Every finding on record at Hitz Memorial Home

Based on interview and record review, the facility failed to ensure that a thorough investigation was conducted for an injury of unknown source regarding a resident who presented with unexplained bruising in 1 (R2) of 5 residents reviewed for abuse in a sample of 6.Finding include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia, Hypertension, Major Depressive Disorder, Generalized Anxiety Disorder, and Mild Cognitive Impairment.R2's Minimum Data Set, dated [DATE] documents R2 is rarely/never understood, is dependent on staff for toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, rolling left and right, chair/bed to chair transfers, and is always incontinent of bladder and bowel.R2's Care Plan Date Initiated 2/23/2024 documents R2 is at risk for impaired skin integrity related to (r/t) decreased mobility, incontinence, dementia, anemia, osteoporosis, osteoarthritis. Intervention Date Initiated 2/23/2024 documents I get my skin checked weekly and as needed. Report any abnormalities to my Primary Care Provider (PCP). Intervention Date Initiated 3/8/26 documents Please do not use my arms or legs to turn and reposition me in bed. I have very fragile skin. I bruise easily.R2's Health Status Note dated 8/16/25 at 3:10 PM documents Resident has several bruises which were noted and measured. Sister and brother-in-law were here with her visiting this morning. She has a purplish bruise to her Left forearm measuring 3.0cm X 3.0cm. She has a bruise to right inner forearm measuring 3.5cm X 3.0cm. She has a bruise to outer Left shin measuring 2.6cm X 3.0cm. When resident was asked if the bruises hurt she shook her head no.On 7/23/26 at 2:00 PM V12, Registered Nurse (RN) stated she is unsure how R2 obtained the bruising she documented on 8/16/2025. V12 stated if she thought R2 was abused by someone or if someone caused bruising to R2, she would have report it to V1, Administrator. V12 denied knowing if she reported the bruising to V1 or filed an incident report.On 7/23/26 at 3:21 PM V1, Administrator, stated she is unaware of any bruising noted to R2 during August 2025 and does not have an incident report regarding the bruises. V1 stated staff are expected to fill out an incident report when a resident is noticed to have any bruising, and the bruising will be investigated.On 7/23/26 at V2, Business Office Manager (BOM)/Administrative Assistant, stated she was not informed of any bruising to R2 from around the time of August 2025, and she does not have an incident report regarding it.On 7/23/26 at 9:33 PM V17, Licensed Practical Nurse (LPN), stated if bruising is noted to a resident, an incident report is made.On 7/24/26 at 9:34 AM V21, LPN, stated if she notices any bruising to a resident, she would chart it, report it to the Administrator, Medical Director, and the resident's family member, fill out an incident report, and monitor the resident.On 7/24/26 at 9:28 AM V6, LPN, stated if she notices bruising to a resident, she will document the bruising, try to determine the cause, fill out an incident report, notify the administrator, family member, and the medical director.The Facility's Undated Abuse, Neglect, and Exploitation Policy and Procedure documents It is the policy of [NAME] Memorial Home that each resident will be free from Abuse. Identification: all staff receive education about how to identify signs and symptoms of abuse. Resident will be monitored for possible signs of abuse. Symptoms that will be monitored: a. Suspicious or unexplained bruising, b. Unnecessary fear, c. Abnormal discharge from body orifices, d. Inconsistent details by staff regarding how incidents occurred, e. Unusual behavior towards other staff, residents, family members, or visitors. Investigation: it is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated.

Based on observation, interview, and record review, the facility failed to conduct thorough investigations for allegations of sexual abuse and failed to protect a resident during active investigations for 1 (R42) of 1 resident reviewed for abuse in the sample of 26. This failure resulted in R42 being vulnerable with no protective measures from future potential abuse implemented. R42 subsequently was subjected to additional abuse allegations, by V17 (family member) on 1/2/25, 7/17/25 and 2 not dated allegations from December 2025. A reasonable person would expect to be free of abuse, and protected from further allegations of abuse. Following these circumstances, a reasonable person would potentially experience severe psychological harm with feeling shame, guilt, anger, and embarrassment. Findings include:The Immediate Jeopardy began on 1/2/2025 when V15, Certified Nursing Assistant, CNA, reported an allegation of sexual abuse involving R42. No protective measures were implemented to ensure R42 remained free of abuse following the allegation, subsequently allowing another sexual abuse allegation to occur on 7/17/2025 and 2 more reported allegations in 12/2025 that were not investigated. V1, Administrator, and V28, Business Office Manager, BOM, were notified of the Immediate Jeopardy on 3/10/2026 at 3:55 PM. The surveyor confirmed by observation, interview, and record review, that the immediacy was removed on 3/11/2026, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service training. R42's face sheet documents an admission date of 2/19/2024. Diagnosis include: Hypertension with Heart Failure, Dementia, Narcolepsy, Chronic Respiratory Failure, Primary Osteoarthritis.R42's Minimum Data Set, MDS, dated [DATE] documents R42 is severely cognitively impaired.R42's hospital records dated 3/5/2026 at 3:10PM stated V39 (family member) stated R42 has always been mentally slow, and she does not like to be touched.On 3/3/2026 at 8:00AM V1, Administrator was informed that a sexual abuse allegation was made to the Illinois Department of Public Health (IDPH). V1 stated she was not aware of any sexual abuse allegations in the facility currently. V1 provided sexual abuse investigations dated 1/2/2025 and 7/17/2025 both regarding R42.On 3/5/26 at 9:46 AM, V14, Police Officer, stated one of the staff he interviewed stated they saw V17 (family member) drop [NAME] and had his penis in R42's face. V14 continued by saying, at this point the facility just needs to take action and remove V17 from the facility and find a new Power of Attorney, POA.R42's sexual abuse allegation dated 1-2-2025 states at 2:20pm, V15, Certified Nursing Assistant, CNA, reported an encounter that made her uncomfortable with R42 and V17 to V27, Social Services Director. V27 immediately came to V1, Administrator, to report this. V1 called V15 to her office to investigate what had happened. V15 reports that she walked into R42's room without knocking to check on R42. The door was shut and V15 did not knock before entering. V15 reports that V17 makes her feel uncomfortable when V15 walks in the room. V15 reports walking in the room and V17 moving his hands from the R42's lap area quickly. V15 reports going back into the room a second time without knocking again and the same thing occurring. V15 reports that she did not see V17 touching R42 inappropriately. V15 reports the encounter just made her feel uncomfortable. Spoke to V17 to inform him of statement made by V15. He says V15 came into the room to check on R42 without knocking and it startled him. He was holding her computer so she could play solitaire so yes when v15 came in the door V17 moved his hands away because he was startled. V17 reports that he would never do anything to harm R42 and has never touched her inappropriately. He reports that R42 has always been not fond of being touched by anyone. He says that if it makes the staff member more comfortable, he will visit with the door open. V17 and V39 close the door for privacy. It is the determination of the investigation conducted by V1 and V27 that no sexual abuse or abuse of any kind occurred involving V17.According to V15's written statement dated 1/2/2025, she entered R42's room during report and observed V17 quickly moving his hands away from the resident's stomach/lap area. Later, while obtaining vital signs, V15 again observed V17 moving his hands from the same area, at which time R42 reportedly had her hand near the waistband of her pants. V15 reported these observations to V1.On 3/6/2026 at 7:33 AM, V1 and V28 confirmed that the investigation dated 1/2/2025 represents the complete investigation. Review of the investigation includes no acknowledgement a computer to have been in use versus V15's written statement account, no interventions implemented to safeguard R42 during the sexual abuse allegation investigation or identify R42's vulnerability and risk for future allegations.On 3/5/2026 at 1:50 PM, V15 stated that while working at the facility in January 2025, she was caring for R42. After assisting with changing R42's shirt, V15 returned to the room and observed R42 seated in her wheelchair facing the window, with V17 seated very close beside her. V15 observed V17's hand in the resident's lap/stomach area and noted that R42's shirt was lifted, exposing her breast. V15 stated R42 would not have been able to expose herself. When V15 attempted to adjust the resident's clothing, V17 quickly intervened and then began moving about in a hurried manner. V15 reported the incident to V1 and spoke with law enforcement, noting that V17's behavior caused concern.The facility investigation on 1/2/2025 did not contain information that R42's breast was exposed and V17 adjusted R42's shirt. No other statements for the 1/2/2025 investigation were provided.The investigation dated 7/17/2025 into alleged abuse involving R42 and V17 was initiated after two staff members reported potentially inappropriate behavior. V16, CNA, observed V17 standing over R42 and reacting abruptly when staff entered the room, by quickly moving away and requesting privacy. A second observation with V24 noted similar behavior, with V17 positioned close to R42's wheelchair and again reacting suddenly when staff entered. However, neither staff member witnessed any inappropriate physical contact. V24's, Dietary Aid, written statement states I, V24, was taking R42's vitals. I came to R42's room. When I walked in V17, I had his hands under R42's blanket. V17 jumped and stood up and said, 'Sorry I didn't know anybody knocked.'On 3/5/26 at 11:30 AM, V16 stated she did write the statement from 7/17/25. V16 stated when she went to room V17 had his chair pushed up almost touching R42's wheelchair. Her wheelchair was laid about halfway back. V17 was sitting in the chair and from the waist up he was over the top of her. Could not tell exactly which parts of him were touching which parts of her but she could not see his hands. It was just weird. V16 reported it to her nurse. Later that day V24 was taking dietary orders and I told her I would go with her because I kind of wanted to see what was happening in the room and he jumped up fast, it was just weird. V16 stated at baseline R42 is calm and nice and typically doesn't get upset or cry. When V17 visited it seemed like R42 didn't want to get touched. I noticed she cried after V17 left. When I first started working here, I was told I needed to watch V17 because R42 can't speak for herself. I can't remember who told me that or why.On 3/5/26 at 11:55 AM, V24, Dietary Aid, stated she went in to take R42's food order in July and R42 was in her wheelchair and V17 was sitting beside her with his arm under the blanket. V17 jumped up fast causing the pillow to fall to the ground. The pillow was on R42's lap propping up her computer. V24 reported this to V28. When V17 comes in he puts a sign on the door, one sign says do not disturb and the other says family is in, please knock. The signs started going up after this incident happened in July. V39 rarely visits. R42 can tell me her favorite color some days, other days just smiles and waves, some days she is not able to even obtain R42's meal order. The day of the incident R42 looked shocked with her eyes wide and seemed jumpy too.The investigation dated 7/17/2025 regarding R42 did not mention V16's allegation of V17 sitting very close to R42 and V16 being unable to see V17's hands upon entering R42's room or V24's allegation that V17's arm was under R42's blanket.On 3/6/2026 at 7:33AM V1 and V28 stated the investigations dated 7/17/2025 is the full investigation.On 3/3/2026 at 11:00AM Surveyor entered R42's room. R42 sitting up in chair with V17 and V39. V39 stated R42 does not speak. Surveyor noted video camera in R42's room and sign on door stating please knock family visit.On 3/5/2026 at 8:30AM V17 was observed to be entering facility alone. At 9:00AM V17 noted to be leaving facility.On 3/5/2026 at 9:00AM V1 stated I did not begin the sexual abuse investigation when you told me on 3/3/2026 since I did not know who it was about. On 3/5/2026 at 10:15AM V10, CNA, stated in December of 2025 I went into R42's room to get a mechanical lift. When I went into the room I saw V17 standing next to the bed with 1 leg on a chair and R42's shirt was pushed up below her breasts. V17 was dressed. V17 was very rude and said they were playing cards, R42 didn't need anything, and I didn't need to be in there. Then he started yelling out card numbers. The room was silent before I entered. I told V1 and she asked me to write a statement. I wrote a statement and left it at the nurse's desk. I don't know if V1 got it.On 3/6/2026 at 2:00PM V1 stated V10 said he wrote a statement of what he saw in R42's room but I never got the written statement.On 3/5/2026 at 11:30AM V25, CNA, stated in December 2025 V10 told me he went in R42's room and V17 was in room alone with R42. V17 had his leg up on a chair and R42's shirt was pushed up under her breasts. V10 reported it. I didn't report it since V10 did.On 3/5/2026 at 1:00PM V1 stated in December 2025 V10 told us about seeing V17 having his leg on a chair and R42's shirt being pushed up. V17 was here at the time, and we went and talked to him. R42's room is under video surveillance. It is V17's video camera. When we went in room V17 replayed the video for us. V27 and V28, Business Office Manager, BOM, both watched the video and saw nothing out of the ordinary. I did not investigate because we watched the video and talked to V17. The video was watched on V17's cell phone and no confirmation of date and time or if video had been edited. No formal investigation was initiated.On 3/5/2026 at 1:05PM V28 stated I watched the video in December when V10 made an allegation of V17 being inappropriate with R42. V10 said V17 had his leg up on a chair and that R42's shirt was pushed up under her breasts. V17 was here at the time. V17 denied anything and replayed the video for us. It is V17's video footage. The video did not show anything inappropriate. We did not see V17's leg up or R42's shirt pushed up.On 3/10/2026 at 12:00PM V38 (CNA) stated I am not sure of the date, but I want to say it was back in December 2025. I went in R42's room and V17 had his leg up on R42's wheelchair and his pant leg was up to his hip. He had on nylon shorts I remember that. When I came in the room V17 jumped back and his pant leg went down. He was very anxious. It was time for R42 to go to lunch. I reported this incident to V28. I had heard rumors of R42's breast being out and V17 being inappropriate. I used to notice when V17's wife was with him he wore pants but when he came in by himself, he would wear gym shorts.On 3/10/2026 at 2:00PM V1 stated V10 told V28 and V1 that V17 was in R42's room and had leg on chair and jumped back when V10 entered without knocking. V10 did not report that any body parts were exposed. V17 was still in facility when V10 made the allegation. V17 came into V1's office. There is a camera in R42's room that is the family's camera. The camera footage did not show anything inappropriate. V17 said V10 startled him. We did not tell V17 to leave, and we did not investigate because the camera footage did not show anything wrong. V10 said he wrote a statement of what he saw in R42's room but I never got the written statement.On 3/10/2026 at 2:20PM V28 stated in December 2025 V10 came in and told V1 and I that he saw V17 with his leg up on a chair holding R42's computer. V17 jumped back when V10 came into R42's room. V17 and R42 were both clothed. V10 wanted to share what he had seen. V17 is 'different.' He gets close when he talks. V10 said he wrote a statement, but it was never given to us. V17 said he was just startled when V10 came in without knocking. V17 showed us the video, and we saw nothing inappropriate. We did not investigate because we did not think anything happened. The video was viewed without confirming date, time, and was viewed on V17's personal cell phone.On 3/10/2026 at 1:00PM V35 (Medical Director) stated R42 is unable to consent to any type of sexual advancement and in a normal person psychological harm of Posttraumatic Stress Disorder, PTSD, or anxiety could occur and it is really unknow the impact long term of psychological harm but had the Potential for serious harm.R42's care plan updated 2/23/2026 documents R42 has a self-care deficit related to weakness, dementia, hypertensive heart disease with heart failure, osteoporosis, osteoarthritis. No potential for abuse and/or interventions to keep R42 safe is included in R42's care plan. On 3/6/2026 at 9:55AM V1 and V28 brought in forms to surveyor and stated We are making a checklist, so this situation never happens again. We are talking to all our staff, and they will sign that they have read and understand how to report any abuse. Anyone can call the police and report this. V28 and I are both the abuse coordinators and staff are to come to us.Facility's undated abuse policy states It is the policy of [NAME] Memorial Home to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility does not discriminate in providing services on account of membership in any protected class, including, without limitation, race, color, creed, religion, national origin, sex, disability, or sexual orientation. A board member, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations state all employees are required, to any reasonable suspicion of a crime committed against a resident, to call 911 or [NAME] Co. Sheriff.Facility remains out of compliance at level 2.Abatement Plan for F610- Investigate/Prevent/Correct Alleged ViolationFacility failed to ensure R42 was free from abuse.The facility has ensured R42s safety by issuing a visitor restriction notice to V17 on 3-5-26 by Social Services Director. Abuse Coordinating Team called C39 to inform her of the restriction moving to indefinitely and the reasoning of these findings on 3/10/26. The letter was mailed on 3/11/26 as well as emailed to V17 and V39 on 3/10/26. Email returned with acknowledgement of receipt on 3/10/26. They were told that this was done to keep our residents, staff, and visitors safe. V17 was informed that this is in effect indefinitely and related to safety concerns regarding incidents from January 2, 2025, July 17, 2025, and two unknown dates from December of 2025. The facility (Administrator) ordered a camera system on to go in our public areas such as the hallways on 3/7/26. The purpose is to aid in staff and resident safety and to monitor visitors in the building. All residents could be affected by abuse. R42 is located at the end of the hallway so this can help monitor visitors to R42 and all residents. Nursing will round at the end of every shift to verify resident has remained free of abuse entered by administrator on 3/10/26. The Social Services Director initiated visits with resident 2x/weekly to monitor for psychosocial changes on 3/10/26. All residents were interviewed and report feeling safe and free of abuse and neglect on 3/6/26 by Social Services Director and Business Office Manager. Administration to round on every shift on 3/11/26 to monitor activites. Sexual abuse care plan has been initiated for R42 by administrator on 3/10/26. Dr. [NAME] updated on 3/10/26 and 3/11/26. R42 remains in the facility as of 3/11/26.2. Facility failed to ensure a thorough investigation for 4 allegations of sexual abuse on 1/2/25, 7/17/25, and 2 unknown dates in December.Facility initiated an Abuse Checklist to ensure compliance and document all required steps with abuse reporting on 3/6/26. All staff have been in-serviced on the checklist by the Social Services Director, ADON, Infection Preventionist, Business Office Manager on 3/6/26 and 3/7/26. All investigations will be a team effort (more than one Abuse Coordinator) to ensure accuracy and complete investigation every single time an allegation is received moving forward.3. Facility failed to ensure a system in place for thoroughly investigating alleged abuse allegations.All residents report feeling safe and free from abuse as interviewed by the Business Office Manager and Social Services Director on 3/6/26. Abuse Checklist is in place to ensure all required notifications and items are available for the investigation as of 3/6/26. The Abuse Coordinators will then use all received documentation including statements to perform a thorough investigation which includes resident assessments, interviews, etc.4. Facility failed to ensure staff are educated and knowledgeable of identification, reporting, and investigation of abuse policy.All-staff have been re-inserviced on facility Abuse and Neglect Policy on 3/6/26. Abuse Coordinators to conducted 10 random competency checks on 3/10/26. New Abuse Checklist is now part of new staff on-boarding.5. Facility failed to ensure ongoing monitoring compliance.QAPI members to hold monthly QAPI meeting on 3/11/26 to discuss abuse investigations, staff compliance, and staff understanding of facility policy.

