Every finding on record at Hillcrest Home

Based on observation, interview and record review, the facility failed to ensure infection control practices were utilized while serving meals in the dining room. These failures have the potential to affect all resident who reside in the facility with a current census of 46 residents. Findings include: The Facility Resident Census Roster and Facility Matrix/802 dated 5/20/25 were reviewed. The Census Roster documented 46 Residents resided in the Facility. The Illinois Food Handler Training power point utilized for training facility dietary staff dated 6/3/16 documents food can become unsafe if staff practice poor personal hygiene. Personal hygiene consists of good hand washing practices, proper glove use, proper hand care and personal cleanliness. Wash hands between tasks. V18's (Dietary Aide) Certificate of Completion of the Illinois Food Handler Non-Restaurant Training was dated as completed on 12/1/23. On 5/20/25 at 11:14 AM, V18 was observed to be at the drink station in the dining room, put two meal tickets in her mouth, one meal ticket fell from her mouth onto the floor, she picked it up off the floor with her bare hand, poured apple juice into a glass and handed the glass off to another staff member, then made three cups of hot chocolate, picked up the three cups of hot chocolate and delivered them to R31. V18 then went to the serving window to deliver meal trays without conducting proper hand hygiene. On 5/23/25 at 11:55 AM, V22 (Dietary Supervisor) stated V18 should not have held the meal tickets in her mouth or picked up the meal ticket off the floor without conduction hand hygiene prior to making and serving R31 his drinks. V22 stated V18 had a current Certification of Completion of the State's Food Handler Training and knows better than to cross contaminate residents' food and/or drinks.

Based on observation, interview and record review, the facility's Governing Body failed to employ a licensed Administrator to oversee and manage the everyday operations of the facility. This failure has the potential to affect all 46 residents residing within the facility. Findings include: The Facility Resident Census Roster and Facility Matrix/802 dated 5/20/25 were reviewed. The Census Roster documented 46 Residents resided in the Facility. The Administrator's Job Description (not dated) documents the Administrator supervises all departments and employees and is responsible for planning, organizing, staffing, directing and coordinating the facility to ensure quality of care for residents, be knowledgeable of and implement federal, state, local laws and regulations applicable to the facility, residents, personnel and physical plant. The Administrator must hold a current, unencumbered nursing facility Administrator's license. On 5/20/25 from 9:15 AM through 3:30 PM, on 5/21/25 from 9:00 AM through 3:30 PM, on 5/22/25 from 9:00 AM through 3:30 PM and on 5/23/25 from 9:00 AM through 3:30 PM there was no licensed administrator within the building and no posted Administrator's license. On 05/20/25 at 9:30 AM, V2 (Director of Nursing) stated the facility has not had an Administrator since 4/9/25 and she was the acting Administrator.V2 stated V1 (County Administrator) was the facility's resource. V2 agreed the Facility did not have an Administrator license posted within the facility.

Based on interview and record review, the facility failed to notify the Ombudsman of all hospital discharge/transfers for four of four (R30, R31, R44, and R48) residents reviewed for hospitalization in a sample of 30. Findings include: The facility's Hospital Tracking Portal, dated 2/1/25 to 5/23/25, documents R30, R31, R44, and R48 were transferred out to the hospital. The facility's Admit Discharge report, dated February 2025, does not include R30, R31, R44, or R48. On 5/22/25, at 3:35pm, V12 Business Office Manager/BOM stated that the Admit Discharge report that V12 sends to the Ombudsman does not include the Private Pay residents. V12 was unaware that it should include the Private Pay residents as well. The facility's Daily Census, dated 5/20/25, documents R30, R31, R44, and R48 have a Primary Payer source of Private Pay.

Based on observation, interview and record review, the facility failed to ensure the resident's environment was kept free from cross contamination during wound care for one of ten residents (R31) who receive wound care. These failures have the potential to affect all resident who reside in the facility with a current census of 46 residents. Findings include: The facility's undated Procedure for Clean Dressing Technique policy documents the following Take treatment cart to the resident's room, but not in contact with the resident belongings. Gather and set up supplies in the resident area. Establish clean field (can be unsterile plastic field, clean linen, etc.) not on the treatment cart. The facility's current Weekly Wound Tracking Forms identify ten residents (R1, R4, R5, R7, R8, R9, R13, R16, R31, R34) who currently are receiving wound care treatments in the facility. R31's Physicians Orders include the following pressure ulcer/wound care orders Cleanse Sacrum with NS (Normal Saline) apply Santyl (wound treatment ointment) to wound bed and cover with (dry dressing) and secure with tape daily and PRN (as needed) every day shift for wound care and as needed for wound care. On 5/22/25 at approximately 11:00 AM, V3 (Wound Nurse and Resident Care Coordinator) wheeled the facility's treatment cart into R31's room, removed R1's wound care supplies from a drawer in the cart and placed them on a clean under pad on the top of cart, including gauze pads, saline cleansing liquid, cloth tape, dry dressing and medicated ointment. V3 performed wound care for R31. After performing R31's wound care, V3 rolled the treatment cart out of R31's room and into the hallway. The wound care supplies for all residents receiving wound care are present in the facility's treatment cart. On 5/22/25 at 11:18 AM, V3 stated she does bring the treatment cart into residents' rooms for wound care treatments and stated, I usually put the treatment cart at the other end of (the resident's) room. On 5/23/25 at 10:30 AM, V4 (Infection Control Coordinator) stated the facility's treatment cart should remain outside the resident's room and should not be brought onto a resident's room. On 5/23/25 at approximately 11:30 AM, V4 provided the facility's Procedure for Clean Dressing Technique policy and verified the treatment cart may be taken to the resident's room door but not inside the resident's room.

Based on interview and record review the facility failed to ensure Advance Directives reflect resident preference for one (R4) of one resident reviewed for Advance Directives in the sample of 30. Findings include: The facility's POLST (Practitioner Order for Life-Sustaining Treatment) policy and procedure, dated 3/20/23, documents the POLST is an important component of advance care planning that emphasizes eliciting, documenting, and honoring patients' preferences about treatments they want to choose or decline during a medical emergency or as their health status changes. The POLST is to be completed or reviewed with the resident and/or Healthcare Power of Attorney, and/or surrogate or guardian. A POLST is not a one-and-done document and is to be reviewed periodically. The POLST order set is intended to be dynamic, reflecting a resident's current condition and preferences about medical treatments. The POLST form for R4, dated 1/10/22, documents If patient has no pulse and is not breathing and Do Not Attempt Resuscitation/DNR The current Order Summary Report and current Care Plan document R4 as a DNR. The clinical medical record for R4 does not document any discussions were had with R4 regarding R4's wishes for Code Status. The admission MDS (Minimum Data Set) Assessments for R4, dated 1/16/22 (admission date) and Quarterly MDS assessment dated [DATE], document R4 as cognitively intact. On 5/21/25 at 2:40 PM, R4 stated no one has asked him what his wishes were if his heart stopped beating and he stopped breathing. R4 stated, without hesitation, I want them to do everything if I die. On 5/23/25 at 9:43 AM V11 SSD (Social Service Director) stated she talks with residents and family regarding Code status during the resident admission or readmission, quarterly, and if there is a significant change in condition. If the family or representative, or legal guardian are not here V11 SSD calls them on the telephone to discuss Code Status. If a resident is alert and oriented the patient makes the decision. We use the BIMS for cognition. V11 SSD stated she calls V17 (R4's) State Guardian, discusses R4's Code Status with her, V17 makes decisions for R4, and R4 is aware of the decisions made.

