14 replies that he was awake this morning at approximately 8 AM and his morning medications were pushed through his feeding tube. Resident normally naps periodically throughout the day so R3 was not acting out of usual behavior until he was noted to be gurgling and non- responsive at approximately 4:30 PM. This is why R3 was sent to the hospital due to abnormal vital signs and behavior. R3's last progress note, from [DATE] at 12:36 PM by V14 documented R3 was in hospital on a ventilator, unresponsive with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes from the local hospital emergency room made by V19 (emergency room Physician) document provider notes made on [DATE], under the history and physical, neurology referred to trauma as SDH (subdural hematoma) implies trauma. Trauma suggested neuro-management, no evidence of trauma and neurosurgery consult. Neurosurgery suggested non-operative management and to propose comfort measures as injury is non-salvageable. Spouse (V7) explained that there was in fact trauma last night ([DATE]) but the patient was not taken to the local emergency room by the nursing home per spouse (R3). This same note states that R3 arrived via medical transport unresponsive and low oxygen in the 70s. The computed tomography (CT) scan from [DATE] lists the 'findings' as: There is a very large acute subdural hemorrhage over the right temporal and frontoparietal convexity measuring up to about 1.2 centimeters in thickness. There is also acute hemorrhage along the anterior falx. On [DATE] at 10:54 AM, V19 (ER Physician) stated that a fall regarding R3 was reported to the emergency department by V7 (Family Member) due to R3 not being responsive when he arrived to the ER. V19 stated that after a discussion with other physicians in the ED (emergency department), it was determined to send R3 to the neurology team due to the brain bleed. V19 stated that this type of bleed is most commonly associated with some sort of trauma to the head and not a spontaneous bleed. V19 said the facility where R3 lived was contacted, and they were unable to give any information of an event where the resident would have received this trauma to his head. When asked about delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes from the receiving local hospital after a transfer from the ER documents the following on [DATE] in the history of present illness by V6 (neurologist): Head CT with large right hemispheric traumatic subdural hematoma with midline shift, cerebral herniation, and infarction. Trauma was contacted and directed the ER to call neurology because there was no evidence of visible trauma. The same progress notes under the section of Neurology attending assessment and recommendations documents the following: in brief, R3 has a traumatic right hemispheric subdural hematoma causing a 1.2 centimeter shift, uncal herniation, and right infarction. The midbrain is compressed and hypodense. R3 had a fall the day prior. Not a surgical candidate due to prolonged down time and abysmal neurological exam. This is a critically ill patient. A progress note dated [DATE] by V22 (Neurologist) documents that the family of R3 had decided to make the resident comfort care and are waiting for family to arrive. On [DATE] at 5:00 PM, V6 (Physician) stated that he was the admitting physician for R3 to the hospital where he was transferred to be closer to V7 (Family Member) because of her hospitalization too. V6 stated that (V7) reported R3 had told her he fell on [DATE]. V6 stated that when he received R3 as a patient on [DATE], that he was in a coma and not responsive. V6 said that the herniation in R3's brain had resulted from a trauma, likely the fall the wife reported, which caused the hemorrhage to occur in his brain. V6 stated that this type of brain bleed is not common from a spontaneous bleed, that some sort of trauma would cause this subdural hematoma that hemorrhaged, and then led to the herniation. R3's Certificate of Death Worksheet signed by V22 (Neurologist) documents that R3's date of death was [DATE]. The cause of death was: subdural hematoma, traumatic and documents that this injury was caused by a ground level fall at the nursing home that R3 resided in. On [DATE] at 9:00 AM, V7 (family) stated that she had spoken to R3 at 10:30 PM on [DATE]. V7 said she, herself had been admitted to a local hospital, and she was calling (R3) to let him know that she was admitted . V7 stated that her mother had called R3 at 6:30 PM to let (R3) know she (V7) was being sent to the hospital. At 10:30 PM, while on the phone, R3 stated that he had fallen that day by slipping in urine and hurt his neck. V7 stated that she asked (R3) why he was not sent to the hospital, and R3 stated he promised he would be ok. V7 stated that she asked him why he was not sent to the hospital and R3 stated he promised he would be ok and not to worry. V7 stated she now knows this was a mistake listening to him (R3), and she should have called the facility, but she had just been admitted to the hospital after an emergency room visit, as they thought she was having a stroke herself. V7 said she then called him the next morning and R3 did not answer, but she was not concerned because she thought maybe he was sleeping or couldn't reach his phone. However, the next call she received was from the hospital asking for consent to treat and she had no idea that R3 had been transferred to the hospital. V7 stated that R3 did not tell her who picked him up or what time for sure, but that he had fallen in urine and layed for a while before someone got him up. V7 stated she assumes that the fall had not happened at 6:30 PM when her mother had called (R3) to let him know she (V7) was being transferred to the hospital, as R3 did not mention it at that time, but when (V7) spoke to (R3) at 10:30 PM, he reported the fall to her. On [DATE] at 11:00 AM, V2 (Director of Nursing/DON) stated that he was the RN working on [DATE] on the rehabilitation side. V2 said he was called over by V14 (LPN) to assess a resident (R3) she found non-responsive. R3's vitals were off, his pupils were not reactive and V2 stated to send R3 to the ED. V2 stated that the hospital did call later and ask about R3's behaviors of the day and about any recent falls, of which none were reported, so they had no information to give. V2 stated that when he came to check (R3's) condition on [DATE], he did not do a full body assessment at that time but did not see any visual markings to indicate R3 had a fall. V2 stated that when a resident is transferred out of the facility, the family or POA should be notified. No type of assessment or form was done at this time other than sending medication, face sheet and bed hold policy. R3 has resided in the facility since October and has no documented falls, and he is unaware of any. R3's spouse was planning on taking him home once she was well enough. R3 had dysphagia and was on blood thinners. V2 stated he talked to staff after the hospital called and inquired about a possible fall, but he did not document these conversations because no one knew of a fall. V2 said nothing was reported to IDPH (Illinois Department of Public Health) either or investigation of any kind. On [DATE] at 12:00 PM, V3 (Assistant Director of Nursing/ADON) stated that R3 would not have had the strength to get up on his own after a fall. V3 stated that R3 was not confused and has not had a reported or documented fall since admit in October of 2021. V3 said that R3 used his call light when he needed assistance all the time and did not try to self-ambulate. R3 was able to ambulate with a gait belt and supervision, and a wheelchair behind him in case he would get tired or weak while walking. V3 stated that she is unaware of a fall that R3 supposedly had. V3 said she was never told of one, nor has she ever investigated one. V3 stated that when a fall occurs, the person who finds the resident should alert a nurse, if that person is not a nurse, have the nurse do an assessment, and then do as the nurse instructs, whether that be to assist up off the floor or call 911. A fall report and investigation is then completed on all resident falls and a note in the chart. On [DATE] at 10:08 AM, V5 (Previous Administrator) stated that she recalls hearing that R3 may have had a fall but is unsure when or who would have told her that. V5 said that it could have been from the hospital calling and questioning a potential fall, but that she had done an 'investigation' into this and found that no one knew of a fall. V5 admitted that her investigation was not written down, it was just that she asked a couple CNA's (Certified Nurse Aides) and probably a nurse and no one reported a fall. V5 said she does not remember who she spoke to when she asked about R3 falling. According to the staffing schedule