Based on observation, interview, and record review, the Facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 43 residents living in the Facility.Findings include: On 3/3/26 at 7:58 AM, the standing refrigerator held three containers of an orange gelatinous substance labeled with R28's last name. The containers were not dated or labeled with the contents inside. V6, Cook, looked at a form labeled Audit: Food/Beverages Brought into the Facility and stated the containers were R28's orange tapioca gelatin and were placed in the refrigerator on 2/22/26. There was also a clear plastic cup containing brown liquid from a retail coffee establishment that was not labeled or dated. The Facility's Audit: Food/Beverages Brought into the Facility documents R28's gelatin was prepared on 2/22/26. On 3/3/26 at 8:00 AM, in the walk-in refrigerator, there was a container labeled beef broth and dated 2/20/26. On 3/3/26 at 8:25 AM, V5, Dietary Manager, stated foods are thrown out three days after preparation. V5 stated she has talked to R28 about throwing the tapioca out, but R28 is often resistant to throwing out food, stating it is still fine for her to eat. On 3/3/26 at 3:58 PM, the front of the refrigerator in the kitchenette next to the lobby had a posting which read, Attention Staff Anything in refrigerator has to have Name and Date on it or it will be thrown out. This pertains to all items, Staff and Residents. The refrigerator contained a bowl of salad covered with plastic wrap that was not labeled or dated. The freezer above contained a bag of taquitos that had been opened, but were not resealed, leaving the contents open to air, and were not labeled or dated. On 3/5/26 at 1:50 PM, V1, Administrator, stated she would expect staff to follow Facility policies regarding food storage and labeling. The Facility's Undated (Facility) Policy on Food Storage in Resident Rooms documents, It is the Policy of [NAME] Home that all food items brought in to the facility from outside must be kept in an air tight container. Any food items left out will be removed from the room. Any perishable foods will be kept in the kitchen refrigerator with name date and food identified on label. These foods will only be kept for two days related to possible risk factors. The Facility's Undated (Facility) Food Safety Requirements Policy documents, It is the policy of (Facility) to provide safe and sanitary storage, handling, and consumption of all foods. This includes food and fluids brought in by family and other visitors. All food items brought into the facility from outside must be kept in an airtight container, with a label of contents, and the date it was put into the refrigerator or freezer is perishable. Any food items not in containers and properly labeled will be removed from the room and thrown away. These foods will only be kept for two days related to possible risk factors. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/26 documents there are 43 residents living in the Facility.

Based on interview and record review, the Facility failed to monitor infection trends and follow infection control procedures in the Facility. This has the potential to affect all 43 residents living in the Facility.Findings include: 1-The Facility's Infection Control Log does not list a causative organism for R2's 8/29/25 UTI (Urinary Tract Infection). The Facility's Infection Control Log does not list a causative organism for R39's 10/29/25 UTI. The Facility's Infection Control Log does not list a causative organism for R6's 11/7/25 UTI. The Facility's Infection Control Log does not list a causative organism for R27's 11/10/25 UTI. On 3/4/26 at 2:51 PM, V1, Administrator, stated R39 was sent home from the hospital to the facility on oral antibiotics, but no urine culture was obtained for R39 during hospitalization. On 3/5/26 at 2:00 PM, V3, Infection Preventionist, stated she tries to put the causative organisms for infections on the Infection Control Log, but there are some missing. Sometimes antibiotics are ordered for residents when no culture has been obtained to determine the organism causing the infection. V3 has not been monitoring the log for infection trends. On 3/5/26 at 4:00 PM, V1 stated she expects the Facility to follow its infection control policy. 2. R3's Undated Face Sheet documents R3 was admitted to the facility on [DATE] and has a medical diagnosis of Functional Urinary Incontinence, Specified Disorders of Kidney and Ureter, and Fistula of Vagina to Large Intestine. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact, is dependent on staff for toileting hygiene, and has an indwelling catheter. R3's Undated Care Plan documents R3 is at risk for impaired elimination related to colostomy placement related to fistula, foley catheter. Undated interventions document R3 needs total assistance with catheter care every shift and as needed (prn). R3's Physician Order dated 12/29/2025 at 7:20 PM documents Enhanced Barrier Precautions related to catheter every shift. R3's Physician Order dated 12/29/2025 at 7:20 PM documents Cath care every shift and as needed. On 3/6/2026 at 12:58 PM catheter care performed by V11, Certified Nursing Assistant, (CNA), and V37, CNA. V11 and V37 did not put on a gown before entering R3's room or before performing catheter care. V11 emptied R3's foley catheter and stated she needed to dispose of R3's urine in another room because R3 has biohazard urine. Sign on R3's door documents Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. On 3/10/2025 at 10:35 AM V3, Infection Preventionist/Assistant Director of Nursing, stated when a resident is on Enhanced Barrier Precautions there will be a sign on the resident's door stating what should be worn when providing care including a gown and gloves. V3 stated if a resident is receiving catheter care and is on Enhanced Barrier Precautions, staff are expected to wear a gown and gloves when providing care. The Facility's Infection Prevention and Control Program Policy reviewed 2/11/26 documents the Infection Prevention and Control Program is a system of surveillance designed to identify possible communicable disease or infections before it can spread to other people in the facility, ensure standard and transmission-based precautions are followed to prevent spread of infections, and monitor infection trends and patterns. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/26 documents there are 43 residents living in the Facility.

Based on interview and record review, the Facility failed to follow its antibiotic stewardship policy to help prevent antibiotic resistance for 4 of 4 residents (R6, R16, R18, R39) reviewed for infection control in the sample of 26. Findings include: 1-The Facility's October 2025 Infection Control Log does not document a causative organism for R39's 10/29/25 UTI (Urinary Tract Infection). R39's Order Summary Report documents the order Cephalexin 500 milligram (mg) oral capsule, give one capsule by mouth twice per day related to unspecified abnormal findings in urine for ten administrations. R39's Medication Administration Records (MARs) for October and November 2025 document R39 received ten doses of Cephalexin. On 3/4/26 at 2:00 PM, V1, Administrator, stated R39 came back from the hospital on oral antibiotics, but no urine culture was completed to justify the use of the antibiotic Cephalexin. On 3/5/26 at 4:00 PM, V1 stated she expects the Facility to follow its infection control policy. 2.R16's Undated Face Sheet documents R16 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia, Type 2 Diabetes Mellitus, Personal History of Urinary (Tract) Infections, Female Intestinal-Genital Tract Fistulae, and Encounter for Prophylactic Measures. R16's Minimum Data Set (MDS) dated [DATE] documents R16 is severely cognitively impaired, needs substantial/maximal assistance with toileting hygiene, and is always incontinent of urine. R16's Undated Care Plan documents R16 is on long-term antibiotics related to history of Urinary Tract Infections (UTI's) and vaginal fistula. Undated Interventions document R16 alternates Keflex, Macrobid, and Bactrim every 3 months. Undated R16's Physician Order dated 11/12/2025 at 8:23 AM documents Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth in the afternoon related to Encounter for Prophylactic Measures for 90 administrations. R16's Physician Order dated 11/24/2025 at 7:12 AM documents Lactobacillus Oral Tablet (Lactobacillus) Give 1 tablet by mouth one time a day for Daily long term antibiotic use related to Encounter for Prophylactic Measures. R16's Physician Order dated 3/4/2026 at 10:38 AM documents Cephalexin Tablet 500 MG Give 1 tablet by mouth in the morning related to Encounter for Prophylactic Measure for 90 Administrations. R16's December 2025 Medication Administration Record (MAR) to March 2026 MAR reviewed and R16 received Bactrim DS as scheduled. On 3/3/2026 at 12:22 PM V36, R16's family member, stated R16 is on antibiotics for recurrent UTI's. 3.R18's Undated Face Sheet documents R18 was admitted to the facility on [DATE] and has a medical diagnosis of Personal History of Urinary (Tract) Infections and Encounter for Prophylactic Measures. R18's MDS dated [DATE] documents R18 is cognitively intact, is dependent on staff for toileting hygiene, and is frequently incontinent of urine. R18's Undated Care Plan documents R18 is on long-term antibiotics related to UTI prevention. Undated Interventions document R18 is currently taking Keflex prophylactically. R18's Physician Order dated 11/26/2024 at 11:38 PM documents Cephalexin Oral Tablet 250 mg Give 1 tablet by mouth at bedtime for UTI prevention. R18's January 2025 Medication Administration Record (MAR) to March 2026 MAR reviewed and R18 received Cephalexin as scheduled. On 3/10/2026 at 8:40 AM R18 stated she was not on any antibiotics for urinary tract infections before coming into the facility and the doctor in the facility put her on it and told her that she will more than likely me on the antibiotic for the rest of her life. 4. R6's Face sheet documents an admission date of 2/10/2026 with a diagnosis of Parkinson's Disease, Urinary Tract Infections, and Osteoarthritis. R6's order sheet dated 2/10/2026 documents Azithromycin Oral Tablet 250 MG (Azithromycin) Give 1 tablet by mouth one time a day every Monday, Wednesday, Friday related to personal history urinary tract infection. R6's Medication Administration Sheets, MARS, dated 2/1/2026-2/28/2026 documents Azithromycin Oral Tablet 250 MG (Azithromycin) Give 1 tablet by mouth one time a day every Mon, Wed, Fri related to personal history urinary tract infection. Doses administered are documented as 2/11/2026, 2/13/2026, 2/16/2026, 2/18/2026, 2/20/2026, 2/23/2026, 2/25/2026, 2/27/2026. R6's Medication Administration Sheets, MARS, dated 3/1/2026-3/31/2026 documents Azithromycin Oral Tablet 250 MG (Azithromycin) Give 1 tablet by mouth one time a day every Mon, Wed, Fri related to personal history urinary tract infection. Doses administered are documented as 3/2/2026, 3/4/2026, 3/6/2026. Facility's Infection Control log does not document a causative organism for R6 or document R6 is prescribed Azithromycin. On 3/6/2026 at 10:30AM V3, Infection Preventionist stated R6 admitted with the Azithromycin, and we continued it. She is a hospice resident, so they take over the orders. We do not do any urinalysis or cultures. We just continue the antibiotic. R16's Face sheet documents admission date of 8/22/2023. Diagnosis includes heart failure, osteoarthritis, and urinary tract infections. R16's order sheet dated 11/26/2024 documents Cephalexin Oral Tablet 250 MG (Cephalexin). Give 1 tablet by mouth at bedtime for UTI prevention. On 3/6/2026 at 10:20AM V3, Infection Control Preventionist, ICPC, stated If a resident is ordered an antibiotic prophylactically, we continue that order. We do not do extra urinalysis or cultures. We just continue the orders. On 3/9/2026 at 7:15AM V35, Medical Director, I don't usually prescribe antibiotics prophylactically so that order was probably written by R6's urologist. I would have to investigate it. Facility's Antibiotic Stewardship policy dated 8/18/2018 states Long term care facilities must develop an Infection Prevention and Control Program that includes an Antibiotic Stewardship Program and designate at least one Infection Preventionist. Antibiotic stewardship programs should include protocols and systems for monitoring antibiotic use. The Antibiotic Stewardship Committee will support and promote protocols which include assessment of residents for infection using standardized tools and criteria. The criteria used by this facility are adapted from the revised McGeer Criteria.