2. The facility's Fall log dated May 2025 documents R9 had a fall on 5/4/25 at 1:15 PM. The Fall Risk Assessment for R9, dated 3/5/25 documents R9 is at Moderate Risk for falls. The facility's Fall Investigation for R9, dated 5/4/25, documents R9 stated My foot wasn't in the right position, then I started just going down. V15's (Agency CNA/Certified Nursing Assistant) witness statement documents V15 was Transferring (R9) into wheelchair from toilet via (mechanical lift), footrest on wheelchair came down, footrest hit (R9's) foot causing (R9) to slip and be lowered to floor. The current Transfer Care Plan for R9 documents R9 requires extensive assistance for transfers. Interventions include to place R9's feet on foot plate of mechanical stand lift and fasten safety strap around R9's legs with knees against the pad. This same Care Plan was revised to include a new fall on 5/4/25. R9 was being transferred by V15 (Agency CNA) and R9's right leg wasn't positioned properly. R9 had to be lowered to the floor for R9's safety. On 5/21/25 at 2:30 PM, R9 stated V15 (Agency CNA) transferred her and didn't put her feet on the lift platform correctly, did not put the strap behind her legs, and did not listen to R9. R9 stated My right foot was curled and not flat. V15 (Agency CNA) said Let go, I got you. When V15 (Agency CNA) started raising the lift (R9's) foot slipped and I had a soft fall. On 5/22/25 at 11:53 AM, V2 (DON/Director of Nursing) stated she does all the fall investigations for the facility and determines the root cause analysis for each resident fall. V2 stated V15 transferred R9 without fastening the lift strap behind R9's legs and should have; and confirmed improper foot positioning prior to transfer. V2 stated the intervention would be for V15 (Agency CNA) to be re-educated on proper transfers. Based on interview and record review, the facility failed to ensure residents were safely transferred, monitored post fall and that the accident was appropriately investigated for two of eight residents (R9, R13) reviewed for accidents in a sample of 30 residents. Findings include: The Fall Prevention Policy dated 8/31/21 documents: All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. All falls are to be investigated and monitored. The Director of Nursing and/or designee is responsible for coordinating all investigations. An accident is an unexpected, unintended event that can cause a resident bodily injury. A 'fall' is the unintentional coming to rest on a lower surface, such as a chair, the bed or the floor or onto the next lower surface. Investigative guidelines documents to call a Post-Fall Huddle and complete a Fall Report, obtain detailed statement from any witnesses and document in the Nurses Notes. Document vital signs, neurological checks, medication taken, last time resident was seen and any other pertinent observations. Continue to observe resident throughout shift and provide documentation. Each nurse, each shift will observe resident and document for 72 hours in the resident's medical record. Monitor closely for any physical or neurological changes. Discuss the incident in morning meeting for review as Interdisciplinary team and update care plan. 1. R13's current Care Plan documents R13 was at risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, unsteady gait, hypocalcemia and weakness. On 3/21/25 R13 was noted to be on the floor by her wheelchair after she attempted to hang up her phone; did not have her wheelchair brakes locked when she was leaning forward to hang up her phone; was re-educated to lock her wheelchair brakes or use the call light to ask for help when needed; obtained a skin tear to her right elbow; monitor for signs and symptoms of infection; refer to therapy; and on 3/24/2025 to obtain an x-ray of right elbow; and to refer R13 to the wound doctor. R13's Physician's Order dated 3/21/25 documents to place and keep right elbow steri-strips in place, monitor for signs and symptoms of infection every shift for skin tear for two weeks. V5's (Advanced Registered Nurse Practitioner) Progress Note dated 3/24/25 documents R13 complained of right elbow pain and worsened with movement. The right elbow did have a deep laceration and complained of being sore from the fall, but the only specific area is the right elbow. There were no steri-strips on the elbow at the time of V5's assessment. V5 ordered an x-ray of the right elbow, prophylactically prescribed antibiotics for ten days and made a referral to the wound doctor. R13's Progress Note dated 3/24/25 documents a right elbow x-ray was conducted. On 3/25/25, the right elbow x-ray was reported as a fracture was not excluded but was inconclusive. On 3/27/25, the Progress Note documents R13's right elbow x-ray was negative. V6's (Wound Care Physician) Progress Note dated 3/26/25 documents Non-Pressure Wound of the right elbow full thickness caused by trauma/injury greater than four days ago and measured three cm (centimeters) by 1.6 cm by 0.8 cm; surface area 4.80 cm; undermining 1.2 cm, to apply collagen sheet to wound once daily and as needed for 30 days; apply gauze island with border once daily and as needed for 30 days.V6's treatments as listed on the Wound Log document on 4/2/25, 4/9/25 and 4/16/25, R13's right elbow wound had worsened and surgical debridement was conducted; 4/30/25 wound was debrided and unchanged; and on 5/7/25 wound was debrided and improved. V6 conducted weekly visits until 5/21/25 when wound was declared healed. The Fall Investigation dated 3/21/25 did not include an interview from V20 (Occupational Therapist) or V21 (Physical Therapy Assistant) who observed R13's fall, documented injuries as a bruise on the right forearm, redness to upper-mid back vertebrae and a skin tear to right elbow and no injuries observed post incident. R13's medical record did not include vital sign monitoring and/or an assessment of her right elbow wound for 72 hours each shift per policy (3/21/25, 3/22/25, 3/24/25) or for two weeks each shift per physician's order. The Interdisciplinary Note (IDT) dated 3/30/25 (nine days post fall incident) documents R13's fall details and post fall findings were discussed/reviewed, although does not include an interview from V20 (Occupational Therapist) or V21 (Physical Therapy Assistant) who observed and responded to R13's fall, why R13's deep laceration that required treatment by a wound doctor and complaints of pain of her right elbow was not accurately assessed until 3/24/25 when V5 (Advanced Registered Nurse Practitioner) conducted rounds. On 5/23/25 at 9:50 AM, V20 (Occupational Therapist) and V21 (Physical Therapy Assistant) stated they were in the room across from R13 and witnessed R13 reach forward to hang the phone up and slid off the front of the wheelchair onto her butt then rolled backward onto her back. V20 and V21 ran into R13's room and the nurse came in soon after. I didn't even know she cut her arm until the next day. On 5/23/25 at 11:00 AM, V2 (Director of Nursing) stated R13's right arm laceration was not appropriately assessed due to positioning of the arm during assessment; agreed post fall assessments were not appropriately conducted and/or documented per policy; and agreed the IDT met nine days after R13's fall.