provided by V3 (ADON), the following staff were assigned to work the wing where R3 resided on the day shift 6am-6pm on [DATE]: V17 (LPN) and V23 (Nursing Assistant). On [DATE] at 12:45PM, V3 (ADON) stated that V16 (CNA Supervisor/Transport) filled in on this shift due to CNA call-offs. On [DATE] at 9:45 AM, V17 (LPN) stated that she is unaware of any falls that R3 would have had at the facility. V17 stated R3 always asked for help and used his call light. After several attempts made by both surveyor and facility, V23 was never able to be reached for a phone interview. On [DATE] at 9:30 AM, V16 (CNA) stated that R3 was unable to even sit up in his bed without assistance. V16 said once R3 was assisted out of bed and given his walker, he then was able to ambulate with a gait belt and supervision. V16 said R3 was a very careful man and always used his call light. He was not confused, and she had never known of him falling. According to the staffing schedule provided by V3 (ADON), the following staff were assigned to work the wing where R3 resided on the evening shift, either from 2pm-10pm or 6pm-6am on [DATE]: V8 (Nursing Assistant) was documented as working from 2pm-10pm, V18 (Nursing Assistant at the time/now a CNA) was documented as working from 6pm-6am, and V21 (LPN) was documented as working from 6pm-6am. Per email communication with V1 (Administrator) on [DATE], V1 verified that V18 was a Nursing Assistant on [DATE] but officially became a Certified Nursing Assistant on [DATE]. On [DATE] at 9:30 AM, V3 stated that V20 (CNA) would have been the CNA that floated down to cover (R3's wing) that evening. On [DATE] at 9:20 AM, V8 stated although it has been a while since [DATE], but off the top of his head he does recall R3 having a fall but is unsure of what the date would have been. V8 went on to ask if he needed to contact a lawyer. V8 stated that he did work the night shift of [DATE] and remembers hearing about a fall happening at some point but was unsure of when or where it happened and was not involved in helping R3 up or reporting it. V8 said he assumed he was on the other side of the building and otherwise busy. On [DATE] at 10:37 AM, V18 (former NA/current CNA) stated that she had worked [DATE] from 6pm-6am and never knew of R3 ever having a fall. V18 stated that R3 never had any markings like bruising from an unreported fall. V18 stated R3 was very good about not self-ambulating and always asked for help when he needed up. On [DATE] at 3:00 PM, V21 (LPN) stated that she took care of R3 on the evening shift of [DATE]. V21 said she never heard of a reported fall, nor had knowledge of anyone getting him up from a fall. V21 said R3 showed no signs of any reason for alarm in his mental status while she took care of him throughout the night shift. On [DATE] at 5:30 AM, V21 stated that she does not remember who she even worked with on the evening shift of [DATE] or their credentials. V21 went on to state that while it is never scheduled to have only nursing assistants work on a hall it can sometimes happen with call offs. If this is the case, then they would have a float CNA come from the rehabilitation side or the nurse would assist the nursing assistants with whatever needs to be done with the residents. On [DATE] at 11:00 AM, V20 (CNA) stated that he had worked the 6p-6a shift on [DATE] on the rehabilitation side of the facility, and R3 lived on the Long Term Care side of the facility. V20 said he does not recall R3 ever having a fall while he lived in the facility. R3 was dependent on help getting to the standing position and out of bed, and he always used a call light and was careful. According to the staff schedule provided by V3, the following staff were familiar R3, but were not assigned to work R3's wing and instead worked the rehabilitation wing on the day shift of [DATE]: V9 (RN) and V15 (CNA). On [DATE] at 9:15 AM, V9 (Registered Nurse/RN) stated that she did work the 6am to 6pm shift on [DATE], but works on the rehabilitation side of the facility, which is separate from the Long Term Care side. V9 stated that she had not heard of R3 falling and was never asked to come assess or assist with a resident fall on the Long Term Care side of the facility. V9 stated when she worked with R3 on the rehabilitation side of the facility, he was good about always asking for help when getting up. V9 stated R3 always had his call light, his cell phone, and a tissue on his table. V9 stated that R3 was able to ambulate with a gait belt with stand by assistance but needed help standing up to get to his walker. On [DATE] at 9:11 AM, V15 (CNA) stated that she worked on [DATE] from 6p-6a. V15 was assigned to the rehabilitation side of the facility, opposite side from where R3 was on the Long Term Care side. R3 was a compliant resident who used his call light. V15 stated that R3 would not have been able to get himself up off the ground if he had fallen, and it would likely take ,d+[DATE] people to get him up considering his size of stature. R3 was very soft spoken and likely would not have been heard had he yelled for help. V15 said R3 had no marks of injury that she recalls, like bruising or abrasions, nor did he mention he had had a fall. V15 said if a resident is ever found to have fallen or potentially injured themselves, the person who finds the resident, if not a nurse, is to alert a nurse to assess the resident for injury, and then notify administration, physician, family and 911 if necessary. V15 said no one is to ever get a resident up without proper assessment of injury and this should also then be documented in the medical record and investigated. According to the staff schedule provided by V3, the following staff were familiar with R3, but were not assigned to work R3's wing and instead worked the rehabilitation wing on the evening shift of [DATE]: V10 (LPN), V11 (CNA). On [DATE] at 9:05 AM, V10 (LPN) stated that she was unaware of any incident involving R3 falling. V10 worked on the rehabilitation side of the facility on [DATE] from 6pm-6am. V10 was never asked to come over and assess or assist with R3. V10 stated that she worked with R3 when he was on the rehabilitation side of the facility, and he was always good about using his call light and not getting up on his own. V10 went on to state that R3 was likely unable to get up on his own without the assistance of others, and it would take ,d+[DATE] people to get R3 up due to size. On [DATE] at 8:50 AM, V11 (CNA) stated that she worked the rehabilitation side of the facility on [DATE] from 6pm-6am. V11 stated that she had heard a rumor that R3 fell but does not know if it was true. V11 said she did not see R3 fall nor was she asked for help to get R3 up. V11 stated that R3 would require the help of more than one person to assist up off the floor and he would not have the strength to get up on his own. V11 stated R3 always used his call light for assistance. According to the staffing schedule provided by V3, the following staff were assigned to work the wing where R3 resided on [DATE] from 6am-6pm: V12 (CNA), V14 (LPN), and V23 (Nursing Assistant). On [DATE] at 2:43 PM, V12 (CNA) stated that R3 was tube fed, was able to walk with supervision and was able to state his needs. V12 said R3 was not confused and did not attempt to get up without help. R3 always used the call light to get assistance and was never known to have a fall in the facility. V12 said if R3 would have fallen, it is unlikely that he would have had the strength to get up alone. V12 stated R3 did not have a roommate and the resident next to him is deaf and blind. V12 said R3 used his call light all the time, but the main things he would need would be his phone, his urinal or he was ready for a walk. V12 said R3 was a very clean man, and it would be a surprise if he had urine on the floor. On [DATE] at 2:00 PM, V14 (former LPN) stated that she was the nurse that worked on [DATE] when R3 was sent to the hospital. V14 said it was not uncommon for R3 to nap off and on during the day. When she passes medications or gives a feeding though R3's tube or does nebulizer treatments, he generally would acknowledge her in the room and maybe talk a little. V14 stated that when she went to give R3's evening feeding, he was not acting right or responsive. V14 called down V2 to report R3's change of status and V2 recommended sending R3 to the ED. The hospital called a little while later asking if R3 had fallen. V14 said nothing was in the chart or reported to her, so she had no information to give the hospital. V14 states that R3 was not confused and was able to communicate and feels that he would have told her if something would have happened. V14 said R3 did have a little emesis that morning, but she contributed it to a possible 'bug' in the facility and stopped the tube feeding for 2 hours and restarted