Based on interview, observation, and record review, the Facility failed to follow its abuse policy in preventing, reporting and investigating allegations of abuse for 1 of 1 resident (R42) reviewed for abuse in the sample of 26. Findings include:R42's face sheet documents an admission date of 2/19/2024. Diagnosis includes Hypertension with Heart Failure, Dementia, Narcolepsy, Chronic Respiratory Failure, Primary Osteoarthritis.R42's Minimum Data Set, MDS, dated [DATE] documents R42 is severely cognitively impaired.R42's care plan updated 2/23/2026 documents R42 has a self-care deficit related to weakness, dementia, hypertensive heart disease with heart failure, osteoporosis, osteoarthritis. R42's hospital records dated 3/5/2026 at 3:10PM stated V39 (family member) stated R42 has always been mentally slow, and she does not like to be touched.On 3/3/2026 at 8:00AM V1, Administrator was informed that a sexual abuse allegation was made to Illinois Department of Public Health (IDPH). V1 stated she was not aware of any sexual abuse allegations in the facility currently. V1 provided sexual abuse investigations dated 1/2/2025 and 7/17/2025.On 3/3/2026 at 11:00AM, Surveyor entered R42's room. R42 sitting up in chair with V17 (family member) and V39, Power of Attorney, POA. V39 stated R42 does not speak. Surveyor noted video camera in R42's room and sign on door stating please knock family visit.On 3/5/2026 at 8:30AM V17 (family member) noted to be entering facility alone. At 9:00AM V17 noted to be leaving facility.R42's sexual abuse allegation dated 1-2-2025 states at 2:20pm, V15, Certified Nursing Assistant, CNA, reported an encounter that made her uncomfortable with R42 and V17(Family Member of R42) to V27, Social Services Director. V27 immediately came to V1, Administrator, to report this. V1 called V15 to her office to investigate what had happened. V15 reports that she walked into R42's room without knocking to check on R42. The door was shut and V15 did not knock before entering. V15 reports that V17 makes her feel uncomfortable when V15 walks in the room. V15 reports walking in the room and V17 moving his hands from the R42's lap area quickly. V15 reports going back into the room a second time without knocking again and the same thing occurring. V15 reports that she did not see V17 touching R42 inappropriately. V15 reports the encounter just made her feel uncomfortable. V1 reported incident to V8, Ombudsman, V35, Medical Director, local police and V39, Power of Attorney. POA Spoke to local Police Department who came to investigate allegation. It is the determination of the investigation conducted by V1 and V27 that no sexual abuse or abuse of any kind occurred involving V17. Relevant parties, including V44, Police Officer, V35,Medical Director, V17, Family memeber and V39 Power of Attorney, were notified that the allegation was unsubstantiated. According to V15's Certified Nursing Assistant, CNA, written statement dated 1/2/2025, she entered R42's room during report and observed V17 quickly moving his hands away from the resident's stomach/lap area. Later, while obtaining vital signs, V15 again observed V17 moving his hands from the same area, at which time R42 reportedly had her hand near the waistband of her pants. V15 reported these observations to V1.On 3/6/2026 at 7:33 AM, V1, Administrator and V28 Business Office Manager (BOM), confirmed that the investigation dated 1/2/2025 represents the complete investigation.R42's abuse investigation dated 7/17/2025 documents two staff members reported possible inappropriate behavior between R42 and her V17. V16, Certified Nursing Assistant, CNA, reports that when she went into R42's room to obtain vitals V17 was standing over R42 and jumped up when V16 entered and grabbed the electronic device. V17 then told V16 to come back later because they were busy. V16 and V24 returned to room, and they reported that V17 was standing over R42 with his hands down by her wheelchair. They reported V17 jumping when they entered the room. They did not see V17 touching R42 inappropriately. County Police Department, V28, Medical Director, V39, Power of Attorney, POA, V8, Ombudsman, and Adult Protective Services were all notified of the incident. V40, local police arrived. V40 stated they will make note of the incident but stated there was nothing they can do regarding this incident as no evidence of any abuse is noted. Adult Protective Services came out to facility. She also noted that there was nothing that they could do as there was no evidence of abuse. V39 noted that this incident is absurd. V17 stated 'Not again, I didn't do anything. We were just playing on the computer. I understand you must investigate.' Based on the statements from the staff members, this abuse is unfounded. No evidence to support abuse.On 3/5/2026 at 10:15AM V10, CNA, stated in December I went into R42's room to get a mechanical lift. When I went into the room I saw V17 (family member) standing next to the bed with 1 leg on a chair and R42's shirt was pushed up below her breasts. V17 was dressed. V17 was very rude and said they were playing cards, R42 didn't need anything, and I didn't need to be in there. Then he started yelling out cards. The room was silent before I entered. I told V1 and she asked me to write a statement. I wrote a statement and left it at the nurse's desk. I don't know if V1 got it.On 3/5/2026 at 1:00PM V1, Administrator, stated R42 went out to local hospital for a sexual assault kit. It was suggested by the police. The nurse did a head-to-toe assessment. I called V39 Power of Attorney. and she consented. V39 was very angry about it. They are looking for different placement for R42. As far as we know R42 is coming back here this afternoon. In December V10 told us about seeing V17 having his leg on a chair and R42's shirt being pushed up. V17 was here at the time, and we went and talked to him. R42's room is under video surveillance. It is V17's video. When we went in room V17 replayed the video for us. V27 and V28, Business Office Manager, BOM, both watched the video and saw nothing out of the ordinary. I did not investigate because we watched the video and talked to V17. The video was not confirmed by date or time and was viewed on V17's personal cell phone.On 3/5/2026 at 1:05PM V28 Ombudsman, stated I watched the video in December 2025 when V10 CNA made an allegation of V17 being inappropriate with R42. V10 said V17 had his leg up on a chair and that R42's shirt was pushed up under her breasts. V17 was here at the time. V17 denied anything and played the video for us. It is V17's video footage. The video did not show anything inappropriate. We did not see V17's leg up or R42's shirt pushed up.On 3/10/2026 at 12:00PM V38 CNA, stated I am not sure of the date, but I want to say it was back in December. I went in R42's room and V17 had his leg up on R42's wheelchair and his pant leg was up to his thigh. He had on nylon shorts I remember that. When I came in the room V17 jumped back and his pant leg went down. He was very anxious. It was time for R42 to go to lunch. I reported this incident to V28. I had heard rumors of R42's breast being out and V17 being inappropriate. I used to notice when V17's wife was with him he wore pants, but when he came in by himself, he would wear gym shorts.On 3/10/2026 at 2:00PM V1, Administrator stated V10, CNA, told V28 BOM, and V1 that V17, Family Member, was in R42's room and had leg on chair and jumped back when V10 entered without knocking. V10 did not report that any body parts were exposed. V17 was still in facility when V10 made the allegation. V17 came into V1's office. There is a camera in R42's room that is the family's camera. The camera footage did not show anything inappropriate. V17 said V10 startled him. We did not tell V17 to leave, and we did not investigate because the camera footage did not show anything wrong. V10 said he wrote a statement of what he saw in R42's room but I never got the written statement.On 3/10/2026 at 2:20PM V28, BOM, stated in December 2025 V10 came in and told V1 and I that he saw V17 with his leg up on a chair holding R42's computer. V17 jumped back when V10 came into R42's room. V17 and R42 were both clothed. V10 wanted to share what he had seen. V17 is 'different.' He gets close when he talks. V10 said he wrote a statement, but it was never given to us. V17 said he was just startled when V10 came in without knocking. V17 showed us the video, and we saw nothing inappropriate. We did not investigate because we did not think anything happened. The video was viewed without confirming date, time, and was viewed on V17's personal cell phone.On 3/6/2026 at 9:55AM V1 and V28 brought in forms to surveyor and stated We are making a checklist, so this situation never happens again. We are talking to all our staff, and they will sign that they have read and understand how to report any abuse. Anyone can call the police and report this. V28 and I are both the abuse coordinators and staff are to come to us.On 3/10/2026 at 1:00PM V35 (Medical Director) stated R42 is unable to consent to any type of sexual advancement and in a normal person psychological harm of Posttraumatic Stress Disorder, PTSD or anxiety could occur and it is really unknow the impact long term of psychological harm but had the Potential for serious harm.Facility's undated abuse policy states It is the policy of [NAME] Memorial Home to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility does not discriminate in providing services on account of membership in any protected class, including, without limitation, race, color, creed, religion, national origin, sex, disability, or sexual orientation. A board member, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations state all employees are required, to any reasonable suspicion of a crime committed against a resident, to call 911 or [NAME] Co. Sheriff.

Based on Interview and Record Review, the facility failed to hire and maintain a current and active license for a Registered Nurse (RN) and allowed that RN to work unlicensed upon hire. The Findings Include: On [DATE] at 11:50 AM, While doing the background check review, one of the facility's RNs (V4) was found to have an expired license and has been working at facility since hired on [DATE]. On [DATE] at 11:52 AM, V1, Administrator, stated I did the background checks on (V4, RN), and I never noticed that her license was expired. I just called (V4) who told me that she thought she renewed her license, but she doesn't have a receipt to prove it. (V4) was calling the Illinois Department of Financial and Professional Regulation (IDFPR) to discuss this with them and will let me know of the outcome. On [DATE] at 12:35 PM, V6, Business Office Manager, stated There are three of them who do the background checks for new employees, V1, herself, and V7, Medical Records. On [DATE] at 12:37 PM, V7 stated We run fingerprints on date of hire or before, but since it takes a while to get them back, we usually accept the acknowledgment email from state indicating they received it, and that the employee is eligible to work with nothing flagged so far. On [DATE] at 12:45 PM, V1 stated I am the one who did (V4's) background check and I printed them out, and never saw the expiration date on her RN license. (V4) has been taken off the schedule. (V4) called the state who told her they never received a check to pay for the license renewal, therefore, it was not renewed and (V4) will have to send a letter indicating what happened and the board will review the issue and get back with her. On [DATE] at 1:45 PM, V1 stated The facility is staffed with two Nurses and five CNAs for Days and Evenings, then one to one and half Nurses and three CNAs for Nights. (V4) only works on Hall-Two with rooms 14 through 36. V4 was hired on [DATE] with a IDFPR License check completed upon hire. This License check indicated that V4's RN License expired on [DATE], prior to V4 being hired by the facility. The Facility's Nursing Schedules from [DATE], through [DATE], were reviewed with V4, RN, working 35 shifts as an RN on the floor. V4 cared for R2, R3, R4, and R5 during her shifts. R2's, R3's, R4's, and R5's Medication Administration Record (MAR), dated [DATE], documents V4 administered medications to each resident on the shifts that she has worked at the facility. The Facility's Policy and Procedure Abuse and Neglect, undated, documents Employee Screening and Training: Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. Licensed Staff: The facility will not employ or otherwise engage a licensed professional who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, and exploitation, mistreatment of residents or misappropriation of resident property. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks.