Based on observation, interview, and record review, the facility failed to ensure their posted nurse staffing information was in a clear format and included the name of the facility. This has the potential to affect all 46 residents in the facility. On 5/20/25, at 12:30pm, the facility's Minimum Daily Staffing Calculations sheet dated 5/20/25 is hanging in the front hallway. The facility's Minimum Daily Staffing Calculations tool sheet, dated 5/20/25, does not include the name of the facility and is not in a clear, readable format. This posting documents the numbers to calculate the total of licensed nurses and non-nurse staffing additional direct care hours needed which is then is multiplied by the designated number of FTEs (full time equivalents) to result in the total number of hours needed. The number of actual Registered Nurses/RNs, Licensed Practical Nurses/LPNs, and Certified Nursing Assistants/CNAs is written in off to the side. On 5/23/25, at 11:20am, V2 Director of Nursing/DON confirmed the Minimum Daily Staffing Calculations sheet is used to calculate the number of staff needed and is the staffing sheet they use to post in the hallway and have used it for a long time. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/20/25, documents 46 residents currently reside in the facility.

Based on observation, interview and record review the facility failed to notify a physician of a fall in a timely manner and failed to notify the physician of the resident taking an anticoagulant medication for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 4. The findings include: The admission record for R2 shows she was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation, unspecified dementia, and aphasia (communication disorder). The facility's 4/29/24 admission assessment of R2 shows severe cognitive impairment. The same assessment shows R2 to be on an anticoagulant medication. The order summary report of 6/23/24 shows R2 was taking Eliquis 2.5 mg twice daily for chronic atrial fibrillation. R2's progress notes for 6/22/24 at 3:15 PM show resident observed on the floor on the side of the bed in front of her wheelchair sitting upright onto buttocks. Vital signs obtained, and remain within normal limits of baseline, full body observation completed with no injury noted, resident denied hitting head, however fall was unwitnessed, so neuro checks in place. MD notified via fax and made aware, with instructions to continue to monitor per facility protocol. On 6/23/24 at 11:25 AM, V16 CNA (Certified Nursing Assistant) said R2 only knows her name, is confused, and wanders around the facility. R2 would not be able to answer any questions correctly such as if she hit her head during a fall. On 6/23/24 at 12:07 PM, R2 was observed sitting in the hallway after lunch. R2 stated she did not have lunch, after observing staff feeding her lunch. R2 denied having any falls and was oriented to her name only. R2 stated the month/year as October 1939, and it was summer. The Communication for Doctor and Nursing home staff form dated 6/22/24 shows the MD was notified at 8:00 PM, 5 hours after the unwitnessed fall. The nurse noted R2 was assisted off the floor, alarm sounding, ROM (range of motion) WNL (within normal limits). No complaints of pain or discomfort. Skin assessment done, vital signs WNL. Will monitor. Neuros initiated. The document does not include the resident was prescribed anticoagulant medications. The fall risk assessment completed by V14 LPN (Licensed Practical Nurse) documents R2 had been in the facility over 3 months, had 1-2 falls within the past 6 months, and was on narcotic medications. V14 did not check the box for anticoagulants. On 6/23/24 at 10:47 AM, V3 ADON (Assistant Director of Nursing) said for an unwitnessed fall the nurse would document the surroundings, such as fall mats, footwear, and identify the cause of the fall if they are able. V3 said, If a resident is unable to speak for themselves maybe ask a roommate if they have one or check with staff to see if anyone saw the event. If a resident cannot say, the nurse would do neuro checks every 4 hours for 24 hours per the facility policy. V3 said the physician would be notified, and the nurse should include if the resident is on any anticoagulant medications. On 6/23/24 at 12:10 PM, V12 LPN said when a resident has a fall she will call the physician, not fax them. V12 said if she can't get ahold of them, she calls the NP (Nurse Practitioner), who knows the residents so V12 would not have to tell NP of any anticoagulants. V12 said the NP can look it up in the computer and has access the same as the nurses. V12 said for a confused resident with an unwitnessed fall and on an anticoagulant, there is no automatic rule, it really depends on the doctor whether they go out. V12 said she does not always tell the physician about the medications, but sometimes the physician will ask. V12 said it all depends on the nurse working and the physician as to what will be ordered. On 6/23/24 at 11:39 AM, V3 said she would ask the resident if they hit their head during a fall, even if they said no she would still do neuro checks. V3 said the physician should have been notified in a more timely manner, and the nurse should have included R2 being on an anticoagulant medication. There would have been more indications/chance for bleeding on a blood thinner. On 6/23/24 at 12:37 PM, V13 MD (physician/ Medical Director) said he was notified of the fall but was not made aware of R2 being on an anticoagulant medication. V13 said that information would have helped. V13 said anyone on a blood thinner will be at a higher risk for bleeding or a subdural hemorrhage. If a fall is unwitnessed and the resident is on an anticoagulant, they should be sent out just to error on the side of caution. V13 said for falls, he prefers a phone call. It should be standing protocol to notify the physician right away of the fall especially when ruling out any head injury. A policy for notification of changes was requested, and none was provided by the facility.

Based on observation, interview and record review the facility quarantined 6 residents to remain in their rooms (R1, R21, R36, R43, R53 and R59) on 5/28/24 without any clear reasoning. This failure caused R53 to be very upset and anxious regarding his inability to leave his room. Findings Include: The Facility's Policy for Outbreak Investigation dated 4/1/2024 documents, It is the policy of (This Facility) that outbreak measures will be instituted whenever there is an incidence of infections above what would normally be expected, considering seasonal variations. The Infections Preventionist will conduct the outbreak investigation. The Facility's Your Rights and Protections as a Nursing Home Resident pamphlet dated 8/2021 documents, You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose You have the right to decide when you go to bed, rise in the morning, and eat your meals. Upon entry to the facility on [DATE] at 8:45AM no staff members were wearing masks and V20 (Receptionist) stated there were no known outbreaks or illnesses happening in the building at that time. At this time, R53 was in the main dining room eating breakfast with three other male residents. R53 appeared to be friendly and talkative with these men. R53's Admission Activity assessment dated [DATE] documents, R53 prefers to be with people and enjoys large groups and small groups. On 5/28/24 at 9:00AM multiple staff members were observed passing out surgical masks to other staff members instructing them that we are in outbreak status we need to mask. On 5/28/24 at 11:00 AM V3 (Registered Nurse/Assistant Director of Nurses/Infection Preventionist) stated, I decided we have had some upper respiratory infections lately, so I am having the staff mask to be careful. V3 did not indicate at that time that residents were being asked to remain in their rooms. On 5/28/24 at 3:15 PM V6 (Licensed Practical Nurse) stated, This is ridiculous. We have had allergic rhinitis in this building for the past couple of weeks because it is that time of year. Nothing has changed other than (Survey Agency) coming in for an inspection. V6 stated, (R53) is very mad about having to stay in his room. On 5/28/24 at 3:30 PM R53 stated, What the hell is this all about? I have been hacking and coughing for at least a week and now that I am starting to feel better. I have to stay in my room? I am almost [AGE] years old, if I die, I die. I would rather eat in the dining room than be made to sit in my room looking at the wall while I am eating. If I am so contagious, why is he (R62/roommate) still alive and able to leave the room? This is infuriating that no one here knows what the hell they are doing. Pure chaos. On 5/29/24 at 8:30 AM V5 (Licensed Practical Nurse) stated, (R53) is very irritated with staying in his room. V5 confirmed, (R53) had been hacking for the past week or so. V5 stated, Everyone has had that allergy cough going on. (R53) actually sounds better than he has. (R1) is one of them that we were instructed to keep in her room, and she sounds no different than she ever has. I just don't understand the reasoning on any of these. On 5/29/24 at 9:15 AM R53 was sitting inside of his room speaking with V7 (Social Services Director) saying, When am I getting out of here? I need to shower. I want to go to the dining room. If the risk is mine, I will take it, if it is because I am infectious, I think we may have killed (R62/Roommate). On 5/29/24 at 9:20 AM V7 (Social Services Director) confirmed R53 had been upset and wanting information regarding when he could leave his room. V7 confirmed that both R53 and his roommate R62 are up and about their room independently and neither of them was wearing masks inside of the room. V7 confirmed R62 was free to come and go from the room as he wished and that she didn't know when R53 would be able to leave his room. That is up to (V3 RN/ADON/IP). On 5/30/24 at 10:30 AM V3 (Registered Nurse/Assistant Director of Nurses/Infection Preventionist) stated she implemented masking because there had been an uptick of respiratory issues at the facility over the weekend. V3 confirmed she instructed staff members to keep R1, R21, R36, R43, R53 and R59 in their rooms related to upper respiratory symptoms. V3 confirmed she did this prior to completing any investigation into duration of symptoms, fever status or speaking with floor staff regarding status of the residents who were being asked to stay in their rooms. V3 stated, I found out (R53) was upset, I just didn't have time to investigate it right then. V3 confirmed that after her investigation into R53's respiratory status he could have come out of his room with a mask on himself and did not need to be kept in his room. V3 confirmed R53 was encouraged to stay in his room on 5/28/24 for lunch and supper meals and on 5/29/24 for the breakfast meal unnecessarily. V3. Stated, I over reacted and I owe (R53) an apology because he was so upset.