it with no issue. R3's feeding tube site showed no issue or trauma from being pulled at. V14 stated R3 always used his call light for his needs and never got up alone. R3 used a walker to ambulate, and someone was always there for safety. R3 knew his limitations and always acted with safety. V14 said R3 would have not had the strength to get up on his own, and it would have likely taken a couple people to get him up because he was very top heavy. R3's vitals and mental status were the reasons they transferred him to the ED on [DATE]. V14 said R3 was sent out as soon as his vitals were crashing, and he was not responsive. As noted above, V23 was never able to be contacted after several attempts were made to reach her throughout the survey. On [DATE] the following staff V13 (CNA) worked the day shift on the rehabilitation side of the facility along with V2 (DON). According to the staff schedule provided by V3, the following staff was familiar with R3, but was not assigned to work R3's wing and instead worked the rehabilitation wing on [DATE] from 6am-6pm: V13 (CNA) On [DATE] at 12:35 PM, V13 (CNA) stated that she worked on the rehab side of the facility the day (R3) was transferred to the hospital on [DATE]. V13 stated that she does not recall a fall with R3, but that he was not confused so if he said he fell , he probably did. V13 stated that R3 was good with using his call light to ask for help, and when he rang, it was because he needed his urinal, his phone or was ready to go for a walk. V13 said R3 needed help getting up and needed a gait belt for safety but was pretty steady on his feet once he got up. V13 said if a resident was found on the floor or was a witnessed fall, the CNA and NA's would call for a nurse to do an assessment prior to getting the resident up and wait for instruction from nurse on what to do next. This should then be documented somewhere in the chart. The following staff was also familiar with R3's care, but were not on the staff schedule to care for R3 on [DATE] or [DATE]: V4 (Therapy Manager) and V24(LPN). On [DATE] at 11:37 AM, V4 (Therapy Manager) stated that R3 discharged from therapy on [DATE]. Prior to that, R3 had been receiving therapy since October when he was admitted into the facility. At the time of discharge, therapy determined that R3 had reached his max potential. On the 9th of March, they were beginning to reassess R3 to start therapy back so when he went home, he would be ready to go. OT (Occupational Therapy) did not get the assessment done, but PT (Physical Therapy) did and was going to restart. On [DATE] at 12:00 PM, V24 (LPN) stated that when she took care of R3 he tolerated his g-tube feedings with no issues. V24 said if a resident on a tube feeding has emesis, normally it would be stopped for at least one hour, and the doctor would be called to get further direction. Vitals would normally be taken at that time too to try to determine what is causing the emesis. V24 stated the vital signs taken would then be recorded in the progress notes. V24 verified the schedule was correct that she did not work [DATE] and came on evening shift on [DATE] after R3 was sent to the hospital emergency room . A document titled Falls Management dated February 2012 under the heading 'Policy' documents the following: It is the policy of Helia Healthcare to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. Under the heading 'definition' it documents: Fall, for purposes of this policy, means any time the resident is actually witnessed falling to the ground or is found on the floor. It also includes when a resident is lowered to the floor or rolls out of a low bed. A document titled Neurological assessment dated [DATE] stated under the heading Policy the following: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. General Guidelines of this document state to: Neurological assessments are indicated: Upon physician order; Following an unwitnessed fall; Following a fall or other accident/injury involving head trauma; or when indicated by resident's condition. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. Under the 'Documentation' heading of the document it states: The following information should be recorded in the resident's medical record: The date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data obtained during the procedure. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Under 'Reporting' the policy documents to: Notify the physician of any change in a resident's neurological status. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards of practice. An Immediate Jeopardy was identified to have begun on [DATE]. V1 (Administrator) and V29 (Regional Director of Operations & Clinical Services) were notified of the Immediate Jeopardy on [DATE] at 2:00PM. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Immediate Changes to Facility Systems: Administrator (V1), Director of Nursing (V2) and Assistant Director of Nursing (V3) in serviced on change of condition policy,

Based on observation, interview, and record review the facility failed to prevent and/or contain COVID-19 when the facility failed to: 1. Ensure residents who developed symptoms of Covid-19 were isolated per current standards of practice to prevent the spread of Covid-19, 2. Ensure staff wear appropriate PPE (personal protective equipment) to prevent the spread of Covid-19, 3. Ensure housekeeping clean isolation room floors according to current standards of practice. These systemic failures resulted in one resident R4 being exposed to a resident (R1) who was exhibiting symptoms of Covid-19 and subsequently tested positive for Covid-19. Due to R4's comorbidities and vulnerabilities, this failure increased her risk for severe illness and possible death. These failures have the potential to affect all 41 residents residing in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ was identified to have begun on [DATE], when the facility failed to isolate R4 from R1 who was exhibiting respiratory symptoms and subsequently tested positive for Covid-19. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:13 PM. The surveyor confirmed by observations, record review, and interview the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility daily census report dated [DATE] documents 41 residents reside in the facility, with six residents listed on the Covid-19 unit (R2, R3, R7-R10). The resident report of laboratory results document R2 and R10 tested positive for Covid-19 on [DATE], R8 tested positive for Covid-19 on [DATE], and R3 and R7 tested positive for Covid-19 on [DATE]. R9 tested positive while at the hospital on [DATE]. The facility resident Covid-19 testing logs dated [DATE] documents R1 tested positive for Covid-19 with the test obtained on [DATE]. The facility resident Covid-19 test log not dated documents R4, R15, R16, R17, and R18 tested positive for Covid-19 on [DATE]. As of [DATE] the facility has had five new residents test positive for Covid-19 (R4, R15-R18) and one death (R3). R3's medical record does not indicate R3 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's medical record documents R3 expired at the hospital on [DATE]. R3's Certificate of Death Worksheet confirms the date of death of [DATE] and lists cause of death as [CONDITION(S)], chronic obstructive pulmonary [CONDITION(S)], congestive heart failure, coronary heart disease, [CONDITION(S)]. With other significant conditions contributing to death listed as [CONDITION(S)] and Covid-19. 1.R1's resident face sheet (not dated) documents R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated [DATE] at 8:47 AM document R1 as having a non-productive cough and coarse bilateral lung sounds and Covid ISO (isolation) precautions implemented. R1's progress notes continue to document the following on [DATE] at 10:49 AM new orders were obtained for a CBC, CMP and chest x-ray, chest x-ray results were received and documents an impression of bilateral atelectasis/infiltrate (pneumonia) and new orders were received to start [MEDICATION(S)] 500 milligrams daily for five days related to pneumonia. On [DATE] at 9:47 AM R1 and R4 were observed sitting in wheelchairs in their room on the long term care unit less than three feet apart. Neither R1 nor R4 were wearing masks and R1 was observed coughing several times. There was a stop sign on the door and PPE (personal protective equipment) observed in a bin just outside of their room. On [DATE] at 10:08 AM V5 (CNA/Certified Nursing Assistant) was asked about the stop sign and bin outside of R1 and R4's room. V5 stated R1 has a bad cough and is going from hot to cold. V5 stated V11 (Licensed Practical Nurse) placed R1 on Covid-19 precautions this morning ([DATE]). V5 stated R4 has no symptoms but because they are roommates, they are both on precautions. R1 and R4's door was