Based on interview and record review, the Facility failed to prevent verbal and physical abuse and neglected to accurately assess a resident for injury prior to initiating a transfer for 1 of 2 residents (R99) reviewed for abuse/neglect in the sample of 25. This failure caused R99 to experience fear and increased anxiety and unknown potential further injury. Findings include: R99's Facesheet dated 9/11/2024 documents R99 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to; osteoporosis, anxiety and post traumatic stress disorder. R99's Progress Notes dated 7/7/2024 documents R99 was attempting to self transfer out of her recliner, in her room and fell to the floor. It further documents R99 began complaining of right hip pain. R99's Minimum Data Set (MDS) dated [DATE] documents R99 was moderately cognitively impaired and required substantial assistance for chair transfers. On 9/9/2024 at 12:56 PM, V9, Certified Nursing Assistant (CNA) stated, I was going through taking people (residents) back to their rooms. I heard screaming and plates breaking. I saw (R99) on the floor and her recliner was tipped up. I said 'hold still, don't move'. The nurse (V5, Licensed Practical Nurse, LPN) came and automatically was like, 'I'm tired of your s**t. If you don't like it, you can go home'. He didn't evaluate her before he mistransferred (incorrectly transferred) her, instead of checking her, grabbed her up by the arms and put her back in her chair. He then walked out of the room. She (R99) wanted to call the cops. (R99) was still complaining of pain, worked up and upset. (R99) kept asking for the cops and an ambulance. (V5) was not nice, abusive in my opinion. The way he (V5) picked her up by her arms. It was rough and you could feel the aggression. He was yelling at her (R99). I called (V1 Administrator), like a minute after. (V1) was super busy and had me call (V6, Assistant Director of Nursing, ADON). She told me she was going to talk to him. Obviously they took care of it because he hasn't been back. It was pretty much the end of his shift. V9 stated R99's roommate is mildly cognitively impaired, depending on the day. At this time, V9 demonstrated how V5 picked R99 up from the ground. V9 demonstrated V5 picked R99 up, from the floor, by bilateral arms, between the elbows and shoulders and place her in her chair. R99's Post Fall Evaluation dated 7/7/2024 at 12:03 PM documents R99 experienced a fall in R99's room attempting to self transfer, Resident was using remote to lift chair up to attempt to get out of chair. It continues, Called to resident room by CNA. Upon arrival it was noted resident had used remote to lift chair to highest position to self transfer. Resident slid out of chair causing her to fall to floor. Resident was laying supine on left side with a pillow under head. ROM (range of motion) WNL (within normal limits). 0 (no) apparent injury noted. V9's Statement, undated, documents V9 found R99 on the floor with her chair reclined forward, R99 asked for help and V9 went to get V5. It continues to state, As soon as he (V5) came into the room, he (V5) started telling her 'She needs to stop her shit and that if she doesn't f*****g like it here, go home'. He then asked me to help transfer her, but before I could help he grabbed her by the arms and put her in her chair. Then he walked out. It further documents V9 stayed with R99 to make sure she was ok or if she hurt anywhere, to which R99 stated she had hip and leg pain. It continues to document V9 told V5 about R99's complaints of pain, he went to check her out, and said she was fine. It further documents, She (R99) rung (used her call light) and asked for (V5) to stay away from her and to call the police. Then she wanted a(n) ambulance as well. I told (V12) and she told me to call the admin (administrator, V1). On 9/10/24 at 12:38 PM, V9 stated, I told her what I told you (see above interview). She fell and he (V5) came in. He (V5) was mean to her. I called (V1) as soon as I Ieft her (R99's) room, after calming her down. I did mention him (V5) being rough and not assessing her. They had me write statement and send to them. (R99) wanted the cops called. The cops never came. On 9/10/2024 at 11:25 PM, V6 stated, (V5) called and told me she fell and had no injuries. (V9) called and said (R99) wanted to go to the hospital, was upset with (V5) and didn't want him back in the room. We suspended (V5) because we had conflicting stories. Also, a family member called (V1) and said (V5) was yelling at (R99). On 9/10/24 at 11:35 AM, V1 stated she was unsure if V9 talked to V1 or V6, reported V5 used profanity and said if R99 wasn't going to do what she needs, why doesn't she go home. V1 stated she does not feel that is acceptable behavior. V1 stated a family member (V21) called and reported the same thing V9 reported. V1 also stated the police were not called/informed. On 9/10/24 at 12:17 PM, V12, (LPN) stated, I did not observe or hear, but (V9) reported to me. I told her to report it. He (V5) wasn't going to send her (R99) (to the emergency room , ER) based on what (V9) heard. (V5) was berating (R99) about non-compliance. He wasn't making further moves to send her (to the ER) and he moved her (R99) without an assessment. I encouraged him to send her immediately. R99's Consult from the hospital dated 7/8/2024 documents R99 sustained an acute right hip fracture from the fall. The Facility's Illinois Department of Public Health Report documents, Abuse Investigation for (R99) for 7-7-2024: (R99), a female resident of (Facility), has a PMH (Past Medical History) of lung cancer, renal mass, osteoporosis, osteoarthritis, (and) skin cancer. Resident had a fall with injury that occurred on the afternoon of July 7th. This was reported as well. The CNA on the floor that assisted the nurse with the fall called to report verbal abuse on resident from the nurse caring for this resident. Per CNA, nurse came into the room and said to resident You need to stop your shit. If you don't fu**ing like it here, go home. After putting (R99) in her recliner, he walked out of the room. She was requesting to go to the ER. Nurse told resident she was fine. The nurse from the other hall informed the administrator that the resident wanted to be sent out and that the nurse responsible for (R99) thought that she was fine. This is when the administrator let the nurse know that if the resident was complaining of pain and requesting to be sent out, especially after a fall, that is what we need to do. The administrator suspended the nurse pending investigation. POA (Power of Attorney) was notified. (V5), LPN, is the nurse in question. His statement is that he did not yell at the resident. He states that the resident was yelling at him and being combative. He informed the administrator that the Emergency Medical Technician's might report him because they were lecturing him about calling 911 in front of the resident and he asked them to transport the resident to the hospital like he called them to do. The CNA that reported the abuse (V9) says that the resident was not yelling or combative, but had been yelling and being disruptive earlier in the AM (morning). She was recently started on a prn (as needed) antianxiety medication to try to help her. The resident's roommate was asked for a statement. She is A&O x 4 (Alert and oriented to person, place, time and event). She reports that the nurse treated her with respect and did not yell or raise his voice at (R99). She reports that he did mumble something on his way out after getting her up off the floor. The CNA that reported the nurse and the nurse [CNA] have had previous issues in the past. Administration wondered if that had a play in this situation. Regardless of the outcome of this investigation, the nurse was going to be required to complete further training regarding properly assessing residents after a fall, as well as respecting their requests to be sent to the hospital for an evaluation at any time. On the morning of July 8th, the administrator received a call from a concerned family member that was visiting on July 7th, in the room next to (R99). She reports hearing the nurse yelling at the resident as well as arguing with the EMTs. A member of this family has also had an issue with the nurse in the past. The family member had been talking with her hands and pointing in the nurse's face and the nurse was upset. So, there is a history with this family member as well. Administrator attempted to call resident in the hospital to obtain a statement. She was not coherent enough to obtain a statement. Nurse was terminated. Nurse and roommate say that resident [V1 verified this was supposed to say (V5)] did not yell. A CNA and family member who have had issues with the nurse in the past say the nurse did. To prevent any further incidents with this nurse, felt it was in our best interest to terminate the relationship. On 9/11/2024 at 1:24 PM, V1 stated she did not feel what V5 said to R99 was intimidation, but she (V1) would not have said it in that manner. V1 stated V5's behavior was inappropriate and against their Facility policy. When asked how V1 thought a verbal altercation occurring at that time made R99 feel, V1 replied, Not good. When asked if the police should have been called, V1 stated she did not know how to answer the question. On 9/11/2024 at 2:47 PM, V19, CNA, stated, (R99) said, 'Please don't leave me. He (V5) just picked me up and threw me. I asked, 'Who?' and she said, 'that mean man'. (R99) grabbed me like she was scared. I held her hand. I figured it was (V5). (R99) asked me to call the police. I didn't know protocol since I couldn't tell the nurse since he was the one she was talking about. (V9) informed the other nurse. (R99) was asking about calling the ambulance and police. (V5) came back and asked (R99) why he should get the police called. Every time he (V5) walked past (R99's room), (R99) said he was mean man. Everything she told me, she (R99) told the EMTs. (V5) and the EMTs got into it (a verbal altercation). (R99) was right there. I intervened by asking if they needed help transferring (R99) on the stretcher. (V5) eventually walked off. I wish it would have been handled differently. On 9/12/2024 at 9:23 AM, V21, R11's niece and witness to the incident, stated, He (V5) didn't see me in the room (R11's). He was in the room next door. I could hear him screaming. I was actually kind of afraid of him. He was very angry and belligerent. I asked the CNA the nurses name and they said (V5). (V5) definitely does not belong in nursing. Poor little thing (R99) had fallen and he was screaming at her. She was confused and said she wanted the police. He screamed, 'what have I ever done to you?' They let him go (terminated employment). Being a nurse myself, I would have considered it verbal abuse for sure. (V5) yelled, 'If you don't want to stay here, why are you here?'. It was so demeaning. The Facility's Abuse and Neglect Policy undated documents, A board member, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations state all employees are required, to any reasonable suspicion of a crime committed against a resident, to call 911 or (local) Sheriff. The Policy continues to define; Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It continues to define: Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment- Inappropriate treatment or exploitation of a resident. Neglect- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It further documents, It is the policy of (Facility) Memorial Home that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on observation, interview and record review, the Facility failed to employ a Full Time Director of Nursing (DON). This failure has the potential to affect all 43 residents residing in the Facility. Findings include: On 9/9/2024 at 8:45 AM, V1 Administrator, stated, I have been doing it (performing DON duties) until we can get someone hired. We have been looking since February (2024). We have interviewed but they wanted $70 an hour. We can't do that. V1 stated she work 65-70 hours a week doing care plans and other DON duties. During this investigation, there was no observations of a DON. The Facility provided a list of Quality Assurance Members, undated, which did not include a staff member as DON. The Facility's Central Management Services (CMS) Form-671 dated 9/9/2024 documents there are 43 residents residing at the Facility.

Based on interview and record review, the Facility failed to follow the Facility Policy by ensuring an abusive and neglectful incident did not occur as well as not notifying all required parties for 1 of 2 residents (R99), reviewed for abuse/neglect, in the sample of 25. Findings include: The Facility's Abuse and Neglect Policy undated documents, A board member, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations state all employees are required, to any reasonable suspicion of a crime committed against a resident, to call 911 or (local) Sheriff. The Policy continues to define; Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It continues to define: Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment- Inappropriate treatment or exploitation of a resident. Neglect- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It further documents, It is the policy of (Facility) Memorial Home that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. R99's Facesheet dated 9/11/2024 documents R99 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to; osteoporosis, anxiety and post traumatic stress disorder. R99's Progress Notes dated 7/7/2024 documents R99 was attempting to self transfer out of her recliner, in her room and fell to the floor. It further documents R99 began complaining of right hip pain. R99's Minimum Data Set (MDS) dated [DATE] documents R99 was moderately cognitively impaired and required substantial assistance for chair transfers. On 9/9/2024 at 12:56 Pm, V9, Certified Nursing Assistant (CNA) stated, I was going through taking people (residents) back to their rooms. I heard screaming and plates breaking. I saw (R99) on the floor and her recliner was tipped up. I said 'hold still, don't move'. The nurse (V5, Licensed Practical Nurse, LPN) came and automatically was like, 'I'm tired of your shit. If you don't like it, you can go home'. He didn't evaluate her before he mistransferred (incorrectly transferred) her, instead of checking her, grabbed her up by the arms and put her back in her chair. He then walked out of the room. She (R99) wanted to call the cops. (R99) was still complaining of pain, worked up and upset. (R99) kept asking for the cops and an ambulance. (V5) was not nice, abusive in my opinion. The way he (V5) picked her up by her arms. It was rough and you could feel the aggression. He was yelling at her (R99). I called (V1), like a minute after. (V1) was super busy and had me call (V6, Assistant Director of Nursing, ADON). V9's Statement, undated, documents V9 found R99 on the floor with her chair reclined forward, R99 asked for help and V9 went to get V5. It continues to state, As soon as he (V5) came into the room, he (V5) started telling her 'She needs to stop her shit and that if she doesn't f*****g like it here, go home'. He then asked me to help transfer her, but before I could help he grabbed her by the arms and put her in her chair. Then he walked out. It further documents V9 stayed with R99 to make sure she was ok or if she hurt anywhere, to which R99 stated she had hip and leg pain. It continues to document V9 told V5 about R99's complaints of pain, he went to check her out, and said she was fine. It further documents, She (R99) rung (used her call light) and asked for (V5) to stay away from her and to call the police. Then she wanted a(n) ambulance as well. I told (V12) and she told me to call the admin (administrator, V1). On 9/10/24 at 12:38 PM, V9 stated, I told her what I told you (see above interview). She fell and he (V5) came in. He (V5) was mean to her. I called (V1) as soon as I Ieft her (R99's) room, after calming her down. I did mention him (V5) being rough and not assessing her. They had me write statement and send to them. (R99) wanted the cops called. The cops never came. On 9/10/2024 at 11:25 PM, V6 stated, (V5) called and told me she fell and had no injuries. (V9) called and said (R99) wanted to go to the hospital, was upset with (V5) and didn't want him back in the room. We suspended (V5) because we had conflicting stories. Also, a family member called (V1) and said (V5) was yelling at (R99). On 9/10/24 at 11:35 AM, V1 stated she was unsure if V9 talked to V1 or V6, reported V5 used profanity and said if R99 wasn't going to do what she needs, why doesn't she go home. V1 stated she does not feel that is acceptable behavior. V1 stated a family member (V21) called and reported the same thing V9 reported. V1 also stated the police were not called/informed. The Facility's Illinois Department of Public Health Report documents, Abuse Investigation for (R99) for 7-7-2024: (R99), a female resident of (Facility), has a PMH (Past Medical History) of lung cancer, renal mass, osteoporosis, osteoarthritis, (and) skin cancer. Resident had a fall with injury that occurred on the afternoon of July 7th. This was reported as well. The CNA on the floor that assisted the nurse with the fall called to report verbal abuse on resident from the nurse caring for this resident. Per CNA, nurse came into the room and said to resident You need to stop your shit. If you don't fu*&ing like it here, go home. After putting (R99) in her recliner, he walked out of the room. She was requesting to go to the ER. Nurse told resident she was fine. The nurse from the other hall informed the administrator that the resident wanted to be sent out and that the nurse responsible for (R99) thought that she was fine. This is when the administrator let the nurse know that if the resident was complaining of pain and requesting to be sent out, especially after a fall, that is what we need to do. The administrator suspended the nurse pending investigation. POA (Power of Attorney) was notified. (V5), LPN, is the nurse in question. His statement is that he did not yell at the resident. He states that the resident was yelling at him and being combative. He informed the administrator that the Emergency Medical Technician's might report him because they were lecturing him about calling 911 in front of the resident and he asked them to transport the resident to the hospital like he called them to do. The CNA that reported the abuse (V9) says that the resident was not yelling or combative, but had been yelling and being disruptive earlier in the AM (morning). She was recently started on a prn (as needed) antianxiety medication to try to help her. The resident's roommate was asked for a statement. She is A&O x 4 (Alert and oriented to person, place, time and event). She reports that the nurse treated her with respect and did not yell or raise his voice at (R99). She reports that he did mumble something on his way out after getting her up off the floor. The CNA that reported the nurse and the nurse have had previous issues in the past. Administration wondered if that had a play in this situation. Regardless of the outcome of this investigation, the nurse was going to be required to complete further training regarding properly assessing residents after a fall, as well as respecting their requests to be sent to the hospital for an evaluation at any time. On the morning of July 8th, the administrator received a call from a concerned family member that was visiting on July 7th, in the room next to (R99). She reports hearing the nurse yelling at the resident as well as arguing with the EMTs. A member of this family has also had an issue with [NAME] in the past. The family member had been talking with her hands and pointing in the nurse's face and the nurse was upset. So, there is a history with this family member as well. Administrator attempted to call resident in the hospital to obtain a statement. She was not coherent enough to obtain a statement. Nurse was terminated. Nurse and roommate say that resident [V1 verified this was supposed to say (V5)] did not yell. A CNA and family member who have had issues with the nurse in the past say the nurse did. To prevent any further incidents with this nurse, felt it was in our best interest to terminate the relationship. The Report does not document the local police were notified. On 9/11/2024 at 1:24 PM, V1 stated she did not feel what V5 said to R99 was intimidation, but she (V1) would not have said it in that manner. V1 stated it was inappropriate and against their Facility policy. When asked how V1 thought a verbal altercation occurring at that time made R99 feel, V1 replied, Not good. When asked if the police should have been called, V1 stated she did not know how to answer the question. On 9/11/2024 at 2:47 PM, V19, CAN, stated, (R99) said, 'Please don't leave me. He (V5) just picked me up and threw me. I asked, 'Who?' and she said, 'that mean man'. (R99) grabbed me like she was scared. I held her hand. I figured it was (V5). (R99) asked me to call the police. I didn't know protocol since I couldn't tell the nurse since he was the one she was talking about. (V9) informed the other nurse. (R99) was asking about calling the ambulance and police. (V5) came back and asked (R99) why he should get the police called. Every time he (V5) walked past, (R99) said he was mean man. everything she told me, she (R99) told the EMTs. (V5) and the EMTs got into it (a verbal altercation). (R99) was right there. I intervened by asking if they needed help transferring (R99) on the stretcher. (V5) eventually walked off. I wish it would have been handled differently. On 9/12/2024 at 9:23 AM, V21, R11's niece and witness to the incident, stated, He (V5) didn't see me in the room (R11's). He was in the room next door. I could hear him screaming. I was actually kind of afraid of him. He was very angry and belligerent. I asked the CNA the nurses name and they said (V5). (V5) definitely does not belong in nursing. Poor little thing (R99) had fallen and he was screaming at her. She was confused and said she wanted the police. He screamed, 'what have I ever done to you?' They let him go. Being a nurse myself, I would have considered it verbal abuse for sure. (V5) yelled, 'If you don't want to stay here, why are you here?'. It was so demeaning.