Based on interview and record review, the facility failed to ensure their Antibiotic Stewardship program was implemented. this failure has the potential to affect all 62 residents residing at the facility. Findings include: The facility's Antibiotic Stewardship Program policy (undated) documents the following: Infection Preventionist will encourage and educate staff to use McGeer's definitions of infections. Standards of infection observation are checking for signs observed and/or resident has a change of condition. The following steps will be implemented: monitor vital signs, monitor intake and output for 48 hours, assessment of lung sounds, and assessment of other signs of infection and update the physician and family. If UTI (urinary tract infection) is suspected, then 48 hour watch will be implemented by monitoring temperature, intake and output, urine color and character, pain assessment and changes in mental status using McGeer's definition as a guide. On 05/29/24 at 09:20 AM, V3 (Registered Nurse/Infection Preventionist) stated the facility does not implement any protocols to review clinical signs and symptoms and/or laboratory reports prior to implementation of an antibiotic for a resident. V3 stated the facility does not utilize any assessment tools or management algorithms to determine if an antibiotic is warranted, We just call the doctor and get an order for an antibiotic if we believe one is needed. The facility's Long Term Care Facility Application for Medicare and Medicaid, Form 671, dated 05/28/24 and signed by V1 (Administrator), documents 62 residents currently reside in the facility.

Based on document review, observation and interview, the facility failed to ensure call lights were equipped to communicate directly to staff. This failure has the potential to affect all 62 residents residing in the facility. Findings include: The Software User Guide dated 2020 documents the web-based application is designed for nurse call and wander management use for Independent and Assisted Living facilities. The Guide documents to log-into the application with username and password. When the Alarms (nurse call or wander alarms) are activated, the computer will make a sound and display the location of the alarms. On 5/28/24 at 10:58 AM, R25 stated, I have to help when I go number two. I have waited up to 70 minutes for them (staff) to respond to my light. I would say the average wait time is between 30 minutes to 70 minutes. On 05/28/24 11:10 AM, R17 stated, The call light response time could be better. Especially in the morning when they are so busy. Sometimes you have to wait a really long time for help. On 5/29/24 at 11:45 AM, V10 Registered Nurse) demonstrated at the nurse's station a device called Code Alert which the screen will light up a resident's room number when the nurse call is activated or identify a resident's location if the wander guard alarm is activated. V10 stated, the computers will also notify the Nurses and/or Certified Nurse Aides (CNA) in the same manner. V10 stated, You (Nurses and CNA's) have to be at the desk (nurse's station) or at their computer to know if a resident needs assistance. On 5/29/24 at 12:00 PM, V12 (Physical Therapist) and V13 (Occupational Therapist) stated call light response time could be a lot better especially when a resident is toileting. V13 stated, We (Therapy) used to be able to help with call lights and toileting but ever since they switched to this new system, we are not alerted to when they (nurse calls) are on. On 5/29/24 at 1:34 PM, R25's nurse call was activated. At 1:37 PM, V17 (Licensed Practical Nurse) was observed to enter R25's room and state Music is in the Activity Room at 2:00 PM. V17 did not address and/or was not aware the nurse call was activated. On 5/29/24 at 1:45 PM, V14 (CNA), V15 (CNA), and V16 (CNA) were observed in the [NAME] Hall with a computer and demonstrated the use of the nurse call system. A call light was activated; an alert was displayed with the room number and location and a sound was heard. V16 stated, If we are not at the computer, we turn the sound on the computer up, but we still have to come out and look to see where the alarm is. On 5/29/24 at 1:55 PM, V8 (Licensed Practical Nurse/LPN) stated the computers time out (of the nurse call/wander guard software application) in one or two hours. On 5/29/24 at 1:55 PM, V5 (LPN) stated, If a call light (nurse call) is shut off in the room, it's still on in the system and we have to restart the system. Sometimes the call light gets stuck on, and we have to restart the system. It's (software application) kinda squirrely sometimes. It worked a lot better when we could just see the lights. On 5/30/24 at 9:45 AM, V1 (Administrator) stated if the wi-fi or power is lost, the facility has bells to give the residents and 15-minute checks are conducted. On 5/30/24 between 10:29 AM and 10:40 AM, two computers in the South Hall, one computer in the [NAME] hall and one computer in the East hall displayed two alarm notifications (1 notification on for 18 minutes in 3 North bathroom, 1 notification on for 9 minutes in 7 [NAME] bathroom) although no sound was heard. On 5/30/24 at 10:40 PM, V18 (CNA) stated, The volume was turned down because it's annoying. The following observations lacked nurse call monitoring by a nurse or CNA: The North Hall- on 5/28/24 between 10:20 AM and 11:00 AM, 12:00 PM and 12:30 PM; On 5/29/24 between 11:45 AM and 11:59 AM, 12:10 PM and 1:30 PM - 1:39 PM; 5/30/24 between 9:29 AM and 9:35 AM and 10:34 AM. The East Hall- on 5/29/24 at 1:40 PM and 5/30/24 at 9:29 AM. The South Hall- 5/29/24 at 1:29 PM and 5/30/24 at 9:28 AM. The Resident Census dated 5/28/24 documents that 62 residents currently reside in the facility.