observed open throughout observation on [DATE]. R1's progress notes documents on [DATE] R1 is having bouts of confusion, has crackles in both lung fields, reports fatigue, and has a productive cough. R1's vital sign monitoring documents an oxygen saturation of 88% on [DATE] at 5:47 AM. All other vital signs assessed as within normal limits. R1's progress notes document on [DATE] at 6:07 PM R1 was transferred to the Covid-19 unit due to a positive Covid-19 test. R1's report of laboratory results document R1 tested positive for Covid-19 on [DATE]. R4's resident face sheet (not dated) documents R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress notes document on [DATE] at 10:13 AM guest roommate (R1) displays sx (symptoms) of Covid .place on iso (isolation) precautions; guest (R4) asymptomatic et (and) remains per baseline . At 3:16 PM R4's progress notes document R4's family representative was updated of R4 being placed on Covid precautions due to her roommate (R1). R4's progress note documents R4 is asymptomatic and displays no symptoms of acute respiratory distress syndrome. R4's progress notes document on [DATE] at 2:25 PM R4 was moved the Covid-19 unit related to a positive Covid-19 test. R4's progress notes document R4 is assessed on [DATE] and [DATE] with fatigue as the only symptoms documented. On [DATE] at 4:45 PM R4's progress notes document, res (R4) changed rooms . This indicates R4 was in the room with R1 for approximately 33 hours after R1 began exhibiting symptoms of Covid-19. On [DATE] at 10:00 am V11 (Licensed Practical Nurse) stated if a resident developed symptoms of COVID, they would be placed on COVID isolation precautions where they are monitored, and tests and chest x-ray would be ordered. If the symptomatic resident has a roommate, V11 said the roommate would be placed on the same precautions and symptoms and vital signs monitored every four hours. On [DATE] at 10:45 AM V3 (Social Services Director/Infection Preventionist) stated if a resident develops respiratory symptoms and has a roommate the roommate stays in the same room with the resident with symptoms and is placed on isolation precautions as well. On [DATE] at 1:48 PM V1 (Administrator) stated any resident who develops respiratory symptoms would be placed on droplet precautions. V1 was not familiar with R1 and R4's situation. On [DATE] at 4:23 PM V1 (Administrator) stated R4 was moved out of the same room as R1 because V16 (family member) requested R4 be moved. On [DATE] at 10:17 AM V16 (family member) stated he received a call from the facility yesterday ([DATE]) and was informed they were moving R4 to a different room. V16 stated he was not sure why R4 was being moved because as far as he knew R4 and her roommate had neither one tested positive for Covid-19. On [DATE] at 12:30 PM V1 (Administrator) stated this was the first time the facility had a case of a symptomatic resident with a roommate. V1 stated they were following the CDC guidance located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html which states the following: Resident with new-onset suspected or confirmed COVID-19 Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [CONDITION(S)]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [CONDITION(S)]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. When asked if they had rooms available to provide R1 and R4 with a private room V1 confirmed they did. When asked why they didn't separate R1 and R4 since the guidance says to place the resident in a single room if possible V1 stated she did not read the guidance that way. That she looked at it as if R4 had been exposed and infected. V1 stated, To me that is a gray area. 2. On [DATE] at 10:14 AM the door to R1 and R4's room remains open V5 enters the room after donning booties, a gown, and gloves. V5 was already wearing a surgical mask. V5 did not don eye protection. V5 leaves the room after providing care and doffing the gown and booties. V5 did not change the surgical mask that she was wearing. After exiting the room V5 went to a bathroom located on the hall and washed her hands then resumed care of the other residents (non-Covid-19 positive). V5 confirmed she wears a surgical mask and no eye protection to provide care to R1 who is suspected Covid-19 positive and that she wears the same surgical mask to provide care to the other residents residing on that unit. R5's resident face sheet (not dated) documents R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:38 AM V7 (CNA) was observed entering R5's room located on the transition unit with a surgical mask, gown, and gloves on. V7 is not observed wearing eye protection or changing her mask when she exits the room. On [DATE] at 11:11 AM V7 (CNA) stated she changed her masks in the bathroom located at the end of the hall after exiting each room. V7 stated there were no masks located in the bins in the hallway. V7 stated she only wears eye protection when working on the Covid-19 unit and changes her mask every couple of rooms for those residents newly admitted to the facility from the hospital. On [DATE] at 11:11 AM after V7 (CNA) reported not having surgical masks available in the PPE bins located outside of the resident rooms V8 (Registered Nurse/RN) retrieved surgical masks from V2's (Director of Nurses) office and placed them in the bins in the hallway on the transition unit. R6's resident face sheet (not dated) documents R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:41 AM V8 (Registered Nurse) is observed entering R6's room with only a surgical mask on. V8 did not don a gown, gloves, or have eye protection on. V8 left R6's room went to the end of the hall and spoke with a peer at the door leading to the long term care unit. V8 was not observed changing the surgical mask or hand sanitizing when exiting R6's room. On [DATE] at 10:56 AM V8 (RN) enters R6's room with a surgical mask on after donning a gown and gloves. V8 does not hand sanitize prior to donning PPE. V8 exits R6's room and keeps the same surgical mask on. On [DATE] at 11:02 AM V8 (RN) was observed entering R6's room wearing a surgical mask and after donning a gown and gloves. V8 was not observed hand sanitizing prior to donning or doffing the PPE. V8 exited R6's room without changing the surgical mask he was wearing. V8 confirmed he did not wear PPE (other than a surgical mask) into R6's room when he entered it at 10:41 AM. V8 stated he used hand sanitizer at the nurse's station after doffing the PPE when he exited both R6 and R8's room. V8 stated he wears the same surgical mask throughout his medication administration pass, but he changes it every three to four rooms the rest of the time. V8 stated he only wears eye protection when working on the Covid-19 unit. V8 stated he is the nurse for the transition hall and the Covid-19 unit and when he leaves the Covid-19 unit he changes all PPE. On [DATE] at 10:45 AM V3 (Social Services Director/Infection Preventionist) stated staff should wear a gown, mask, gloves, and eye protection when providing care to residents exhibiting Covid-19 symptoms. V3 stated the same should be worn in the rooms of newly admitted residents and/or residents who have just returned from the hospital and are in a 14 day quarantine period. When asked if staff should change their surgical masks when exiting a room V3 stated yes or don one over the top and remove the top mask when they exit the room. V3 stated they have N95's for staff working on the Covid-19 unit and have face shields available for staff at the nurse's station. V3 confirmed staff should be wearing eye protection when providing care to residents who are symptomatic but was unsure if they should wear eye protection when providing care to residents who are new admits and/or returning from a hospital stay. On [DATE] at 11:00 AM V14 (Physical Therapy Assistant) stated she does physical therapy with residents on the Covid-19 unit at the end of her shift. V14 was observed providing therapy services on the Covid-19 unit wearing a surgical mask, gown, gloves, and eye protection. V14 stated she was unable to find her N95 mask, so she just put on two surgical masks. On [DATE] at 12:30 PM V1 (Administrator) stated the facility was not currently in an extended use situation for PPE. V1 stated she would expect staff to keep the doors closed on rooms with residents who were on isolation precautions for suspected or confirmed Covid-19. V1 confirmed that included residents who were newly admitted to the facility or returning to the facility after a hospital stay. V1 stated staff should wear eye protection in any room with a resident with suspected or confirmed Covid-19 which included the residents newly admitted to the facility or returning to the facility after a hospital stay. V1 stated staff should change the surgical masks after exiting an isolation room. V1 stated the facility policy states staff should wear N95's if available when providing care to a resident with suspected or confirmed Covid-19 if they are available. V1 confirmed the facility staff all have an N95. 