Based on record review, interviews, and observation, the facility failed to follow a physicians order for wound dressing for 1 of 1 resident (R25) in the sample of 25 reviewed for wounds. Findings include: 1. R25's Facesheet documents R25 was admitted to the facility on [DATE] with diagnosis of systolic and diastolic congestive heart failure, diabetes, atherosclerotic heart disease of native coronary artery, diabetic retinopathy, acquired absence of left great toe, moderate protein-calory malnutrition, polyneuropathy, glaucoma, phantom limb syndrome with pain, gastro-esophageal reflux disease, generalized anxiety disorder, acquired absence of right leg above knee, hypertension, and hyperlipidemia. R25's Minimum Data Set, (MDS) dated [DATE] section C documents R25 has severe cognitive decline with a Brief Interview Mental Score, (BIMS) of 3. Section GG documents R25 requires use of a wheelchair and is dependent on staff for all care areas. Section H documents V25 is always incontinent of bowel and bladder. R25's Care plan dated 7/24/24 documented that R25 has problems related to activities of daily living, (ADL) self-care performance deficit, rejects care at times and becomes verbally abusive, impaired visual function, risk for impaired gas exchange, impaired nutritional status, and high fall risk. A problem for impaired skin integrity is included with a goal to be free of any avoidable pressure injuries. Interventions include to encourage to change position every 2 hours, check skin weekly and follow current treatment orders as written. R25's Physician Order Sheet dated 8/23/24 stated to cleanse umbilicus wound with wound cleanser, apply xeroform to wound bed, and cover with dry dressing. R25's August 2024 Treatment Adminstration Record documented R25's umbilicus dressing change was not performed on August 1 2024, which was left blank. On 9/10/2024 at 10:00 AM R25's Umbilicus wound was observed open to air with creamy white drainage noted. When asked V7, CNA, about the fact that there was no dressing on the umbilicus wound, V7 stated that staff had been letting it air out, especially since R25 has been picking at the dressing. V7 stated she did not know if the dressing was present ealier this morning because night shift had gotten him up. 09/11/24 10:55 AM V16, Registered Nurse (RN) stated the wound care orders for the umbilicus wound is performed by evening shift and are to apply xeroform and a dry dressing. V16 stated she put a dressing on the wound this morning because there was not one there. V16 stated R25 is constantly picking the dressing off and touching the wound. R25's Progress notes dated 8/22/24 at 11:24 AM documented that R25 continues with open area to navel. R25 picking at navel, arms, and head. Lotion applied to skin daily. R25 picks at skin often and per baseline. Open area to navel measures 2.5 x 1.8 x 0.1 cm. Wound bed is granulation tissue with scant/light serosanguineous drainage noted. R25 removes dressing often. R25's Progress notes dated 8/30/24 at 10:09 AM documented that an open area to navel measures 1.2 x 1 x 0.1 cm. Normal peri-wound. Wound bed is white/pink. Light serosanguineous drainage present. Xeroform and dry dressing continues. R25 picking at skin less this week. R25's Progress notes dated 9/5/24 at 10:00 AM, documented that an open pen area to navel measures 2 x 1.3 x 0.2 cm. Normal peri-wound. Wound bed is white/pink. Scant to light serosanguineous drainage present. R25 noted to be picking at skin less. Treatment same. 09/11/24 11:30 AM Spoke with V6, Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON), regarding R25's wound. When asked about R25's umbilicus wound, she stated that R25 continuously picks the dressing off. V6 stated that V15, (R25's) physician, is aware and provided a copy of an order dated 9/11/2024 from V15 that he had been informed that R25 has continued to pick at skin and open area to umbilicus continues as R25 removes the dressing often. V15 wrote an order for Aquaphor to skin areas. The not dated policy titled, (Facility Name) Policy for Skin Issues and Pressure Ulcers documents, Policy: It is the policy of (facility name) that all skin issues, pressure ulcers, and areas of concern related to skin will be documented in PCC (point click care).

Based on observation, interview and record review, the facility failed to label multi dose vials of medication and multidose insulin pens when accessed. This has the potential to affect all 38 residents in the facility. Findings include: 1. On 8/24/23 at 2:50 PM V19, Registered Nurse (RN) removed a multi-dose vial of Tuberculin Purified Protein Derivative from the refrigerator in the medication room on the 100-Hall. The multi-dose vial was opened but did not have a date on the box or the vial indicating when the vial was opened. The instructions on the label on the box documented, Discard opened product after 30 days. V19 stated, I only work per diem. I don't know when this bottle was opened but I may be able to find out. 2. On 8/24/23 at 3:00 PM during observation of the 100-Hall medication cart with V19, there was an opened insulin pen with the label indicating it contained Novolog 70/30 insulin in the top drawer. This insulin pen had R32's last name only on it, but no label with medication instructions, dosage or prescription number, and there was no date on the pen documenting when it was opened. V19 stated she did not know there needed to be a label on the pen since R32's last name was written on it. She stated R32's spouse brings her medication into the facility from an outside pharmacy, and they send multiple pens in one box each time. V19 stated the pen should be discarded 30 days after being opened. On 8/24/23 at 3:37 PM V1, Administrator, sent an email which documented, The resident with the outside pharmacy-regarding the insulin pens; I called them and they said moving forward they can individually label each pen. I called her husband as well. He said he will make sure they do when he picks them up every time. I know it doesn't matter now, but I just wanted you to know that moving forward it will be fixed. On 8/24/23 at 4:30 PM V1 sent another email which documented, The pharmacy also called us back. They cannot legally open the box to label all of the pens, but they will send extra labels for us to use. On 8/25/23 at 9:19 AM V2, Director of Nursing (DON) stated she would expect any multi-dose bottles or vials to be dated as soon as they are opened and discarded per the instructions on the label. V2 stated the R32's insulin pen should have had a label on it with her name on it, and should have been dated when it was opened, and the Tuberculin test solution should also have been dated when it was opened because both of these medications are to be discarded after 30 days of opening them. V2 stated the TB test solution has the potential to be used for any resident requiring a TB test when admitted or an annual TB test if needed. On 8/24/23 at 4:05 PM V1 provided the facility's undated policy, Pharmacy Services Policy, which documents, (Facility) provides routine and emergency medications to all residents. (Facility) has a contracted pharmacy that delivers on a routine and emergent basis. Residents are free to utilize any pharmacy of their choosing and are made aware that if chosen pharmacy does not deliver, it will be the family's responsibility to bring all medications. Medications are labeled in accordance with accepted professional principles and include the expiration date when applicable. All medications are stored in locked compartments under proper temperature controls. The schedule II medications are stored in a separate, locked compartment. The facility's Resident Census and Conditions of Residents form, CMS 672, dated 8/22/23, documents there are 38 residents residing in the facility.

Based on observation, interview and record review the Facility failed to ensure infection control guidelines were being followed and staff were using the correct Personal Protective Equipment (PPE) on contact isolation for 4 of 4 residents (R5, R35, R190, R191) reviewed for infection control in the sample of 35. Findings include: 1.On 08/22/23 at 8:36 AM on R190's door was open and on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, Certified Nursing Assistant (CNA), exited R191's room and was not wearing any gloves or gowns, without washing or disinfecting her hands. V13 had just came from the room and was carrying out a breakfast tray. V13 left R190's room and proceeded to check on residents on the 200-hall. A list of residents in the facility with contact isolation was provided and R190 was identified as having C-diff (Clostridioides difficile) a highly contagious infection. 2.On 08/22/23 at 8:46 AM on R191's room on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, entered R191's without washing or disinfecting her hands. V13 had just came from R190's room. On 8/22/2023 at 8:50 AM, V13 provided care to R5 after she had finished with R191. On 8/22/2023 at 8:59 AM, V13 was observed not to wash her or disinfectant her hands and or follow the CDC guidelines for infection control and entered R35's room and brought him fresh drinking water. On 8/22/2023 at 9:11 AM, V13 stated, I did not wear any gowns when giving care to R191, but I should have followed the guides and disinfected my hands and wore a gown. It was just a mistake. I was in a hurry and forgot. On 8/25/2023 at 9:28 AM, V2, Director of Nursing stated, I would expect staff to always disinfectant their hands when coming and going into any room when the resident is on contact isolation and to wear gowns at all at times when a resident is positive for C-diff. The Facility undated Infection Control Policy Guidelines for Contact Precautions in Addition to Standard Precautions documents It is the policy of (Facility) to follow contact precautions as ordered in addition to standard precautions for residents on contact isolation. Wash hands with soap and water before wearing gloves. Gloves should be worn when entering the room. Gown when entering the room if you anticipate your clothing will come in contact with resident or environmental services such as doorknobs, bed rails or facet handles.

Based on observation, interview and record review, the facility failed to ensure that medications are administered using nursing standards of practice for 14 of 14 residents (R1, R4, R6, R7, R8, R16, R19, R25, R26, R30, R32, R34, R240 and R243) reviewed for pharmacy services in the sample of 35. Findings include: On 8/24/23 at 3:00 PM the medication cart for the 100-Hall was observed with V19, Registered Nurse, RN. There were 14 clear medication cups stacked 2-3 cups deep with each cup containing multiple pills and/or capsules. There were last names on these cups, but no date or time of when they were set up or when they were to be administered. V19 identified the cups as the evening medications that she had pre-set up for her evening medication pass for the following residents: R1, R4, R6, R7, R8, R16, R19, R25, R26, R30, R32, R34, R240 and R243. V19 stated she is per-diem and stated she always pre-sets up her evening medication pass, or it would take her a longer time to do her medication pass. She stated she did not know this was not alright. She stated, I don't know if you have ever worked in a nursing home or not, but it's a lot of work to pass medications to this many residents. It's either set up their medications or it will take longer for them (residents) to get them. V19 stated she passes medications to 14 residents on this hall. On 8/24/23 at 3:59 PM V1, Administrator, confirmed there are two evening shift nurses on that shift. On 8/25/23 at 9:19 AM V2, Director of Nursing, stated pre-setting up medications before it is time for them to be administered is never condoned. She stated medications should be popped out of cards as the nurse is preparing to give them to the resident. The facility's undated policy, (The Facility's) Liberal Medication Pass Policy documents, Policy: It is the policy of (Facility) to assure that medications are administered safely and accurately to residents for whom they are prescribed in accordance with good nursing practices. Purpose: To establish a mechanism to ensure accuracy in medication administration while providing quality of life. The liberal medication pass program, in order to provide a homelike environment for the resident, will adopt a time pass according to the following. Time sensitive medications must be prepared and administered within one hour of the designated standard administration. During the Medication Pass-Nursing should always check the 5 R's a. Right Resident-before administering medication, identify resident according to facility policy b. Right Drug-verify that correct drug is being given using med card, label and EMR (Electronic Medical Record) c. Right Dose-verify that correct dosage is being given using med card, label, and EMR d. Right time-administer drugs per liberal med pass policy e. Right Route-verify that medication is being given by correct route using med card, label and EMR If the comparison is correct, the medication is to be punched from the bubble card into the medication cup with appropriate technique. Nursing must initial EMR for appropriate medication, date, and time.

Based on interview and record review the facility failed to ensure antibiotics used, are effective to treat the organisms causing the infections for 2 of 20 residents (R27 and R22) reviewed for antibiotic stewardship in the sample of 35. Findings include: 1. R27's undated Care Plan documents R27 has an ADL self-care performance deficit related to chronic kidney disease, atherosclerotic heart disease, major depression disorder, glaucoma, generalized weakness, incontinence, and poor mobility. The Infection Control Surveillance Log for March 2023 documents R27 had a Urinary Tract Infection (UTI) on 3/11/2023 but no organism was documented and 'No growth was documented on the surveillance log for the use of any antibiotics. R27's Physician Order Sheet (POS) for March 2023 documents, Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's Medication Administration Record (MARS) dated 3/2023 documents Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's MAR was documented as receiving cefdinir (antibiotic) for 5 days. On 8/24/2023 at 3:24 PM, a Culture and Sensitivity Report was requested for R27. No Culture and Sensitivity Report was provided but a Clinical Laboratory Report was provided that documents, on 3/11/2023 a urine culture was taken and documents, No further testing (including susceptibility) will be performed. The Lab Report does not document and information regarding Sensitivity or if Cefdinir would be appropriate or indicated for the use of Cefdinir. 2. R22's undated Care Plan documents she has an ADL self-care performance deficit related to acute respiratory failure with hypoxia, congestive heart failure, partial intestinal obstruction with colostomy status, anxiety disorder, spinal stenosis, transient cerebral disorder, incontinence, generalized weakness and poor mobility. R22's POS dated January 2023 documents Cipro Tablet 250 MG (milligrams) (Ciprofloxacin HCL) give 1 tablet by mouth two times a day related to urinary tract infection for 5 days. The Infection Control Log for the month of January 2023 does not document any infections or urinary tract infections for R22. R22's MAR dated January 2023 documents she was taking 250 milligrams of Cipro two times a day related to a urinary tract infection, 1 tablet my mouth, two times a day for 5 days. The MAR documents R22 only received 9 out of the 10 doses for the Cipro and misses a dose on 1/2/2023. R22's Progress notes does not document R22 was sent out to the hospital or was not in the facility for January 2, 2023, to January 6, 2023. On 8/25/2023 at 10:13 AM, V2, Director of Nursing stated, We provided you with all of the C & S reports that we had. If we did not provide them, then we do not have them. I would expect all urinary tract infections to have the organism documented on the infection control surveillance log. The antibiotic Stewardship Policy with an effective date of 8/18/2023 documents, Therapeutic decisions regarding antibiotic statements from clinical and academies societies) that is appropriate for the care of Long-term care facility residents.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse and failed to protect residents from further abuse by allowing an alleged perpetrator of abuse to have contact with residents for 19 of 19 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) reviewed for abuse investigation in the sample of 19. Findings include: R2's Facility's Verbal Abuse Investigation dated 4/20/2023 document, It was reported on the night of April 20, 2023, by a staff member, that (V5, Certified Nursing Assistant) yelled at (R2) during care. (V5) is a CNA at the facility. (V5) was the CNA for (R2) on the evening shift. During the bedtime rounds, (V4), Housekeeping/Laundry Assistant, reported hearing (V5) yelling at (R2) to stand up. (V4) also reported that (R2's) roommate, (R5), then yelled She has alzheimer's. Don't you be yelling at her. An investigation was conducted on April 21, 2023, by (V3), Assistant Director of Nursing, ADON. (R5) has no cognitive impairments. When asked about the incident, (R5) stated (V5) yelled at (R2). (V5) told (R2) to stand up. It upset (R2) who yelled back I'm trying to. (V5) stated (R2's) depend was full of feces and it went on the floor during the transfer. (R2) reported hearing the frustration in (V5's) voice. Since a staff member heard the incident, and an alert resident also heard the incident, (V5) was terminated as soon as today April 21. 2023. Social Service also spoke to (R5) who told the same story. (V5) was asked for her side of the story. (V5) said that she did not yell at (R2). (R2's) Power of Attorney, was notified of the incident and outcome. (V10), Medical Doctor, MD, was notified. Nursing is to follow up with (R2) every shift for the next 72 hours. Social Services conducted a visit today with (R2). (R2) does not recall the incident. (R2) was pleasant. Her appetite remains unchanged. No signs of depression noted. On 7/19/2023 at 2:00PM V1 stated the Social Services Director (SSD) oversaw the investigation for the incident with R2 on 4/19/2023. On 7/18/2023 at 2:30PM V8, SSD, stated I was alerted on 4/20/2023 that V5 had yelled at R2 to stand up. I am not sure who I told about the abuse first. I did not write down statements from other residents. On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated We did not interview any other residents about abuse. Only (R2) and (R5). We saw no need to interview any others since the incident happened in R2's and R5's room. The facility's schedule was reviewed and documented V5 worked on Hall one on 4/19/2023. V5's Timecard was reviewed and documented that V5 worked the entire shift on 4/19/23 and was not sent home after alleged abuse occurred with R2. On 7/18/2023 at 1:00PM, staff and resident interviews were requested regarding the abuse allegation between V5 and R2 on 4/20/23. No further documentation was provided of any other resident or staff interviews for the night of 4/19/2023 and into morning of 4/20/23. Only interviews provided were on the initial report. On 7/19/2023 at 1:30PM the facility provided documentation of residents living residing on the hall the incident occurred on 4/19/2023 into morning of 4/20/23. Residents listed are as follows: R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19. Facility's undated abuse policy documents It is the policy of (Facility) that reports of abuse (mistreatment, neglect, abuse, and injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated.