Based on interview, observation and record review, the facility failed to ensure fall interventions were implemented to prevent further falls for one of four residents (R38) reviewed for falls in the sample of 29. Findings include: The facility's Fall Reduction Program policy (revised 09/01/21) documents the following: All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care Plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. On 05/28/24 at 10:10 AM, R38 was lying in a low bed with a fall mat in place next to her bed. R38 was nonverbal and did not respond to verbal stimuli when approached due to her impaired cognition. R38's Fall Investigation (dated 01/08/24) documents the following: Nurse notified at this time of resident (R38) sliding out of chair in dining room. CNA (Certified Nursing Assistant) stated resident slid out of chair and did not hit head. R38's current care plan documents the following focus: Risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, poor coordination, poor safety awareness. This same care plan documents the following fall prevention intervention: 01/08/24: Re-educated staff to ensure (R38) has (non-slip mat) placed under her. On 05/30/24 at 02:00 PM, V17 (Licensed Practical Nurse/Care Plan Coordinator) stated that after investigation of R38's 01/08/24 fall, R38 did not have (non-slip mat) in place in her wheelchair and should have had it in place since it had been a previously implemented fall prevention intervention. V17 stated that staff was re-educated to check above and underneath R38's wheelchair cushion to ensure (non-slip mat) is in place.

Based on observation, record review and interview the facility failed to ensure psychotropic medications given on an as needed basis were not prescribed more than 14 days for 1 resident (R27) of 5 residents reviewed for unnecessary medications in a total sample of 29. Findings include: The facility's Policy / Procedure regarding Treatment/Services for Mental/Psychosocial Concerns dated 11/18/21 documents, A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R27's Physician Order Sheet (POS) dated May 30, 2024 documents R27 is prescribed Lorazepam 0.5 milligrams by mouth every eight hours for anxiety. On 05/28/24 at 9:38 AM R27 was observed laying quietly in her bed on her left side. R27 was asleep and having no behaviors. On 05/28/24 at 12:23 PM, R27 was noted laying in her bed quietly, having no behaviors. On 05/30/24 at 11:09 AM, R27 was sitting in a wheelchair in the dining room at a table with two other residents and a staff while eating her lunch independently. R27 was not noted to have behaviors. On 05/30/24 at 11:07 AM V18, Certified Nursing Assistant, stated R27 sometimes hallucinates but is not aggressive nor displays self-injurious behavior. On 05/30/24 at 1:00 PM, V8, Licensed Practical Nurse/LPN, stated R27 had behaviors when she was new to the facility and the environment was different to her, however, typically her behaviors are an indicator of the beginning of a urinary tract infection or sometime similar. R27's Medication Administration Records document the last time she was administered Ativan on an as needed basis was February 15, 2024. A Note to Attending Physician/Provider documents R27 has an as needed (PRN) psychotropic order for Ativan 0.25 mg (milligrams) q8h prn (every eight hours as needed). Previously documented stop date of 04/23/24 will expire soon. 6 months is handwritten into the area for duration and dated 04/18/24. On 05/30/24 at 2:07 PM, V17, LPN, stated, It is not in our policy for a PRN psychotropic to not be ordered for more than 14 days, but it is our practice.

Based on interview and record review, facility staff failed to operate the facility van, with a resident aboard, in a safe manner to prevent an accident, for one of seven residents (R1), reviewed for accidents. FINDINGS INCLUDE: The facility policy, Transportation, dated 8/2019 directs staff, Employees are required to use (facility) vehicles when transporting residents, running errands for the (facility) or attending workshops outside of the (facility). Any accident involving (facility) property or vehicles shall be reported immediately to the employee's supervisor. Employees are also required to notify law enforcement when appropriate. All traffic violations, citations and fines incurred when driving for work purposes are the sole responsibility of the authorized driver. The (facility) reserves the right to review both the drivers' license and motor vehicle record (MVR) of all authorized drivers, at any time. R1's Nursing Progress Notes, dated 4/2/24 at 2:06 P.M. document, (Hospital Social Worker) SW called and updated (facility staff) that (R1) will return today. (Hospital Social Worker) said (R1's) last IV (Intravenous Antibiotic) will be done at 3:00 PM. R1's Nursing Progress Notes, dated 4/2/24 at 3:45 P.M. document, Informed Power of Attorney (POA) of auto accident (R1) was in during transport back to our facility. (R1) states she is ok. This writer instructed our driver to have (R1) transported to ER (emergency room ) for evaluation and treat (treatment). Physician notified. The Police Report dated 4/2/24 and signed by V6/Police Officer documents, 4/2/24 at 3:28 P.M., (V3/Certified Nursing Assistant) was driving the facility van to pick (R1) up from the hospital. (R1) was securely tethered in a wheelchair, in the van. (V3) was traveling east bound, went through the intersection, failing to yield to oncoming traffic. The second vehicle struck (V3's) (facility) van on the front, right passenger side. The second vehicle had an airbag deployment. After the first collision, (V3) struck a third vehicle, that was stopped at the stop sign. All three vehicles were towed (from the scene) due to damage. (V3) and (R1) were taken to the local emergency room (ER) and evaluated. No injuries were noted. V3 was issued a traffic citation for failure to yield, at an intersection. On 4/22/24 at 9:30 A.M., V1/Administrator stated, (V3/Certified Nursing Assistant/Transport Driver) had driven the facility van on 4/2/24 to pick (R1) up from the hospital, after a stay for an acute illness. (V3/Certified Nursing Assistant/Transport Driver) has been employed at the facility as a CNA (Certified Nursing Assistant) for the past couple of years and is also trained in transportation and driving the facility van. On this day, (V3) stated he stopped at a stop sign, looked both ways and proceeded through the intersection when (V3) collided with another vehicle. (V3) was given a ticket for failure to yield (at an intersection). Immediately after the accident, (V3) and (R1) went to the hospital for an evaluation with no injuries noted. Per company policy, (V3) was urine tested for drugs and alcohol, which was negative. (V3) was very upset about the incident and the potential for resident injury. On 4/22/24 at 12:47 P.M., V7/Witness to accident confirmed the incident occurred when V3/Certified Nursing Assistant failed to yield at a stop and hit two other vehicles. On 4/22/24 at 2:54 P.M., V3/Certified Nursing Assistant/Transport Driver stated, I have been an employee of the facility for the past [AGE] years. I started driving about six or seven years ago. I took a class (Transportation) before I started driving. I rarely drive any more. I had never driven the (Transit) and I was not trained on how to do it. I was coming into work on that day (4/2/24) for second shift. It was windy and cold out and it was snowing. As I came in, (V4/Transportation Director) yelled at me and told me I was to go pick (R1) up at the hospital. The CNA (Certified Nursing Assistant) I was to relieve, had to stay over while I was gone, to cover for me. I can honestly say I wasn't happy about the situation. I hadn't been trained on that van and no one told me what to do. My (Mother-in-Law) (V8/Registered Nurse) came outside and showed me how to operate the lift and this van. (V8/Registered Nurse) also told me take clothing for (R1), blankets to cover her and (R1's) wheelchair. When I got to the hospital, I pulled in the ER (emergency room ) lot, thinking (R1) would be there and ready to go. (R1) wasn't, so I had to park the van, lower the lift (took me 10 minutes to figure it out) and go upstairs to the second floor to get (R1). When I got there, (R1) was still in bed and not dressed. After they finally got (R1) dressed, I took (R1) out to the van and had to mess around with the lift for another 10 minutes to get it to engage. I was worried about (R1) because it was so cold outside, and I wanted to get back to the building so my co-worker could go home. I was about 5 blocks from the hospital and this weird intersection. I had a stop sign. There is a boulevard, so after I stopped, I had to get across two lanes of traffic. I did not even see the girl in the first car that I hit. Then the van hit another car that was stopped at a stop sign opposite of where I had stopped. I was very shaken up. I asked (R1) if she was okay and she said yes, but she was upset. (V5/Maintenance Director)) is also a volunteer on the city ambulance and fire department and he arrived on the scene. We put (R1) in an ambulance to go to the ER to get checked out and (V5) drove me to the hospital to be checked out. We were both okay, but I am still seeing a chiropractor for my right hip and back. The first car I hit; the impact was on the right front side. I know I don't want to ever drive again to transport residents. I'm still pretty shook up. On 4/23/24 at 8:26 A.M., V6/Police Officer stated, I was the responding officer to the scene of the accident. (V3) was very shook up. That intersection has been the scene of many accidents. You must drive through two lanes of traffic. The posted route from the hospital avoids that intersection. (V3) was issued a citation for failure to yield at an intersection, causing an accident, as (V3) caused the accident. All three vehicles had to be towed from the scene.