3.On [DATE] at 10:50 AM V9 (housekeeper) is observed leaving an isolation room with a mop and removing her gown and gloves. V9 left the surgical mask on. A wet floor sign was placed outside the door. V9 placed the mop into the mop water on the cleaning cart. V9 put on a new isolation gown and gloves and entered another isolation room wearing the same mask and using the mop that was used to mop the previous rooms. The mop head and mop water were not replaced after mopping an isolation room. On [DATE] at 9:30 AM V9 (housekeeper) stated she does not change the mop water or mop head until she has cleaned 3 to 5 isolation rooms. V9 stated there has been plenty of cleaning supplies, PPE, and ABHR (alcohol based hand rub). On [DATE] at 9:40 AM V10 (Maintenance and Housekeeping Director) said that he has been able to maintain an adequate stock of cleaning supplies. V10 stated if a resident is on isolation, the mop water and mop head are changed between each room. V10 stated housekeeping staff are required to wear a gown, surgical mask, and gloves when entering a room used to isolate a resident. The PPE is to be changed after each room is entered. On [DATE] at 7:43 AM V21 (Nurse Practitioner/NP) stated she is the NP for V17 (Physician) and sees residents at the facility four days a week. V21 stated she would expect the facility to follow the current Center for Disease (CDC) guidance to prevent the spread of Covid-19 and if the facility did not follow the current CDC guidance it could have a negative impact on the residents and contribute to the spread of Covid-19. The facility Covid-19 preparedness policy dated [DATE] documents, It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for Covid-19 and to adhere to Federal and State/Local recommendations (to include, for example: Admissions, Visitation, Precautions: Standard, Contact, Droplet, and/or Airborne Precautions, including the use of eye protection). Under resident care the policy states, ensure .Necessary PPE is available immediately outside of the resident room and in other areas where resident care is provided Under ongoing monitoring and assessment of residents the policy documents, Ongoing, frequent, active screening of residents for fever and respiratory symptoms will occur. Resident will be actively monitored every 8 hours for possible symptoms of Covid-19 (shortness of breath, new or change in cough, sore throat, runny nose, unexplained [CONDITION(S)], malaise, fatigue, lethargy, chills, muscle aches, headache, nausea, vomiting, diarrhea, new loss of taste or smell, chest pain, [CONDITION(S)], decreased blood pressure, oxygen saturation below 92% or unexplained [CONDITION(S)], or fever (greater than) 99.6 (or 2 degrees above baseline). If positive for fever or symptoms, implement recommended infection prevention control practices to ensure prompt detection, triage and isolation of potentially infected residents and notify Physician .If this occurs the nurse must-Place the resident in contact/droplet isolation and close the door. All staff must wear full PPE. Notify family, and physician, obtain contact/droplet isolation order and give instructions to staff. Isolation signage should be placed outside of resident room. Under new admissions the policy documents, Newly admitted or readmitted patients will be monitored for evidence of Covid-19 for 14 days after admission. Staff will use all recommended Covid 19 PPE for contact droplet precautions when caring for newly admitted /readmitted patients. Under clusters of respiratory infection, the policy documents, A resident with known or suspected Covid-19, immediate infection prevention and control measures will be put into place. Complete assessment with VS (vital sign) including O2 saturation every 4 hours. 1. Contact/Droplet Isolation, 2. Shut the door. Keep closed for the duration of isolation. 3. Notify Physician, Family, and Medical Director. 4. Test resident for Covid 19. 5. Contact State/Local Public Health immediately for direction. Under Outbreak Management the policy documents, .A single new case of [CONDITION(S)]-CoV-2 infection in any HCP (Health Care Professional) or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be considered an outbreak Place residents in private rooms on standard, contact, droplet (airborne if available) precaution and keep resident room door closed. Cohort residents identified with same symptoms/Covid-19 confirmation. Implement consistent assignment of employees and allow only essential staff to enter rooms/wings with appropriate PPE and respiratory protection. PPE includes: gloves, gown, medical face mask and eye protection will be used. Eye protection that covers both the front and sides of the face. Remove before leaving resident room. Reusable eye protection will be cleaned and disinfected according to manufacturer's recommendation. Disposable eye protection will be discarded after use unless extended use protocols for PPE are in force. N95 masks should be used if available when providing care for confirmed or suspected cases. Hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves. The Center for Disease Control website located at; https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html#previous documents the following; The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator or Facemask .Put on an N95 respirator (or equivalent or higher-level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask . Eye Protection Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use . Remove eye protection after leaving the patient room or care area, unless implementing extended use . Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area . Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene .Gowns Put on a clean isolation gown upon entry into the patient room or area . On [DATE] the surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the immediacy: .All staff are expected to follow facility policy and procedures in regard to COVID-19: identification, isolation, proper PPE and proper cleaning of isolation rooms. This will be ensured by performing updated education to the current standards of practice and Policy with all staff [DATE] .V22 (Physician) and V17 (Physician) were notified of R4's Primary Care Physician and facility Medical Director .Facility system to isolate residents who develop symptoms of Covid-19 has been implemented. All staff have been educated on facility policy to isolate residents who develop symptoms of Covid-19 until the infectious process can be determined. Facility system for wearing appropriate PPE has been implemented. All staff have been educated on facility policy for wearing appropriate PPE. Facility has updated their policy of cleaning isolation room floors to prevent further spread of COVID-19. All staff have been educated on facility policy for cleaning isolation room floors. All housekeeping staff have been educated on procedure for cleaning isolation room floors with return demonstration. DON and/or designee will audit for proper PPE use daily. Housekeeping supervisor and/or designee will audit staff daily to ensure cleaning techniques are being completed per current standards of practice. DON and/or designee will monitor residents for change of condition that have developed to ensure any residents that have developed symptoms of Covid-19 are isolated per current standards of practice. Administrator or designee will oversee that audits are completed. Education Plan: As of [DATE], all current staff on duty and all remaining staff have been in-serviced by the facility IDT (Interdisciplinary Team). IDT members are V4 ADON, V3 RN, V10 Housekeeping Supervisor, V23 Regional Director. No staff will be allowed to begin their scheduled shift prior to being educated in accordance with the policies and procedures listed below. Facility system to isolate residents who develop symptoms of Covid-19 has been implemented. All staff have been educated on facility policy to isolate residents who develop symptoms of Covid-19 until the infectious process can be determined. Facility system for wearing appropriate PPE has been implemented. All staff have been educated on facility policy for wearing appropriate PPE. Facility has updated their policy of cleaning isolation room floors to prevent further spread of Covid-19. All staff have been educated on facility policy for cleaning isolation room floors. All housekeeping staff have been educated on procedure for cleaning isolation room floors with return demonstration. All education will be completed by [DATE] by the facility IDT and/or Regional Director of the facility.