Based on interview and record review, the facility failed to report allegations of abuse immediately to the Executive Director, which delayed the abuse investigation for 1 of 3 residents (R2) reviewed for reporting of abuse in the sample of 19. Findings include: R2's Facility's Verbal Abuse Investigation, dated 4/20/2023 document, It was reported on the night of April 20, 2023, by a staff member, that (V5, Certified Nursing Assistant) yelled at (R2) during care. (V5) is a CNA at the facility. (V5) was the CNA for (R2) on the evening shift. During the bedtime rounds, (V4), Housekeeping/Laundry Assistant, reported hearing (V5) yelling at (R2) to 'stand up'. (V4) also reported that (R2's) roommate, (R5), then yelled She has alzheimer's. Don't you be yelling at her. An investigation was conducted on April 21, 2023, by (V3), Assistant Director of Nursing, ADON. (R5) has no cognitive impairments. When asked about the incident, (R5) stated (V5) yelled at (R2). (V5) told (R2) to stand up. It upset (R2) who yelled back I'm trying to. (V5) stated (R2's) depend was full of feces and it went on the floor during the transfer. (R2) reported hearing the frustration in (V5's) voice. Since a staff member heard the incident, and an alert resident also heard the incident, (V5) was terminated as soon as today April 21. 2023. Social Service also spoke to (R5) who told the same story. (V5) was asked for her side of the story. (V5) said that she did not yell at (R2). (R2's) Power of Attorney, was notified of the incident and outcome. (V10), Medical Doctor, MD, was notified. Nursing is to follow up with (R2) every shift for the next 72 hours. Social Services conducted a visit today with (R2). (R2) does not recall the incident. (R2) was pleasant. Her appetite remains unchanged. No signs of depression noted. R2's 4/21/2023 4:56PM Incident Note documented It was reported on the night of 4-20-23 a CNA (certified nursing assistant) yelled at (R2) to stand up. An investigation was conducted all parties were all notified. (R2) continues to be pleasant. She does not recall the incident. Appetite is unchanged. (R2) is currently in the dining room for supper. R2's Progress Notes dated 4/21/2023 at 4:10PM documented Social Services visit conducted regarding verbal abuse incident. R2's mood is happy/pleasant. Social Service (SS) asked resident if there was anything she would like to talk about or any concerns she may have. (R2) stated that she is happy and feels she is fortunate to have her family. Social Service will continue to follow. On 7/18/2023 at 3:00PM V4, Housekeeping/Laundry, stated, I was here working that night because I remember (V5) had (R2) on the (manual stand assistance device). (R2) and (V5) were arguing. (V5) was speaking unprofessionally to (R2). (V5's) tone was unprofessional, and no one should speak to a resident the way she was speaking. It was more than speaking loudly for someone hard of hearing. I don't think anyone should be treated that way. When I went back in the room, there was feces all over the bathroom. That may have been the problem, but I am not sure. Either way that did not give her the right to speak to her the way she was speaking to her. V4 stated that the Administrator and DON were not in the facility so she told them the next day. On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated, The incident involving (R2) and (V5) was reported the day after the incident occurred. We followed the chain of command letting all parties know. The staff member (V4) did not report this to us until the next day. We then tried to speak to (R2), but she did not remember anything and could not tell us anything. (R5), the roommate told us everything that happened. I don't know why (V4) waited until the next day to say anything. I would expect staff to notify management immediately not the next day. On 7/18/2023 at 1:00PM V1, Administrator, stated V5, Certified Nursing Assistant, CNA, was terminated for raising her voice to R2. The incident happened on 4/19/2023 but wasn't reported to us until 4/20/2023. V1 stated V5 was terminated over the phone. The Facility's undated abuse policy states Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator.

Based on interview and record review the facility failed to ensure residents are free from employee-to-resident verbal abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 19. Findings include: R2's Face sheet documents R2 has diagnoses of dementia, encephalopathy, type 2 diabetes, major depressive disorder, and anxiety. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired. R2's MDS dated [DATE] documents R2 requires extensive 2-person assist with toileting, transfers, and bed mobility. On 7/18/2023 at 1:00PM V1, Administrator, stated V5, Certified Nursing Assistant, CNA, was terminated for raising her voice/verbal abuse to R2. V1 stated The incident happened on 4/19/2023 but wasn't reported to us until 4/20/2023. (V5) was terminated over the phone. R2's Facility's Verbal Abuse Investigation, dated 4/20/2023 document, It was reported on the night of April 20, 2023, by a staff member, that (V5, Certified Nursing Assistant) yelled at (R2) during care. (V5) is a CNA at the facility. (V5) was the CNA for (R2) on the evening shift. During the bedtime rounds, (V4), Housekeeping/Laundry Assistant, reported hearing (V5) yelling at (R2) to stand up. (V4) also reported that (R2's) roommate, (R5), then yelled She has alzheimer's. Don't you be yelling at her. An investigation was conducted on April 21, 2023, by (V3), Assistant Director of Nursing, ADON. (R5) has no cognitive impairments. When asked about the incident, (R5) stated (V5) yelled at (R2). (V5) told (R2) to stand up. It upset (R2) who yelled back 'I'm trying to!'. (R5) stated (R2's) depend was full of feces and it went on the floor during the transfer. (R5) reported hearing the frustration in (V5's) voice. Since a staff member heard the incident, and an alert resident also heard the incident, (V5) was terminated as soon as today April 21. 2023. Social Service also spoke to (R5) who told the same story. (V5) was asked for her side of the story. (V5) said that she did not yell at (R2). (R2's) Power of Attorney, was notified of the incident and outcome. (V10), Medical Doctor, MD, was notified. Nursing is to follow up with (R2) every shift for the next 72 hours. Social Services conducted a visit today with (R2). (R2) does not recall the incident. (R2) was pleasant. Her appetite remains unchanged. No signs of depression noted. On 7/18/2023 at 3:00PM V4, Housekeeping/Laundry, stated, I was here working that night because I remember (V5) had (R2) on the (manual stand assistance device). (R2) and (V5) were arguing. (V5) was speaking unprofessionally to (R2). (V5's) tone was unprofessional, and no one should speak to a resident the way she was speaking. It was more than speaking loudly for someone hard of hearing. I don't think anyone should be treated that way. When I went back in the room, there was feces all over the bathroom. That may have been the problem, but I am not sure. Either way that did not give her the right to speak to her the way she was speaking to her. On 7/18/2023 at 2:30PM V8, Social Services Director, stated, I was alerted on 4/21/2023 that (V5) had yelled at (R2) and (V5) was being verbally abusive to (R2). I asked (R2's), roommate (R5) because she was there when it happened. I asked her if (V5) spoke rudely to (R2), and (R5) said 'yes'. (R5) said she felt safe but was concerned about retaliation. Because of this we had to let (V5) go. (R2) did not comprehend what had happened and could not tell us any details. It was the roommate who was able to confirm what had happened to (R2) and (V4). On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated the incident involving R2 and V5 was reported the day after the incident occurred. V3 stated We followed the chain of command letting all parties know. The staff member did not report to us until the next day. We then tried to speak to (R2), but she did not remember anything and could not tell us anything. (R5) told us everything that happened. I don't know why (V4) waited until the next day to say anything. I would expect staff to notify management immediately not the next day. We did not interview any other residents about abuse. Only (R2) and (R5). We saw no need to interview any others since the incident happened in R2's and in R5's room. The Undated Abuse Policy documents, It is the policy of (Facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. The Policy documents A board member, licensee, administrator, licensed nurse, employee, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the nursing home administrator. The policy documents Definitions of Abuse and Neglect Abuse- Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.

Based on observation, interview, and record review, the facility failed to ensure staff are vaccinated for COVID-19. The facility failed to develop a policy that includes a process for ensuring staff are vaccinated for COVID-19, medical or religious exemptions, and a contingency plan for staff who are not vaccinated and do not have an exemption or temporary delay. This has the potential to affect all 40 residents in the facility. Findings include: On 9/6/22 at 8:00 AM, upon entry to the facility there was a sign on Facility's Visitor Entrance door that read, We are COVID positive at this time. The facility's COVID-19 test results printed on 9/8/22 at 10:45 AM, documents three residents (R14, R31, R35) tested positive for COVID on 9/1/22, and two residents (R6, R20) tested positive for COVID on 9/5/2022. The facility's Contract Tracing Form, undated, documents that V34, Maintenance Director, had COVID symptoms on 8/23/2022 and tested positive on 8/25/2022. It also documents V40, RN (Registered Nurse), had COVID symptoms on 9/2/22 and tested positive for COVID on 9/3/2022. The facility's COVID-19 Staff Vaccination Status for Providers list documents the following staff members are not vaccinated with one dose of a single dose vaccine or all doses of a multiple vaccine series without exemption or temporary delay: V8, Housekeeping/Laundry Aide; V9, CNA (Certified Nursing Assistant); V14, Activities Director; V19, Social Services Director; V20, Dietary Aide; V21, RN, V22, Housekeeping/Laundry Aide; V24, Dietary Aide; V25, Dietary Aide; V26, LPN (Licensed Practical Nurse); V27, Housekeeping/Laundry Aide; V28, Dietary Aide; V29, CNA, V30, Dietary Aide; and V31-V33, all CNAs. The Staff Vaccination Matrix Calculator documents that the facility has 54 employees. Of these employees, 16 are unvaccinated, indicating a 31.5% unvaccinated rate. On 9/8/22 at 9:05 AM, V20 stated she is not vaccinated and generally works Monday through Friday in the facility. On 9/8/22 at 9:07 AM, V14 stated he is not vaccinated and works Monday through Friday in the facility. On 9/8/22 at 9:09 AM, V21 states she works 32 hours per week in the facility and has not been vaccinated for COVID-19. On 9/8/22 at 9:11 AM, V8 stated she usually works Monday through Friday and every other weekend and has not received the COVID vaccine. On 9/8/22 at 9:12 AM, V22 stated she has not been vaccinated for COVID and works Monday through Friday in the facility. 9/8/22 at 9:14 AM, V19 stated she works Monday through Friday in the facility and has not been vaccinated. On 9/6/22 at 2:01 PM, V4, Infection Control Preventionist (ICP), stated the facility's outbreak status began toward the end of August 2022. He confirmed that the COVID-19 Staff Vaccination Status for Providers list is correct and there are 17 unvaccinated staff members without any exemption or delays. He stated he did not have any documentation regarding employees who were not vaccinated. On 9/7/22 at 3:18 PM, V4 stated, I do not have any documentation regarding employee vaccine refusals. I assume they are all for personal reasons. We have not had any changes in employee roles based on vaccination status. I believe IDPH (Illinois Department of Public Health) recommends that we attempt to vaccinate all staff. On 9/8/2022 at 1:50 PM, V19 stated that she is not vaccinated. V19 was asked if she had a religious or medical exemption, and she stated that she did not know what an exemption was. V19 stated that she had not been educated or spoken to about an exemption. On 9/8/22 at 1:52 PM, V22 stated she has not heard of vaccine exemptions before. On 9/8/2022 at 1:56 PM, V21 stated she was not vaccinated by choice. When asked if she had an exemption, V21 stated that she did not have an exemption and the facility did not request one. On 9/8/2022 at 2:00 PM, V14 stated that he was not vaccinated. V14 stated that he did not have an exemption for his vaccination and did not know what an exemption was. V14 stated that no one had talked to him or educated him about vaccine exemptions. On 9/8/2022 at 2:28 PM, V4 stated that (V8, V9, V14, V19-22, V24-33) do not have exemptions. V4 stated that in the beginning there were a couple of staff that had exemptions, but after that the staff just verbally refused. V4 verified there was a meeting around 7/12/22 about COVID vaccination, but he was unsure if exemptions were discussed. The facility's COVID-19 Policy & Procedures updated 7/29/22 documents, Core Principles of COVID-19 Prevention: Vaccination. Covid-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized , and even dying. The policy does not address a process to ensure 100% staff vaccination requirement by CMS (Centers for Medicare and Medicaid Services) rate is met, medical or religious exemptions, or contingency plans for those not vaccinated without exemptions or temporary delays. The Resident Census and Condition of Residents Form (CMS 672), dated 9/6/2022, documents that the facility has 40 residents living in the facility.

Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) to serve as Director of Nursing (DON) on a full-time basis. This has the potential to affect all 40 residents living in the facility. Findings include: On 9/6/22 at 10:35 AM, V1, Administrator, stated (V2) was our DON but she stepped down on 2/22/22 and only works floor shifts. She is still considered our DON though. We also have two ADON's (Assistant Director of Nursing) who are only LPN's (Licensed Practical Nurse), but they are taking care of the responsibilities of the DON until we can find another DON. On 9/7/11 at 11:35 AM, V1 stated, We have not had a full time DON since last December. The interim DON always works the floor. We are trying to hire a full time DON. On 9/7/22 at 1:52 PM, V4, ADON, stated, I do not believe we have a policy regarding DON staffing. We just follow the regulations. The Facility's Resident Census and Conditions of Residents form, (CMS 672), dated 9/6/22, documents the Facility had a census of 40 residents.