Based on record review and interview the facility failed to prevent verbal abuse to one of five (R1) residents reviewed for abuse in the sample of five. Findings include: An undated policy titled Abuse and Neglect Prevention documents, Abuse refers to any act that willfully injures or hurts a resident and includes unreasonable isolation, intimidation, or punishment of a resident. Examples of physical abuse would include hitting, kicking, pinching, choking, shoving, pushing, slapping, punching, striking with an object, burning, cutting of a resident or inappropriate sexual language or conduct. Verbal abuse includes the use of words, signs or gestures to intimidate, demean, harass, or threaten the resident. Mental Injury/Verbal Abuse refers to the use of oral written or gestured language that includes disparaging and derogatory terms to residents or within their hearing or seeing distance, regardless of their age, ability to comprehend, or disability. R1's Minimum Data Set (MDS), dated [DATE] document R1's BIMS (Brief Interview for Mental Status) is 9 of 15 indicating R1 is not cognitively intact, and R1 has a history of dementia and requires assistance with ADLs (Activities of Daily Living). A facility reported incident #145949, sent to the State Agency, documents an incident involving V3/CNA (Certified Nursing Assistant) and R1. R1's family members reported The CNA that works night shift who is heavy set is not nice to (R1) and yells and cusses, telling (the) resident to be quiet. During an investigation on 01/11/24, V2 DON (Director of Nursing) documents R1 stated during interview, That big woman (who is) fat yells at me, cusses at me and tells me to shut up. Every day she is here, (she) throws my clean clothes on the floor. This facility reported incident further documents, Upon investigation, it was determined that the verbal abuse allegation was substantiated. (V3) did cause the resident emotional distress by her actions. Due to these findings, (V3) was terminated on 01/17/2024 at 1:35 PM by (a) phone call. Interview was attempted at 11:55 AM and 12:38 PM on 02/6/24. R1 was asleep and did not respond to voice. On 02/06/24 at 1:40 PM, V2, confirmed the allegation against V3 and involving R1 was substantiated, that V3 was suspended upon notification of the allegation on 01/11/24 and terminated upon completion of investigation on 01/17/24.

Based on interview and record review the facility failed to ensure residents were free of verbal and physical abuse for two residents (R1-R4) of five reviewed for abuse in a sample of five. Findings include: The facility's Summary of Abuse and Neglect Prevention policy, undated, documents staff's first responsibility is for the safety of the resident. The facility will not tolerate abuse or neglect of its residents by any individual including staff, family, volunteers or consultant. Abuse refers to any act willfully injuries or hurts a resident and includes unreasonable isolation, intimidation, or punishment of a resident. Examples of physical abuse would include hitting, kicking, pinching, choking, shoving, pushing, slapping, punching striking with an object, burning, hitting or a resident or inappropriate sexual language or conduct. This form also documents verbal abuse includes the use of words, signs, or gestures to intimidate, demean, harass, or threaten the resident. 1. R1's electronic face sheet documents the following diagnosis: Alzheimer's Disease with late onset, Anemia, Chronic Obstructive Pulmonary Disease, Disorientation, Macular Degeneration, Sciatica, Fatigue, Chronic Pain, Rhinitis, Weakness, Palpitations, History of Urinary Tract Infections, Radiculopathy of Lumbar Region, Rheumatoid Arthritis, Spinal Stenosis, Left Artificial Knee, Disease of the Digestive System, Peripheral Vascular Disease, Constipation, Chest Pain, Hypo-Osmolality and Hyponatremia, Atherosclerotic Heart Disease. R1's current care plan documents R1 is at risk for abuse as evidenced by Dementia, Hearing loss, personality characteristics, with being combative with cares. R1's goal is to be abuse free. R1's Progress Notes, dated 10/19/23 documents V13, R1's Family, called V1, Administrator, concerning care was given to R1 on 10/11/23. The facility's final notification of investigation of staff for physical/emotional abuse, dated 10/20/23, documents at V3, Assistant Director of Nursing, determined V5 Certified Nursing Assistant, took care of R1 on 10/11/23. V3 immediately escorted V5 out of the building. This form documents the allegation of physical/mental abuse is substantiated and V5 was terminated. On 11/16/23 at 9:30am, V9, R1's Caregiver, stated on 10/11/23, V9 asked V5, CNA/Certified Nursing Assistant, to transfer R1 from the recliner to her wheelchair. V9 stated V5 told R1 to put her hands around V5's neck. R1 did not understand V5, so V5 pulled R1's hands up and placed them on her shoulders. V5 picked R1 up and sat her down on the front of the wheelchair. V5 then asked R1 to remove her hands from V5's shoulders, but she did not understand. V9 stated V5 grabbed R1's hands off her shoulders, then yanked R1 back in the chair by the back of her pants. V9 stated V5 did not explain to R1 what she was doing. V9 stated R1 began screaming and yelling. V9 stated it took a several minutes to calm R1 down after the transfer. V9 verified V5 did not use a gait belt for the transfer. 2. V5's signed statement, dated 9/16/23 documents V4 CNA/Certified Nursing Assistant, was trying to get R4 to eat, when R4 would not eat, V4 said You're a psychopath. V4 then asked R3 if she was going to eat. When R3 did not answer, V4 said You're a dumb b .h. V7's signed statement, dated 9/16/23, documents V4 was pushing R2 to breakfast and said, Could you f .g not. R2 was trying to scratch V4. V4 then walked away from R2. The facility's final notification of investigation of staff for verbal abuse, dated 9/16/23, documents R2 and R3 are cognitively impaired and R4 is severely cognitively impaired. V3, Assistant Director of Nursing, escorted V4, CNA/Certified Nursing Assistant, out of the building pending an investigation into allegations of verbal abuse. This form documents the allegation of verbal abuse is substantiated and V4 was terminated. On 11/16/23 at 10:00am, V2, Director of Nursing, stated the facility does not tolerate any type of abuse. V2 verified V5 was terminated because of her demeanor and the improper transfer. V2 stated V4 was terminated because of the verbal abuse.