A. Based on observation, interview and record review, the facility failed to comprehensively analyze the circumstances of falls, develop interventions to prevent the recurring falls and assess interventions for 2 of 4 residents (R11, R2) with falls from the sample of 15. This failure resulted in R11 sustaining a fracture to her left maxillary sinus on 10/19/11, a laceration requiring sutures to her left eyebrow on 12/11/11 and a laceration to her right eyebrow on 12/12/11. Findings Include: 1. According to R11's Nurse's Notes, R11 was admitted to this facility on 07/16/11. Upon review of R11's History and Physical dated 07/16/11, R11 is a [AGE] year old female with a [DIAGNOSES REDACTED]. The facility's "Fall Risk Assessment" for R11 dated 10/21/11 shows that R11 has a risk score of 16. Documentation of the Fall Risk Assessment states that if the total score is 10 or greater, the resident should be considered at high risk for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Per review of R11's Physical Therapy Discharge Note dated 10/04/11, documentation states that a restorative program has been created for R11. Upon review of R11's "Restorative Care Program" dated 10/05/11, documentation states, "Use gait belt." "Monitor while ambulating to improve safety." Review of the facility's incident reports show that R11 fell on [DATE], 10/15/11 and 10/17/11. Documentation also states that R11 did not receive injuries as a result of these falls. Although R11 sustained falls, the facility failed to put interventions in place to prevent further falls on the care plan until another fall occurred on 10-19-11. 10/19/11 - 1:45 p.m. - "[AGE] year old female. Dx: Dementia - independently ambulatory. Walking in A - wing hall. Walked around corner and tripped over scale, tried to grab handrail to catch herself but lost balance and hit head on floor. Laceration above left eye. Sent out to ER for eval. Incident witnessed by staff, staff unable to get to resident before she fell . Neuro checks initiated." Res sent to ER" Investigative Results for R11's 10/19/11 fall at 1:45 p.m. state, "Tripped over scale, losing balance. Scale moved to B - wing foyer. Physical Therapy notified for possible eval. (Name of Physician) to review meds. Neuro checks - Obtained fx of left maxillary sinus (Name of Physician) to follow." R11's Plan of Care, dated 10/19/11 states, "Resident is at risk for falls r/t (related to): Wanders s (without) purpose. Resident has a dx of Dementia (had 3 prior falls)..." The facility's approaches to R11's risk of falls states, "Call light within reach while in room, Instruct/remind res to call for assist with mobility/transfers as needed, Clutter free environment, Proper footwear as indicated, Use of proper assistive device, Wheelchair/walker as needed, Cues/redirect as needed, Rest periods as needed, Invite/escort to activities of choice as tolerated as desired, Observe for safety." During interview with E13 (Licensed Practical Nurse) on 12/15/11 at 2:30 p.m., E13 stated that Physical Therapy has not re-evaluated R11 as indicated on the facility's incident report dated 10/19/11. Per observations on 12/09/11, from approximately 10:30 a.m. until 4:00 p.m., R11 was noted to be independently ambulating and wandering around the facility almost constantly. Upon entering the facility on 12/13/11 at approximately 8:30 a.m., surveyor observed that R11 had 2 black/purple eyes, a laceration above each eye and a bruise to her left cheek. During interview with E2 (Registered Nurse/Director of Nurses) on 12/13/11 at 10:00 a.m., E2 said that R11 had fallen on 12/11/11 and had been sent to the emergency room where she received 3 sutures above her left eyebrow. The facility's incident report 12/11/11 states that at 7:20 a.m., "Res observed in floor between ARCH et (and) Helia on L side c (with) laceration to L eyebrow. Res c/o pain et says she's unable to get up. Res sent to ER..." Documentation continues to say that R11 received 3 sutures to her left eyebrow. This incident report also says that R11 appeared to have tripped over an area rug in the foyer. The Care Plan dated 12-11-11 indicates that the only intervention put in place after this fall was that staff were to re-direct R11 as soon as she is seen leaving her comfort zone which includes area not within staff's eyesight and remove the area rug. Documentation in R11's Nurse's Notes dated 12/12/11 at 10:00 a.m. states, "Res up amb c unsteady gait..." R11's Nurse's Notes dated 12/12/11 at 11:00 a.m. states, "...Res was seen in floor in her room down on her hands & knees. Noted 3 cm (centimeter) laceration to ^ (upper) R eyebrow. Area cleaned drsg applied..." There is no evidence that the facility investigated as to why or how R11 fell . The Care Plan dated 12-12-11 indicates that the only intervention put in place after this fall was that R11's bed was moved to the lowest possible position. R11's table and drawer were moved to decrease clutter in the room. Per interview with E2 (Registered Nurse/Director of Nurses) on 12/13/11 at 10:00 a.m., E2 stated that R11 is independent in ambulation and wanders constantly. When asked about R11's Restorative Care Program recommending the use of a gait belt, E2 said that R11 refuses to allow staff to use a gait belt. E2 also stated that there is no documentation that shows the facility attempted to follow R11's Restorative Care Program. During continuing interview with E2 on 12/13/11 at 10:00 a.m., when asked how staff are to monitor R11 while ambulating as per R11's "Restorative Care Program" E2 said, "We don't have 1 staff person continually monitoring her 24 hours a day - all staff monitor her when she is in their area. All staff keep an eye on her." 2. According to facility Incident Reports, R2 experienced falls on 5/7/11, 5/17/11, 5/23/11, 6/7/11, 7/14/11, 8/15/11 and 9/12/11. According to the incident report dated 6/7/11, R2 was evaluated by therapy post fall and, and in order to prevent further incidents "walker now used for stabilizer." According to the incident report of 8/15/11, R2 fell in the hallway, while ambulating wearing rubber flip flops, not using a walker, and sustained a hematoma to the right forehead. The report indicates that the fall was witnessed: however the witness' name is left off of the report. The intervention to prevent a recurrence states, "staff removed unsafe shoes from resident's room with her approval." B. Based on record review and interview the facility failed to adequately supervise and prevent peer to peer altercations for 1 of 1 resident (R11) reviewed for frequent behaviors of hitting, touching and taking peer's personal possessions in the sample of 15. Findings Include: During the group interview on 12/09/11 at 10:00 a.m., R13 told surveyor that R11 had, "Cracked R17 on the head with a mop sign." R13 continued to say that R11 comes into the resident's rooms "all the time" and that she takes their things. R13 stated that the residents tell staff about R11 hitting them, coming into their rooms and taking things and that staff tell them that they can't do anything about it. R13 stated, "Afraid she's going to hurt me, she could hurt you - never know. We shouldn't have to live under these conditions should we?" R17 stated that R11 walks in and out of resident's rooms and goes through the drawers all night. Upon review of R11's "Psychoactive Drug Monthly Flow Record" dated 12/01/11 through 12/09/11, R11's behaviors are identified as: Delusions, Hitting, Paranoia, Yelling, Signs and Symptoms of Depression and Elopement Attempts. During review of R11's behavior tracking from 12/01/11 through 12/09/11, documentation shows that R11 was hitting others constantly 13 out of 27 shifts. Documentation continues to show that R11 hit others 19 times in addition to the constant hitting. Per review of R11's behavior tracking form, there are 4 shifts that have no documentation at all. Per interview with E13 Licensed Practical Nurse on 12/09/11 at 1:20 p.m., E13 stated that R11's behavior tracking sheet does not identify whether R11 was being aggressive to peers or staff. Review of R11's Comprehensive Care Plan dated 10/24/11, documentation regarding Physical and Psychosocial Needs states: "Wandering (up and down) halls - res rooms - etc..." R11's Goals/Objectives for wandering states: "Res will not put self in harm by wandering." The facility's "Approaches/Interventions states: "1) 1:1 - redirect res away from doors - others rooms. 