Based on interview and record review the Facility failed to provide progressive interventions to prevent accidents for 1 of 5 residents (R2) reviewed for falls in the sample of 10. This failure resulted in R2's fall requiring hospitalization for subsequent subarachnoid hemorrhage and death. Findings Include: R2's Physician order [REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] documents R2 was moderately impaired cognition for decision making and has impairments of his upper and lower extremities. The MDS also documents R2's Balance was not steady but able to stabilize without staff assistance moving from seated to standing position, on and off the toilet, and surface to surface transfers. R2's Quarterly Fall assessment dated [DATE], documents, intermittent confusion, 1-2 falls in last 3 months, ambulatory, balance problems when standing, Total score of above 10 represents high risk (R2) scored a 16. (R2) transfers independently. R2's Care Plan with an onset date of 6/6/2020 documents (R2) is at risk for injuries related to falls, related to a history of falls 10/19/2019, 12/16/2019, 1/31/2020, 2/11/2020, 3/20/2020, 3/22/2020, 4/20/2020, and 7/8/2020, High score on his fall risk assessment, weakness, [MEDICAL CONDITION] and [MEDICAL CONDITION], R2 has had 8 falls in the facility since 10/2019. On 12/1/2020 at 9:28 AM, V14, Certified Nursing Assistant (CNA), stated, (R2) was constantly confused, he could never sit still and was always wandering around the facility. He was frail, and he had falls in the past. I don't really remember much about him and his falls. He could be redirected if he was close to a door or something, but he was very confused at times and could never remember anything you told him. (R2) was a fall risk and had several falls. On 12/1/2020 at 9:32 AM, V12, CNA stated, (R2) had dementia and Parkinson disease, so he was very confused. He had his good days and his bad days. Overall, he could not remember things and was very forgetful. On his bad days, you could not really rely on him to obey or listen to you. (R2) had several falls while he was here. 1-R2's Nurses Notes dated 1/31/2020 documents, Resident found by staff laying on back on floor next to bed with head near bed frame. Resident states he was standing up to go to the bathroom and lost his balance. Also states that he bumped the back of his head. Skin inspection performed with 3- cm (centimeter) x 2 cm slightly reddened area to back of skull. R2's Incident Report, date of incident 1/31/2020 at 8:07 AM, document, Resident found by staff laying on back on floor next to bed with head near bed frame. Resident states he was standing up to go to the bathroom and lost balance. Intervention: 'Keep my pathways clear and clutter free,' Root Cause, 'Resident attempted to stand from bed and lost balance trying to move past bedside table. Unable to regain balance then fell to the floor'. R2's Care Plan date entered 1/31/2020 documents, Make sure all my pathways are clear and clutter-free. 2-R2's Nurses Notes on 2/11/2020 at 6:29 PM, documents, Found sitting on bottom, laughing in front of recliner. Intervention, 'Place gripper tape in front of recliner.' We think he slid out of his recliner. R2's Care Plan with an entered dated of 2/19/2020 document, I have gripper tape placed in front of my recliner to assist me with transferring. R2's Incident Report, dated 2/11/2020 at 6:13 PM, document, Found on his bedroom floor sitting on his buttocks, legs extended out in front of him. He was laughing denies hitting his head, no complaint of pain and or discomfort. Intervention, monitor blood pressure at every shift, related to postural hypertension. Encourage to ask for assistance, due to bouts of weakness. Ensure room and path is clutter free. Root Analysis, Increased paranoia and agitation, and refusal of medications noted on shifts prior to fall. Resident stood up from recliner and lost balance landing on the floor. 3-R2's Nurses Notes dated 3/20/2020 at 2:45 PM, document, Patient was in a hurry to get onto the toilet related to diarrhea. Patient feet got tangled underneath him and he fell backwards through the doorway of the bathroom into (another room). R3's Incident Report dated Incident occurred 3/20/2020 at 10:15 AM, documents, Patient was in a hurry to get onto the toilet due to diarrhea. Patient feet got tangled underneath him and he fell backwards through the doorway of the bathroom into (next room). Intervention: Resident needing to use toilet and ambulated in a hurry to bathroom. Lost balance while in bathroom and fell to ground. Resident hit head. R2's Care Plan entered on 3/20/2020 documents, I am independent in my room, but I still require cues for toileting. Sometimes I wait too long to go to the bathroom and rush too quickly. Please remind me to toilet every 2 hours as needed. 4-R2's Nurses Notes dated 3/22/2020 at 11:15 AM, document, Patient fell attempting to get up from his recliner. Unknown if he hit his head. No injuries noted. R2's Incident Report, dated 3/22/2020 at 11:15 AM, document, Patient fell while attempting to get out of his recliner, No injuries noted, range of motion normal. Intervention, Pathways clear and clutter free. Root Analysis, Patient has a history of falling, while attempting to maneuver out of recliner in room. While attempting to stand, residents left leg stand of chair in highest position and lost balance. This intervention is the same intervention that was documented for a previous fall on 1/31/2020 for R2. R2's Care Plan entered on 4/5/2020 documents, Care Plan, My recent fall involving my recliner have had my leg rest up on my recliner while I attempted to transfer. Please remind me to lower my leg rests and give me positive encouragement when I successfully transfer with my recliner. 5- R2's Nurses Notes dated 4/20/2020 at 2:25 PM, staff called writer to room. CNA in room giving care to resident roommate. Resident was standing next to recliner with walker, resident states he became dizzy, lost his balance and fell hitting his head on bed. no injuries noted. Range of Motion within normal limits. Neuro checks initiated. Resident denies any pain or discomfort. Resident encouraged to call for assistance with transfers. R2's Incident Report dated 4/20/2020 at 1:51 PM, Resident became dizzy while staff was in room and lost balance striking head on bed. Intervention, monitor blood pressure every shift related to [MEDICAL CONDITION], and dizziness while standing. Root Analysis, Resident stood up too quickly from bed and became dizzy, Unable to catch self before falling to the ground. R2's Care Plan entered on 4/23/2020 document, Encourage me to remain sitting for a few minutes before attempting to stand up. 6- R2's Nurses Notes dated 7/8/2020 at 9:05 AM, document, Patient fell backwards in his room hitting his head. CNA was in the room but back turned caring for another patient. Bedside table under his feet. Patient unable to respond to verbal commands or open eyes during first 90 seconds. Then patient opened his eyes and yawned. Swelling and bruising noted to the back right of scalp and Skin tear to the LFA (left frontoanterior ). MD (Medical Doctor ) in house and aware. Send to ER (emergency room ) for Head CT (Computed Tomography). R2's Incident Report for 7/8/2020 at 9:05 AM, documents, Patient found on the floor per CNA after hearing a loud crash behind her. STAT (as soon as possible) call brought this nurse to patient's room where patient was found on the floor on his back. Eyes closed not responding to verbal or physical cues. Pupils not responding to physical light. Approximately 4 cm hematoma noted to the back of the scalp towards the right side above the occipital bone. Medical Doctor in house came into room and determined patient needed to be sent to the emergency room for Head CT. Call placed to 911. Patient started to verbally respond and blink his eyes on his own after approximately 60 seconds. When EMT (Emergency Medical Technicians) arrived, patient was talking per norm and joking about flirting with the cute nurses at the hospital. Interventions: Keep pathways clear. Encourage resident to lower foot rests while attempting to get out of the chair. Root Cause: Resident tripped over lower leg of bedside table and fell to ground striking head. This is the same intervention documented for 1/31/2020 and 3/22/2020 and on both of these occasion R2 hit his head during these falls. No new intervention was documented. On 12/2/2020 at 12:15 PM, V12, CNA, stated, I was in (R2's) room giving care to his roommate when he fell backwards back in July of this year. My back was turned to him and I heard a big thump from where he had fell . He was on his back. I did not see him fall. I only heard it. (R2) was independent for transfer in his room and he could transfer himself. He had dementia and [MEDICAL CONDITION] and he had good days and bad days. At times he was confused, and he would shake a lot and things like that related to his [MEDICAL CONDITION]. Depending on the day, because it varied whether (R2) was compliant and asked for help. Sometimes, (R2) could ask for help when he needed help and sometimes, (R2) just could not remember. On 12/2/2020 at 12:40 PM, V11, Licensed Practical Nurse (LPN), stated, I remember that day and the intercom telling the nurse to go to (R2's) room back in July. When I got into (R2's) room and I went there immediately, (R2) was on the floor and he was out like a light. (V12) had his head in her lap and we were softly telling him to wake up and wake up. He had a very large lump on his head and (V13, Medical Doctor) was in the building and he heard the code too and we both got there about the same time. (V13) looked at me and told me to send (R2) out. A few minutes later, (R2) woke up and was joking. We sent him out to the hospital, but he never came back. (R2) had dementia and [MEDICAL CONDITION] and he had days of confusion some days were better than other days. There would be some days that you would tell him something and he would forget quite easily. You never knew what you were going to get because some days he could be okay and other days he was very confused. R2's Nurses Notes dated 7/8/2020 at 9:30 AM, document R2 was sent out to the (hospital) on 7/8/2020. Emergency Medical Technicians here, Patient transferred safely onto stretcher, report given. Patient speaking now and cracking jokes. R2's Hospital Records dated 7/8/2020 at 10:24 AM, document, Patient sent to ED (Emergency Department ) via EMS (Emergency Medical System) for an unwitnessed fall to back of head. This occurred in the bathroom of his memory Care Center. It was unclear whether he had loss of conscious. EMS report positive loss of conscious however nursing home staff in their phone call to ED RN (Registered Nurse) stated no loss of conscious. R2's CT Scan dated 7/8/2020 documents, there is acute subarachnoid hemorrhage (brain bleed) along the right cerebral convexly measuring up to 10 mm (millimeters) in thickness. Right anterior and posterior parafaicne subdural hematomas. Subarachnoid hemorrhage along the sylvian fissure and right frontal and temporal lobes. Mild subfalcine shift to left, proximally 4 mm. R2's Death Certificate dated 7/11/2020 documents cause of death fall at ground level, subarachnoid hemorrhage. The Facility's undated Accident/Incident Fall Report Policy documents, The incident report is filled out each time an incident occurs. The root case analysis is also filled out, signed off by a charge nurse in an effort to know what happened to cause the accident and also to help staff find preventative approaches to prevent further accidents.

Based on observation, interview, and record review, the facility failed to provide safe transfers and supervision to prevent falls for 3 of 7 residents (R25, R36, R38)) reviewed for falls in the sample of 21. This failure resulted in R25's fall from the full mechanical lift during which she sustained a left lower knee hematoma that subsequently resulted in an abscess resulting in permanent deformity to her left lower knee. Findings Include: 1. R25's Fall Risk Assessment, dated 12/4/18, documents R25 having confusion, chairbound, and having a score of 10, indicating the resident should be considered at HIGH RISK for potential falls. The Facility Fall Log, dated 3/2/19, documents R25 sustained a fall that resulted in Bruising to LLE (left lower extremity) and LUE (left upper extremity). R25's Care Plan, onset date of 10/30/17, documents R25 requiring staff assistance to perform Activities of Daily Living (ADLs) related to [MEDICAL CONDITION], functional [MEDICAL CONDITION], and weakness as evidenced by requiring total assistance. The Care Plan further documents R25 requiring a full mechanical lift for all transfers. The Care Plan has no documentation of R25's fall incident of 3/2/19, nor any interventions related to the fall. Incident Report, dated 3/2/19, documents R25 having sustained a fall. The description of the fall was slid out of (full mechanical lift) sling during transfer. Interventions listed were, Staff re-education on transfer procedures, (full mechanical) lift safety, and use of proper sling size. The Report also documents the Root Cause Analysis. (Full Mechanical Lift) sling noted to be improper fit for resident. Sling unable to distribute resident weight effectively causing resident (R25) to fall out. The Incident Report for R25 further documents, Transferring from bed to (high back) chair, Missed Chair and Contributing Factors (Full Mechanical) sling too small. Nursing Progress Note, dated 3/2/19 at 5:30 AM, documents that a Certified Nursing Assistant (CNA) reported that resident (R25) slid out of the (full mechanical lift) sling during a transfer. Noted as lying on left side of floor. Transferred back to bed x (times) 3 staff and (full mechanical lift). Nursing Progress Note, dated 3/2/19 at 5:39 AM, documents, Massive bruising and swelling over almost the entire lateral aspect of the left lower extremity. Large 5 inch by 8 inch bruise over the lateral aspect of the left upper arm. Bruise on right index finger. Facsimile (Fax), dated 3/5/19 (un-timed), documents V15, Medical Director (MD), was notified of the following, On top of hematoma to LLE is developing a fluid filled water blister 5 x (by) 3 cm. LLE swollen tight shiny slightly warm to touch. Please advise. Fax further documents V15, MD, ordered Keflex, 500 mg, three times daily for five days for presumed [MEDICAL CONDITION]. Nursing Progress Note dated 3/6/19 at 12:29 PM, documents, (R25) LLE remains tight, shiny, blister remains intact on hematoma. Wound management consultant progress note/wound assessment dated April, 2019, documents R25 was seen for an initial evaluation of wound to left lateral knee. The progress note also documents R25 having [DIAGNOSES REDACTED] and swelling, measuring 5.5 cm (centimeters) (length) x 5.0 cm (width) x 4.0 cm in depth. The Wound assessment further documents Undermining: 12 to 12 o'clock, Periwound: Abnormal [DIAGNOSES REDACTED], Exudate: Large Amount blood (sic), Signs and Symptoms of Infection: [DIAGNOSES REDACTED], Odor, Warmth. Physician order [REDACTED]. Inject 1 gram IM (intramuscular) x 5 days. Diagnosis: [REDACTED]. Physician order [REDACTED]. Fill in with a wet-to-dry dressing soaked with sterile water. Cover with 4 x (by) 4s. Wrap with kling. Change BID (twice daily) and prn (as needed). Nursing Progress Note dated 4/3/19 at 12:43 PM, documents in part, (R25) area to LLE -lateral aspect classified as an abscess secondary to trauma per (wound management consultant) NP (Nurse Practitioner) Area measures 6.5 x 5.0 x 4.0 cm. Tunneling noted. Adipose tissue is visible. Large amount of coagulated blood removed from wound. [MEDICATION NAME] (antibiotic) 1 gram ordered x 5 days. Wound management consultant progress notes dated 4/11/19, documents the wound to R25's left lateral knee as 6.5 cm x 5.0 cm x 4.0 cm, with exudate having Large Amount tea color. R25's Face Sheet undated, documents R25 having the following [DIAGNOSES REDACTED]. Minimum Data Set ((MDS) dated [DATE], documents R25 having severely impaired cognition, and requiring total dependence for transfer with two or more physical assistance. On 10/23/19 at 1:03 PM, V10, V12, and V14, CNAs, all assisted with a full mechanical lift transfer from R25's high back wheelchair to the bed. V14 and V12 applied the straps of R25's sling to the full mechanical lift. As V10 raised the full mechanical lift from R25's high back chair, V12 stepped away from the wheelchair, and V14 moved the high back wheelchair toward the bed, leaving R25 suspended in the air free swinging above the floor. R25's wheelchair remained unlocked prior to and during the transfer. V14, CNA, stated she was unaware of a specific policy or procedure on whether or not to lock the wheelchair. On 10/24/19 at 8:36 AM, V12, CNA, stated she has been a CNA for about 8 years. She stated she is not aware of a specific procedure on the use of the full mechanical lift, only that the lift has information printed on it for how much weight it holds. On 10/23/19 at 2:40 PM, V1, Administrator, stated R25 fell out of the full mechanical lift while being transferred. On 10/24/19 at 9:15 AM, V2, Director of Nursing (DON), stated the abscess to R25's left lower knee was the direct cause of the fall on 3/2/19, and that R25 has a deformity from having the abscess, and the wrong sling was used on her, and she fell causing the injury to her left leg. On 10/28/19 at 9:14 AM, V2, DON, stated the indentation to R25's left lower extremity measures 3.1 cm (length) by 1.0 cm (width) and is 1.1 cm deep. 10/23/19 1:58 PM, V15, Medical Director (MD), stated R25's hematoma and abscess wouldn't have happened had she not fallen from the full mechanical lift. V15 further stated R25 came to the facility as a functional quadriplegic, was in poor health and improved with therapy, and is currently declining further. 2. On 10/23/19 at 10:33 AM, V17, CNA and V16, CNA, transferred R38 from her high back wheelchair to her bed using a full mechanical lift. V16 and V17 connected the sling to the lift, raised R38 up over the highback wheelchair and over to the bed and lowered her into her bed. The highback wheelchair was not locked prior to and during the transfer. 3. On 10/23/19 at 11:40 AM, V17 and V16, transferred R36 from her bed to her highback wheelchair using a full mechanical body lift. V17 and V16 placed the sling under R36 and connected it to the lift, and raised her up over the bed and over to the wheelchair and lowered her down into the wheelchair. Only 1 brake on the wheelchair was locked. The highback wheelchair has 4 wheels, each wheel has a lock and only 1 lock was on. The wheelchair was easily moveable with 1 brake locked. On 10/24/19 at 9:45 AM, V2, DON, stated, Staff should lock the wheelchair prior to transferring residents with a mechanical lift and the facility does not have a procedure to instruct staff on transferring residents with full mechanical lifts. The Manufacturers Guidelines, Instructions for Use, dated 12/2018, documents in part, Safety Instructions, WARNING: To avoid falling during transfer, always make sure that the brakes are applied on all equipment being used.