Based on observation, interview, and record review the facility failed to perform wound care in a way that prevents cross contamination of wounds for 2 residents (R56 and R68) of 4 residents reviewed for wound care in a total sample of 36. Findings Include: The Facility's Aseptic Wound and Skin Treatment Procedure, dated 08/21, documents the purpose of the procedure is to prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structure and to promote resident comfort. The Aseptic Wound and Skin Treatment Procedure documents, Establish your clean and dirty fields. Remember the dirty field should be the farthest away from your clean field. (Place the plastic bag at the end or foot of the bed to receive soiled dressings). Clean the wound as ordered. Clean from center outward, never going back over area which has been cleaned. (If two (2) wounds, treat each wound as separate wounds.) On 4/5/23 at 8:05 AM V4 (RN) donned gloves, opened a single protective barrier wipe package, lifted R58's right arm sleeve and wiped up and down on a small skin tear, then lifted R58's left pant leg and with the same gloves and the same wipe wiped up and down and back and forth on a small skin tear. On 4/5/23 at 8:15 AM V4 used spray Normal Saline to wash R68's two sacral wounds. V4 sprayed both areas and used the same gauze 4x4 to wipe back and forth and up and down on both wounds. V4 dropped the gauze on the bed linen and picked it up and wiped the areas again. After cleansing the area V4 washed her hands, changed gloves, and then put both of her hands inside both of her scrub top pockets to get her scissors and then touched both wounds again. On 4/5/23 at 11:00 AM V4 (RN) stated, I should have treated both wounds separately for both (R58) and (R68). I also should not have put my hands with clean gloves in my pockets.

Based on observation, interview, and record review, the facility failed to provide Range of Motion exercises for residents with limited range of motion for two of five residents (R29, R32) reviewed for range of motion in the sample of 32. Findings include: The facility's Range of Motion policy, no date available, documents, Purpose: To move the resident's joints through as full a range of motion as possible; To improve or maintain joint mobility and muscle strength; To prevent contractures; To increase strength and activity tolerance; To reduce pain; To prevent complications of mobility. 1. On 02/14/22 at 12:44 PM, R29 was alert sitting up in her wheel chair. R29 stated she has issues with her shoulders as she attempted to lift her arms up. R29 was only able to lift her arms level with her shoulders. R29 stated that the staff don't always help her with her exercises. R29's Care plan, dated 5/21/20, documents, ADLs (Activities of Daily Living: R29 understands ADL tasks well, she is forgetful and has reduced flexion in her shoulders so can't raise up her arms too high. R29's care plan has no documentation of R29 receiving ROM programming. R29's MDS (Minimum Data Set), dated 12/16/21, documents that R29 has functional limitation in range of motion in R29's bilateral upper extremities, and R29 has not received any ROM restorative programs in the seven days prior to the MDS assessment reference date (12/16/21). R29's Contracture Assessment, dated 12/16/21, documents, Range of Motion: Right Shoulder: limited in flexion; Left shoulder: limited in flexion like the right. On 2/17/22 at 1:00 p.m., V2 (Director of Nursing) stated, R29's Contracture assessments show that she has good ROM in all of her extremities with the exception of the limitations in both of her shoulders, so we didn't feel the need to have a ROM program in place. 2. R32's Restorative Progress Notes, dated 1/27/2021 at 4:23 p.m., document, PROGRESS: Transfer, He is no longer able to walk, he still talks about discomfort in his left knee at times though it doesn't bother him a lot since he isn't walking on it. He has a soft support brace to wear when walking or transferring, mainly for walking, but he never did like to wear it and was resistive about having it put on, it was difficult to put on, his therapist stated the last time he had skilled therapy that walking needn't be a priority for him since his left knee was badly [CONDITION(S)]. His left shoulder can be sore and limited in flexion so raising him up too high in the Stand aide lift could hurt his shoulder, so that should be avoided. R32's MDS (Minimum Data Set) Assessment, dated 2/2/22, documents that R32 has functional ROM limitations in one side of his upper extremities, and that R32 has not received any ROM restorative programming in the seven days prior to the assessment reference date (2/2/22). R32's Contracture Assessment, dated 2/2/22, documents, Range of Motion: Right shoulder: His shoulders are stiff; Left shoulder: Limited flexion to only shoulder level. R32's care plan, dated 2/4/22, documents, ADLs (Activities of Daily Living)-He has mostly good ROM but is losing more dexterity in fingers due to confusion, is unsteady on feet, fatigues and becomes short of breath quickly. He's been more fatigued lately, less energetic and not participating as much lately. R32's current care plan has no documentation of R32 receiving ROM programming. On 2/17/22 at 1:40 p.m., V2 (Director of Nursing) confirmed that R32 is not on ROM programming.

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of pain medication for one of two residents (R28) reviewed for pain in the sample of 32. Findings include: The facility's Pain Management Program policy, no date available, documents, The facility shall provide adequate management of pain to ensure that residents maintain the highest practicable physical, mental, and psychosocial well-being. The policy also documents, Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: Facial expressions: grimacing, frowning, fear, grinding of teeth. The following are general principles for prescribing analgesics in the long-term care setting: Reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects. Reassess patients with pain regularly. If when re-evaluated, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. On 02/15/22 at 10:10 AM, V5 and V6 (both Certified Nursing Assistant-CNA) transferred R28 from her bed to her high back reclining wheelchair using a mechanical lift. During the transfer R28 was grimacing. V5 who was positioning R28 in wheel chair as she was lowered stated, We will try and get you positioned so you are comfortable the best we can. R28 stated, They have to put small stuffed animals beside me to help position me right. I had a back injury, and it causes me a lot of pain. So, it's hard to get comfortable in this chair. I get [MEDICATION(S)] four times a day. Right now, my pain is at an 11 on a scale of 0-10. I always have pain, and I could use something in between my scheduled doses, but I can't get anything, so I just have to try and just deal with it. The pain varies. It could be sharp stabbing aching throbbing or all of the above. It just depends on the moment, but there is always pain. The pain is mainly in my back, but my hands hurt as well. My pain gets so bad sometimes all I can do is pray. Throughout the conversation, R28 had furrowed brows. R28's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's Care plan, dated 12/24/21, documents, R28 has chronic, occasional low back pain related to old fracture and surgery on (R28's) spine in the past. She may not always express pain to staff appropriately, she may become restless or moan, cry out when moved. Increase in pain in shoulders, arms, hands, knees lately, joints more stiff. Left lower leg pain related to fracture in past. She reports headaches/pressure behind her eyes, sometimes the pain is 'all over.' The care plan also documents the following interventions: At times, R28 will make statements that the [MEDICATION(S)] she receives is sugar and does not help. Listen to her complaints and provide support without judgment. Monitor her for nonverbal signs of pain and report to the nurse; CNAs will move R28 slowly and carefully due to back pain, no sudden or twisting movements. Be careful with her arm and hands as well, they hurt her lately; Nurse will assess pain, ask resident where it is, what it feels like and have resident rate it with 0 - 10 pain scale or with descriptive words; Staff will monitor more closely for non-verbal signs of pain as resident isn't expressing her pain verbally as in the past. She may moan or cry out when moved. She may say OW!; Give scheduled and PRN (as needed) medications as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's Pain Assessment, dated 9/21/21, documents, R28 complains of pain 'all over' and 'all the time'. This time, she mentioned her back (states it is broken in 6 places.) The pain does not keep her up at night, but sometimes limits her activity. R28 did her own ROM (Range of Motion) and was cooperative. She has discomfort in her hands and shoulders all of which are somewhat stiff. She has contracted fingers on both hands and shoulders are limited in flexion as well. Her lower extremities are in normal limits. She doesn't understand the 1-10 pain scale as she will be completely calm and report 10 level pain. Her discomfort is felt to be mid-moderate at most, maybe sometimes more. She said today her pain varies from mild to moderate amount to her back. R28's MAR (Medication Administration Records) dated 1/22 & 2/22, document that R28 is receiving scheduled [MEDICATION(S)] four times a day, however, there is no documentation of pain level when administered or following the dose to monitor the effectiveness. On 02/16/22 at 12:05 PM, V2 (Director of Nursing) stated that there is no formal pain assessment daily or on a regular basis when a resident is on scheduled pain medication. On 02/16/22 at 12:23 PM, V4 (Registered Nurse) stated, No pain rating is required when administering scheduled pain medication. On 2/17/22 at 1:00 p.m., V2 stated, The nurses are not charting the effectiveness of (R28's) pain medication. When the pain medication is administered to her four times a day our MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She is confused at times and will say different things about her pain, but we should be assessing the nonverbal signs as well. We should be assessing her pain at least once a shift. Right now, all we have is her quarterly pain assessments, and her last one did mention having severe pain at times.