2) Try to involve res in choice of activity. 3) Offer res snack - drink in D room. 4) Comfort res the best you can. 5) Call family (Russian Interpreter) to talk to resident. 6) Periodic (checks) c resident." Review of R11's Comprehensive Care Plan dated 10/24/11, documentation regarding Physical and Psychosocial Needs states: "Resistive Care - (ADL's) (hit - spit - yell at staff) Touching others." R11's Goals/Objectives for being resistive to care states: "Res needs will be met. Will allow staff to assist. Will be redirected not to touch others." The facility's "Approaches/Interventions" states: "1) Remind res others don't like to be touched..." Per interview with E13 (Licensed Practical Nurse) on 12/09/11 at 1:20 p.m., E13 stated that the facility does not have interventions in place to prevent R11 from aggressing others, but that she is stopped and redirected after she has aggressed others. E13 continued to say that the staff tries to keep R11 in their vision and when she is missed, staff go look for her. During review of R11's Nurse's Notes, documentation states: 10/21/11 - 11:00 a.m. - "Res continues to wander constantly in and out of res rooms." 10/23/11 - 10:00 a.m. - "...Constantly touching peers and taking objects out of rooms..." 10/24/11 - 2:00 p.m. - "Res hit another resident c a wet floor sign." 11/09/11 - 1:00 p.m. - "Cont to grab objects from other res..." 11/11/11 - 3:30 p.m. - "Resident went to B-wing and started yelling at another resident and then slapped him in the mouth..." 11/12/11 - 5:45 p.m. - "...Res put her hand up peer's shirt et touched peer's breast..." 11/22/11 - 11:00 a.m. - "Wandering in and out of peers room." 12/03/11 - 1:30 p.m. - "Res was witnessed by staff member slapping another resident in his face..." 12/03/11 - 6:20 p.m. - "Resident went into peer's room et grabbed peer's both wrists et shook them." 12/04/11 - 10:00 a.m. - "...Requires constant staff supervision. Res amb into other rooms et will take items belonging to others..." 12/12/11 - 10:00 a.m. - "...Amb in & out of residents rooms on unit..." Upon review of the facility's "Abuse Prevention Program" forms documentation regarding R11's aggressive behavior states: 10/24/11 - "...Around 1:50 p.m. in res (R17's) room. According to (R17) peer (R11) was in her room c a wet floor sign in hands. (R17) stated she told (R11) to leave room. Then (R11) hit (R17) c sign on bridge of nose. Res separated." 11/12/11 - "...Around 5:45 p.m. (Peer) (R11) came up to res shook w/c, res (R24) told peer to stop then (R11) put her hand up res (R24) shirt et shook her breast..." 12/03/11 - "...Around 1:20 p.m. dining area - Res (R11) agitated, pacing, etc. Staff saw res (R11) by peer (R23) et went to redirect (R11) away from (R23). (R11) then slapped (R23) L side of face for no apparent reason. Residents separated. Red hand print to L side of (R23's) face." There have been no interventions put in place to prevent R11 from aggressing others since the original care plans were developed on 10/24/11. During interview with E2 (Registered Nurse/Director of Nurses) on 12/12/11 at 10:00 a.m., when asked how the facility was preventing R11 from harming other residents, E2 stated that staff on the floor are continually keeping an eye on her and redirect her when she goes into someone's room or gets close to peers. C. Based on record review, and interview the facility failed to attempt to identify how a resident ingested alcohol without staff or family knowledge for one (R4) of five residents reviewed for incidents and accidents in the sample of 15. Findings include: R4's daughters Z2 and Z3 on 12-8-11 at 9:20 AM, stated that recently they were called to go to the emergency room because R4 was acting strange. Z2 stated when they arrived at the emergency room R4 was acting "drunk, laughing histerically, and goosing the nurses." Z2 and Z3 stated that they know on some Friday's the residents are served wine. On 12-8-11 at 11:00 AM, two bottles of wine were observed in the refrigerator in the main dinning room of the Arch Unit. However, on 12-8-11 at 10:33 AM, the current Activity staff E5 stated that she did not believe they had a wine and cheese social which would include wine. E5 stated that she was unaware that R4 was found to have an elevated blood alcohol level. R4's admission record showed R4's birthday as 7-28-27. R4's nurses notes of 11-18-11 showed an un timed note that identified that R4 was in good spirits, laughing and joking. At 11:25 PM staff chart that R4 was mumbling incoherently, and unable to follow simple commands such as squeezing staff hands. R4's pupils were pin point. R4's physician-Z1 was called, and gave an order to send R4 to the emergency room for evaluation. Review of R4's labs done in the emergency room by ER physician Z4 showed that R4's alcohol blood level was 17.0 mg/dl. Normal range for blood alcohol level identified on the same lab sheet was 0-3 mg/dl. Z2 and Z3 stated during the above interview that Z4 kept insisting that the blood alcohol level was accurate. The hospital discharge notes stated that the evaluation [DIAGNOSES REDACTED]. Instructions included stop taking your Remeron, Celexa, and Buspar until directed otherwise by physician Z1 or physician Z5. On 12-8-11 at 10:10 AM, Director of Nurses E2 stated that she was not sure if the nurse completed an incident report on R4 having to go to the hospital and being found to have an elevated blood alcohol level. E2 stated that she was on duty on 11-18-11, and R4 was acting fine until the night shift. E2 did not smell alcohol, or see any alcohol in R4's room. Later at 3:00 PM E2 stated that there was not an incident investigation completed as to the cause of R4 having an elevated alcohol level because she was sent out for a medical reason. E2 was unable to identify how she would prevent the reoccurrence of R4 having a elevated alcohol level. Review of the facility's undated "Accidents and Incidents-Investigating and Recording Policy" fails to define what the facility believes justifies the completion on an incident investigation. The policy does say all accidents or incidents occurring on our premises must be investigated and reported to the administrator D. Based on observation and interview the facility failed to ensure safe lavatory water temperatures for one of three residents (R9) whose sinks were tested in the sample of 15. Findings include: R9 resides in a private room with a private bathroom. On 12-8-11 at 8:45 AM, the lavatory water was checked with Illinois Department of Public Health (IDPH) thermometer. The water was hot to touch and registered 124.1 degrees Fahrenheit (F). At 12:30 PM on 12-8-11, E7, Maintenance Supervisor, stated that he randomly checks water temperatures every morning around 6:30 AM. E7 stated he has only checked R9's room "once in a blue moon". E3 stated when he checks the water temperature on R9's hall (A Hall) it is taken at the lavatory in the community bathroom. E7 also stated R9's room has a separate hot water heater that also services R16's private bathroom. No temperatures of R16's private lavatory were recorded by E7. The facility's Focused Rounds Checklist completed daily by E7 has an area for a sample of resident room water temperatures. E7 stated this is where he records the community lavatory water temperature from A Hall bathroom. E7 stated he was informed around 9:30 AM on 12-8-11 that the water was hot in R9' s room and therefore turned the hot water heater down. When the lavatory was rechecked with IDPH thermometer at 10:15 AM it was 113.3 degrees F. The facility's policy dated 4/15/01 for Monitoring Water Temperatures states to check hot water temperatures at both individual and common resident use areas and schedule sampling to cover the entire building every 3 days and sample problem areas daily. The hot water in R9's bathroom was discussed with E1, Administrator, at 3 PM on 12-8-11.

Based on resident observation, record review and interview the facility staff failed to ensure residents with pressure areas receive treatment orders by the physician, and all wound areas are monitored and treated. This was evident on two (R2 and R4) of 3 residents reviewed with pressure ulcers. Findings include: 1. R2's medical record has a doctor's order on a transfer form dated 9-27-10 for a wet to dry dressing on the sacral area and left heel and change daily. On 10-28-10 an order for [REDACTED]. A stage IV was noted on the coccyx and a stage II was on the outer aspect of the left foot. Both areas were treated as ordered. A stage III pressure area on the inner left heel was not treated at this time. The Skin Integrity Report for 11-5-10 indicates this is a 1 X l x .25cm stage III. There is no specific order for this wound. The Integrity Report dated 11-5-10 does not note the stage II area on the outer left foot that was treated with [MEDICATION NAME]. On 11-17-10 at 11:20AM, R2 was observed with E15, (LPN) for wound observation. A transparent bandage was on the left inside calf. There is no order for a treatment to this area or status of the area. E15 removed the undated bandage and a 2cm X .5cm open area was noted. Air boots were not on R2 on 11-15-10 or 11-17-10 as indicated on the Skin Integrity Report for pressure reducing devices. 2. The treatment record dated 9/12/10 notes R-4 has a stage two open area to the buttocks. An order was not obtained to treat this area until 9/15/10. The order written on 9/15/10 noted [MEDICATION NAME] is to be applied to open areas, on R-4 's right ankle, left heel and buttock. A report sent to the doctor on 10/25/10 noted the area on R-4's left ankle was 4 centimeters by 3.5 centimeters with eschar on the wound bed. During an observation of treatment on 11/16/10 at 1:10 PM, R-4's right outer ankle had an open area that was approximately four centimeters round with eschar present in the wound bed. [MEDICATION NAME] was applied to the wound at this time. The most recent Skin Integrity Report dated 11/12/10 notes R-4 has a stage two open area on the right ankle that measures 0.75 centimeters by 2 centimeters by 0 .2 with no eschar present. The list of pressure ulcers presented to the surveyors on 11/14/10 by E2 (Director of Nurses), notes R-4 has a stage three pressure ulcer on the right ankle. The facility Pressure Ulcer Policy dated 9/97 notes any area covered with eschar so the wound is not visible, cannot be staged until eschar is removed and adequate visual assessment is possible. The Skin Integrity Report dated 10/8/10 through 11/12/10 notes R-4 is to wear heel protectors to relieve pressures. R-4 did not have heel protectors on 11/15/10 at 11:00 AM, 11/16/10 at 1:10 PM, 11/17/10 at 10:50 AM. This was confirmed with E1, (Administrator), during the daily status meeting at 4:40PM on 11-17-10.

Based on medical record review, resident observations and staff interviews the facility failed to ensure optimal nutritional status for two (R2 and R12) of 13 in house sampled residents reviewed. This failure resulted in unplanned undesirable weight loss for R2 and R12. Findings include: 1. The medical record for R2 includes an admission sheet noting an admission date of [DATE]. The record includes a doctor's order dated 11-3-10 for the dietitian to assess the resident due to poor dietary intake. As of record review on 11-16-10, the dietitian had not made an evaluation on R2 since 10-15-10. Interview with E13, (Registered Dietitian, RD) at 2:30PM on 11-16-10 indicated she was unaware of the doctor order dated 11-3-10 for a nutritional assessment. R2's history and physical for a hospital stay dated 10-19-10 notes [DIAGNOSES REDACTED]. The history and physical also notes recurrent [MEDICAL CONDITION] and recurrent urinary tract infections. The Minimum (MDS) data set [DATE] indicates R2 requires assistance with eating. Weight records indicate a weight last recorded on 11-12-10 of 130 pounds. A weight obtained and observed on 11-16-10 at 1:55PM was noted to be 113 pounds. This is a 17 pounds weight loss (13%) in one week. Weight history reflects a steady weight loss of 172 pounds on 7-9-10 to a current weight of 113 pounds. This is a 59 pound loss (34%) in 4 months. A dietary progress note by E14, (Dietary Manager, DM), on 11-4-10, notes she will refer R2 to the speech therapist for evaluation of food texture needs. The medical record dietary progress notes indicates R2 is currently receiving a regular diet with ground meat with lunch and supper. An interview with E16, (Speech Therapist), at 10AM on 11-16-10, indicated R2 was referred to her by a Certified Nursing Assistant (CNA) after R2's last readmission 10-28-10 for difficulty chewing food and questioned a need to down grade R2's diet to a pureed consistency. E16 stated she was advised that E14 and nursing staff would look at R2 and determine consistency needs. E16 noted it was taken out of her hands. November 2010 meal intake records completed by CNA's for R2 were printed out of the computer by E2, (Director of Nursing, DON) on 11-16-10 for review. This form is termed "Dart Chart" for eating/drinking. E14, (Dietary Manager) and E13, (RD) indicated at 2:30PM on 11-16-10 they have never seen these records and they are not printed for review. The computer printout notes R2 frequently eats less than 25% of all three meals. There is no monitoring of the intake of [MEDICATION NAME] which was ordered to aid wound healing. (The wound tracking sheet for 11-12-10 notes R2 has a Stage IV and a Stage III pressure area.) At lunch on 11-17-10, R2 was not served [MEDICATION NAME] with lunch as ordered. R2 was fed by E8 (Rehab Aid) and observed to eat less than 25%. Ground meat was served and hashbrowns and broccoli with cauliflower were mashed with a fork by E8. Neither the bun nor sliced apples was attempted. R2 has a doctor's order dated 10-28-10 to inject [MEDICATION NAME] 10 Units at bedtime if morning fasting glucose is greater than 180. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the morning fasting blood sugar readings indicate less than a 180 reading on 11-2=97, 11-3=119, 11-5=46, 11-6=119, 11-9=125, 11-10=151, 11-11=165, 11-12=66, 11-14=150 and 11-15=131. R2's lack of evaluation and monitoring for significant weight loss, a history of dehydration and ketoacidosis, the recurrent urinary tract infections and [MEDICAL CONDITION], and the providing of insulin when blood sugar levels were below 180 was confirmed with E1, (Administrator) and E2, (Director of Nursing) during the daily status meeting at 4:40PM on 11-17-10. 2. R12 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to R12's Minimum Data Set assessment dated [DATE], R12 requires one staff supervision for eating coded (1/1). R12 is on a Mechanical Soft diet with whole milk, 1/2 cup super cereal at breakfast, a snack 3 times a day and med pass 2.0 - 2 ounces four times a day according to the November physician's orders [REDACTED]. R12 was noted to receive pain medication frequently ([MEDICATION NAME] 34 times in Oct and 13 times as of Nov. 16, 2010) according to the medication administration record. R12 was observed in the dining room during the noon meal on 11-17-10 at 12PM, R12 was hollering regarding pain in back and legs. R12 fed herself but only ate a few bites of each of her food items (total 30%) with no encouragement from 12PM to 12:14PM. R12's 10AM snack (ice cream) was given to the resident at 11:30AM and she ate only 2 bites. Chocolate whole milk was served in a carton with the meal but no straw or glass was provided for milk. R12 did not drink any of her milk. The facility's weight record for R12 reveals a weight loss of 4.4% in 1 month (5 pounds) and a 8.3% weight loss in 3 months (10 pounds). R12's height is 63" and ideal body weight is 95# to 116# according to the dietary note 10-15-10. R12's July weight was 120#, September weight is #115 and October/November weight is #110. E13 (Registered Dietician) stated in the 10-15-10 note that R12's weight loss and her meal acceptance is poor even with attempts to assist. E13 states R12 "is just not eating" and recommended to increase the med pass 2. 0 from 2 ounces to 4 ounces four times a day. Per record review and interview with E2 (DON) on 11-17-10 at 2PM, no increase of the med pass 2.0 to 4 ounces was done and the recommendation was not given to the physician. No record of R12's acceptance or intake of the med pass 2.0 or the snacks between meals was recorded. Per interview with E15 (LPN) on 11-17-10 at 9AM, R12 usually takes 100% of the med pass supplement but refuses the in-between meal snacks at times. Meal intakes percentages are recorded on a computer called "Dart Chart" for Eating/drinking documentation by CNA's for the past 6 months. E14 (Dietary Manager) and E15 (Registered Dietician) were not aware this information was recorded and no print out of this information could be located per interviews with E14 and E15 on 11-16-10 at 2:30PM. Meal intake percentages are not consistently documented on this form (ex on 11-17-10 breakfast only is documented). No assessment was found for the undesirable unplanned weight loss or loss of appetite for R12, confirmed by interview with E2 on 11-11-17-10 at 2PM. The above was confirmed with E1 (Administrator) and E2 (Director of Nursing) on 11-17-10 at 4:40PM during the daily status meeting.