Based on interview and record review, the facility failed to prevent resident to resident abuse for one resident (R1) of three residents reviewed for abuse. Findings include: Facility Abuse Prevention Policy (undated) documents: Resident to resident abuse incidents will be immediately assessed to determine the plan of intervention. A resident who has a decision making ability and knowledge of his actions, will be acknowledged as a perpetrator. Physical Abuse includes hitting, slapping, pinching and kicking. Facility Incident Report dated 7/3/21 documents V6, Dietary Aide witnessed R3 shake R1's wheelchair from behind then slap R1 across the face for being loud. This report indicates V6 immediately separated R1 and R3 and notified nursing. R1 was assessed, vital signs stable and slight redness to left side of face. R1 unable to provide an account of what happened due to level of cognition. POA (Power of Attorney) and Physician notified. Incident Report indicates the reason for Reporting to the State Agency is Physical Abuse. On 7/9/21 at 3:15pm V3, ADON (Assistant Director of Nursing)/Abuse Coordinator stated R3 physically slapped R1 because he was being loud. Progress Note dated 7/3/21 at 6:31pm indicates kitchen staff reported to this nurse at 4:32pm that at 4:30pm in the dining room R3 hit another, R1 ,on the face once with his right hand after shaking (R1's) chair. Staff stated they were immediately separated. This nurse immediately went to dining room and R3 was brought back to room to assess. No redness or swelling observed on right hand, (R3) denied pain. This nurse asked (R3) what happened. (R3) stated I got mad. I was trying to tell (R1) he was doing something he shouldn't be doing. This nurse stated What? Being loud? (R3) stated Yes, so I hit (R1) but not very hard. This nurse did educate resident that residents do not hit other residents and (R3) replied It wasn't very hard. On 7/9/21 V7, SSD (Social Service Director) stated neither R1 nor R3 had ever been in any type of altercation in the past. V7 stated that R1 is very vocal at times. V7 stated that there was no change in R1's behavior after the altercation. V7 stated that R3 is fairly new to the facility (admitted [DATE]) and has not had any behavior issues. V7 stated R1 and R3 do not sit near each other in the dining room and are not to be left alone together when in the dining room.

Based on observation, interview and record review, the facility failed to keep a resident's bed away from a heat source and monitor heat surface temperatures to prevent injury for one of three residents (R1) reviewed for supervision in the sample of three. This failure resulted in R1 receiving a burn with blisters to the right knee and requiring medical attention. Findings include: According to the American Burn Association severity determination, dated 5/2017 (ameriburn.org), a Second degree (partial thickness) burn, skin may be red, blistered, swollen. Very painful. R1's Minimum Data Set assessment (MDS), dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) score is a three, indicating R1's cognitive status is severely impaired. This MDS also documents R1's bed mobility requires extensive physical assistance of one person. R1's current care plan, dated 2/23/21, documents Mobility/Transfers: (R1) is in failing health, she likes to spend most of her time in bed. This same care plan documents an intervention, dated 2/17/21, to Assist (R1) with all bed mobility as needed, since she is getting more and more weak, even if it's just stand by assist. Encourage (R1) to reposition in bed regularly since she is there about the entire day. (R1) has thin skin and her skin could breakdown easily. R1's nursing progress notes, dated 2/18/21 at 3:15 AM, document Upon bed check at 3:00 AM, V5 (Certified Nursing Assistant) observed two red marks on (R1's) right knee measuring three centimeters by less than one centimeter each. V5 stated that when entering (R1's) room, (R1's) knees were positioned in contact with the heater surface below the window sill. On 2/23/21 at 7:30 PM, V5 (Certified Nursing Assistant) stated I went in to (R1's) room about 2:30 AM because I had not seen her get up to use the restroom. When I was helping (R1) get out of bed, I felt her legs and they were hot ,so that's when I looked at (R1's) skin. I could see the impression marks from the register on her right knee and two blisters. I called the nurse in and I moved her bed away from the heater. Prior to this incident (R1's) bed was always against the heater. If staff needed to be on both sides of (R1's) bed, you would not be able to access that side without physically moving her bed. When this happened, I felt the heater with my hand and it was hot to touch. I wouldn't want my skin touching it for sure. R1's Physician order [REDACTED]. On 2/23/21 at 12:00 PM, R1 was lying in her bed in her room. V6 (Assistant Director of Nursing) peeled back R1's right knee dressing to reveal a clustered reddened area approximately nickel sized with a smaller tan-yellow area in the center. On 2/23/21 at 12:15 PM, V7 (R1's Physician) stated I came in to see (R1) the day after the incident, on Friday. We felt the radiator (wall heat). It was very hot. I wouldn't want to keep my hand on it for any period of time. Very hot to touch. (R1) initially had a blister on the site but it had released by the time I saw her and just contained the reddened area. The wall heat was very hot when this happened. On 2/23/21 at 12:30 PM, V3 (Maintenance Director) stated I do not have a log of broiler temps or resident room surface temperatures for the heaters. I don't have anything in place currently to check surface temperatures. Each room could have a different surface temperature, depending on what the heat in the room is set at as well as the outside temperature. On 2/23/21 at 12:40 PM, V2 (Director of Nursing) stated I am not sure why (R1's) bed was so close to the wall and heater. No explanation for why it was so close.