Based on record review and interview the facility failed to operationalize the facility's abuse policy by failing to report allegations of abuse to the Administrator immediately, not investigating the allegation, and allowing two Certified Nursing Assistant to have direct contact with residents after a potential abuse incident The facility also failed to screen employees prior to hiring them; and failed to have a policy for injuries of unknown origin. This had the potential to affect all 46 residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. The findings include: 1. a) The facility's Abuse Prohibition Program Policies,definitions of abuse; example G. documents repeated verbal harassment such as name calling, cursing, yelling or rough tone of voice at a resident. It also defines neglect and identifies an example of allowing a resident to sit in urine or feces for an excessive amount of time, failed to change diaper, clothing, or bed clothing when needed. It documents that it is everyone's responsibility to report suspicions of neglect or abuse to the administrator immediately. It documents that if an employee is suspected of resident abuse, they will be immediately suspended. The allegation will be documented on an Incident Report for matters of physical abuse and on a Grievance Form for matters of suspected misappropriation of resident property or verbal abuse. An initial report will be sent to the Department Of Public Health within 24 hours of alleged abuse. It defines the Administrator as the Abuse Prevention Coordinator and documents that they will discuss the situation with the resident and / or legal representative and notify staff who need to conduct the investigation assessments which will be in narrative form on the incident report or the grievance report. These will then be given to the Abuse Prevention Coordinator. The Abuse Prevention Coordinator will investigate the matter and compose a narrative report. The Abuse Prevention Coordinator will make a determination that will be sent to the Department regarding the validity of the matter. b) A review of the facility's Abuse Prohibition Policy indicated there were no procedures to follow for injuries of unknown origin and how they would be investigated and reported to the Department. E1, Administrator, was asked for their policies and none were produced. c) The facility's Abuse Prohibition Program policy documented that all employees in all departments will complete a criminal background check. All employees are checked before hired and monthly through the nurse aid registry. The policy did not include checking past employers to determine eligibility or to check licensing boards for professional staff. 2. During the review of the facility's grievances, a grievance documented that on [DATE] R14 had stated that he was unhappy with the way one aide acts towards him. It documented that a group meeting was held with E3, Director Of Nursing (DON), E4, Social Services (SS), E5 , Social Services Director (SSD) and R14. The resolution of the grievance was that the aide was to no longer work on R14's hall. The form did not include an interview with the resident or identify the staff person that was alleged to have mistreated R14. E3 and E5 are not currently employed by the facility. E4, Social Services, is still employed by the facility . E4 was interviewed at 12:15 PM on [DATE] about the grievance. She said she recalled that R14 said that E6, Certified Nursing Assistant (CNA), had talked to him harsh and yelled at him. R14 stated that it had happened more than once. E4 said that E6 was fired shortly after the complaint. She was asked if it was reported to the Administrator, E1. E4 stated that she tells E1 everything. She said at the grievance meeting that E3, former DON, made the decision that E6 would not work on the hall where R14 resided. E6 was not suspended. On [DATE] at 11:50 AM, E1 was interviewed about the incident and did not recall what had happened. All information on the investigation was requested. On [DATE] at 10:15AM E1 stated that she recalled that she was off during that time period for medical reasons. The Department was not notified of the allegation. The allegation was not investigated by the administrator. In an interview with E10, CNA, on [DATE] at 2:10 PM, she stated she recalled an incident where E6 and R14 were screaming at each other about R14 not wanting to stand for E6. She said she went to R14 and took over care from E6. She said she reported it to the nurse but didn't recall which nurse. E6's employee file was reviewed. There was an employee warning notice dated [DATE], five days after R14 had made the grievance/abuse allegation against E6. It documented the type of offense was neglect of resident and documented "You left a resident in his wheel chair and had the curtain pulled around him. The resident normally requests to be put in bed early evening. He was exhausted. You did not relay to staff that he was still up in chair. You need to do a walk through and give the next shift information as to who still needs to be put to bed. You need to be a team player. If another complaint of this nature you may be suspended. Progressive discipline will occur." E6 refused to sign the employee warning notice and then did not show up for work. E1 was not notified of the allegation of abuse, the employee E6 was not suspended, and the Department was not notified and an investigation was not conducted. On [DATE] the facility sent E6 a letter documenting " You are considered to have abandoned your position at (facility name) due to the fact that you clocked out and left on [DATE] after one hour of working when you were scheduled for eight hours that day. In addition you did not show up or call on your scheduled days to work on [DATE]rd, [DATE] th or [DATE] th." E6's time report was reviewed for [DATE]-[DATE]. She worked 8.5 hours on [DATE] the day after the first allegation of mistreatment, 8.25 hours on [DATE]/11, 8.5 on [DATE], and 1 hour on [DATE] the day of the second allegation. E1 was interviewed on [DATE] at 2:10 PM about the allegation of neglect that occurred on [DATE]. She stated " Did not know anything about it. found out when the surveyor asked for E6's employee file." 3. During the review of the facility's grievances on [DATE], a grievance documented that on [DATE] R15 had a concern that someone on the midnight shift told her to go ahead and urinate in bed since it was already wet. There was no documentation of an interview with the resident or resident representative. No staff was identified. No staff interviews were documented. It stated that the concern was reported to E7, Licensed Practical Nurse (LPN). Actions to resolve the concern was to type a written inservice to read and sign. Review of the inservice dated [DATE] documented staff should be kind to residents and included, " NEVER, NEVER tell a resident that they can go and wet or soil the bed / brief when they are requesting to go to the bathroom even if they are wet or soiled." R15's Minimum Data Set ((MDS) dated [DATE], under cognitive patterns, scored 11 out of a possible 15 points answering most questions correctly. E7, LPN, was interviewed on [DATE] at 12:05 PM. She said that R15 had reported to her daughter that an aide had told her to go ahead and wet the bed since it was already wet. She said the daughter told her the concern. She said she reported it to E5, SSD, who no longer works at the facility, instead of E1. An interviewed of E1 at 11:50 AM on [DATE], indicated she recalled the grievance/allegation and stated that the resident could not identify the staff and that no staff would admit to it. She was asked for documentation of the investigation and none was produced during the survey. The only documentation was the written inservice for staff to read and sign. E1 did not do an investigation , narratives were not written of the interviews that were done, no names of staff, residents, or family members were listed. A narrative of the investigation determining the validity of the allegation was not done. The Department was not notified of the allegation. 4. R16's MDS, dated [DATE], under cognitive patterns, was scored 4 out of a possible 15, answering most questions incorrectly. R16's MDS dated [DATE] documents that she is dependent on staff for transfers and hygrine/bathing and needs extensive assist from staff for dressing, and eating. She expired at the facility on [DATE]. The facility's occurrence report of [DATE], documented R16 sustained an injury of unknown origin to the right lower leg. The documented resident statement was, "It hurts. I don't know what happened." Other actions to be taken were to continue to make sure side rails are padded . Cradle right lower extremity with bath blanket for comfort. Minimize movement. The report documented that there was pain when range of motion was performed. It also documented that she transfers with a mechanical lift and she was independent in bed mobility. The facilities narrative report dated [DATE] documented "R16 is a [AGE] year old female resident first admitted to this facility on [DATE]. She had been living in her daughter's home. Review of her history and physical reveals a history of advanced [MEDICAL CONDITION]'s chorea, major [MEDICAL CONDITION] and anxiety. The primary medical doctor was updated as well as her responsible party and hospice nurse." It goes on to document that, "On [DATE] the charge nurse noticed bruising to the the right lower leg, and updated the medical doctor who ordered a x-ray. Mobile x-ray was able to get the x-ray the same day and results revealed displaced fractures of the tibia and fibula. The report goes on that R16 is typically up in a reclining chair for all meals and then repositioned back in bed. R16 may have struck her lower leg on the edge of the table before the discovery. The report did not mention if staff were interviewed or how they came up with the possibility of her hitting her leg on the table. The injury of unknown origin was faxed to the Department on [DATE], seven days after the discovery, and five days after the injury was identified as a fracture. 5. During an interview with Z1, family member of R2, on [DATE] at 11:30AM, Z1 stated: a) She had witnessed E8, CNA, acting inappropriately with 2 residents on two different occasions. The first incident was in the Dining Room when a male resident (R34) stepped away from his walker and fell . "It was an accident." E8 was talking mean to the resident and stated loudly that the resident needed to be seated at the "feeder table". Z1 stated she didn't remember exactly when, about ,[DATE] months ago. Z1 stated she reported it to the E5, SSD. b) Z1 stated the second incident concerned R12 in the Dining Room. R12 was on a liquid diet and didn't want to finish her liquids. R12 started to leave the Dining Room in her wheel chair. E8 pulled the wheel chair back to the table and told R12 she was not leaving until she finished her dinner and she would not put R12 to bed until she finished drinking her liquids. Z1 stated she reported this to E1. On [DATE] at 1:05PM, E1 was interviewed about the incident of a resident falling and E8 talking mean to the resident and stating loudly that the resident needs to eat at the feeder table. E1 stated she was not aware of the incident and confirmed there was no documentation in the Grievance Log as per facility policy. E1 stated she was not informed of the complaint by E5 and that no investigation was conducted concerning the allegation. E1 stated she would terminate E8 due to past allegations and will report immediately to the Illinois Department of Public Health and begin an investigation. E1 was interviewed about the incident with E8 and R12. E1 stated Z1 had called her and told her of the incident. Z1 was upset. E1 provided a piece of paper with Z1 and E8's name on it with documentation, "R12 you will drink before you leave this table I'm not putting you to bed till you finish your dinner R12 looked sad was not crying Feels she is embarrassed. Very inappropriate..." E1 stated she did not fill out a Grievence Report as per facility policy. E1 stated she gave E8 a written warning and suspended E8 for 1 day but did not terminate E8. E1 stated E8 admitted she did it. E1 stated she considered it abuse. E1 could not provide any documentation that a thourough investigation was done. Employee Warning Notice was dated [DATE] and confirmed E8 was given a 1 day suspension. E1 stated E8 was still working at the facility part time while going to school maybe ,[DATE] days every week. E1 allowed E8 to continue to work even though she determined E8 had abused R12. On [DATE], at 10AM, E1 stated she was able to determine that R34 was the resident who fell in the Dining Room and the incident took place on [DATE]. E1 stated she did interviews with staff, residents and family during the investigation and that E8 was terminated. E1 provided documentation of her investigation. 6. Thirteen employee files were checked on [DATE] for reference checks, registry checks and if checks were made with licensing boards. E15 - E24 , CNA's, files were reviewed. The facility failed to have evidence in their files that past work histories were checked for E15 - E20, E22, and E24. The nurse aide registry was not checked in a timely manor for E17, E18 and E19. E17 was hired on [DATE], her registry check was dated [DATE]. E18 was hired on [DATE], her registry check was dated [DATE] the day the files were requested. E19 ws hired [DATE], her registry check was was dated [DATE] the day the files were requested. The files of E25, Activity Assistant, and E26, Housekeeper, were checked. The facility failed to check their past work histories for concerns. The file of E27, LPN, was checked. There was no evidence that the Department Of Professional Regulations was checked to see if their had been any disciplinary action. 7. The facility's CMS-672, Resident Census and Conditions of Residents, dated [DATE] documented the facility's census as 46. The Immediate Jeopardy was identified to have begun on [DATE] when it was determined that R15 had a concern that someone told her to go ahead and urinate in the bed since it was already wet and the facility failed to follow their abuse policy and did not investigate the allegation of potential abuse. E1 and E2 were notified of the of Immediate Jeopardy on [DATE] at 1:15PM. The facility took the following actions to remove the immediacy: 1. On [DATE] at 3:35 PM, 67 employees from all three shifts and all departments were inserviced by the Administrator on the abuse prevention program and proper reporting. Emphasis was placed on immediately reporting of suspected abuse to the Administrator; the definition and identification of suspected abuse and neglect; the investigation policy addressing the immediate barring from further contact with residents until the matter is properly investigated and resolved.. 16 staff members who could not attend the inservice, were inserviced over the phone on [DATE]. 2. On [DATE], the Administrator and Director of Nursing reviewed the facility Abuse Policy which addressed the reporting of abuse, investigation of abuse allegations, need to immediately remove the employee, family member or visitor from the facility for suspected abuse and the need to document the investigation as per their Policy and Procedure on abuse. 3. On [DATE], the Administrator was interviewed to ensure she understood the importance of immediately reporting an allegation of abuse to the Illinois Department of Public Health; removing a staff, family or visitor from the facility during an investigation; interviewing staff, which may include different shifts, family and residents to determine if allegation can be substantiated; termination of staff member if allegation is substantiated; and documentation of the investigation. 4. On [DATE], a complete review of the Abuse Prevention Program, Policy & Procedure was completed. Review showed revisions to the Policy and Procedure that included the investigation of injuries of unknown origin, obtaining finger print report and reference checks and reporting immediately to the Department of Public Health. 5. On [DATE], an inservice was given to staff responsible for reference checks and check with the CNA registry and/or Professional Regulation were to be done on all residents before hire. The Business Office Manager will monitor all applications to ensure that this is being done.

A) Based on record review and interview, the facility failed to report an allegation of abuse to the Administrator immediately, allowed two Certified Nursing Assistant's to have direct contact with residents after a potential abuse incident, and failed to investigate potential abuse. This had the potential to affect all 46 residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. Findings include: 1. During the review of the facility's grievances, a grievance documented that on [DATE] R14 had stated that he was unhappy with the way one aide acts towards him. It documented that a group meeting was held with E3, Director Of Nursing, (DON): E4, Social Services (SS); E5 , Social Services Director, (SSD); and the resident (R14). The resolution of the grievance was that the aide was to no longer work on R14's hall. The report did not mention the staff that was not treating him properly or what he was accusing them of and did not include an interview with the resident . R14's Minimum Data Set, under cognitive patterns dated [DATE], scored him at a 7 out of 15 possible points answering some question correctly and some not correctly. E3 and E5 are not currently employed by the facility. E4, Social Services was still employed by the facility . E4 was interviewed at 12:15 PM on [DATE] about the grievance. She said she recalled that R14 stated that he said that E6, Certified Nursing Assistant, (CNA) had talked to him harsh and yelled at him. R14 stated that it had happened more than once. She said that E6 was fired shortly after the complaint. She was asked if it was reported to the Administrator, and E4 stated that she tells E1 everything. She said at the grievance meeting that E3, former DON, made the decision that E6 would not work on the hall where R14 resided. On [DATE] at 11:50 AM, E1, Administrator, was asked about the incident, and did not recall what had happened. Additional information on the investigation was requested. On [DATE] at 10:15 AM E1 stated that she recalled that she was off during that time period for medical reasons. The Department was not notified of the allegation. According to E10, CNA, on [DATE] at 2:10 PM, she stated she recalled an incident where E6 and R14 were screaming at each other about R14 not wanting to stand for her. She said she went to R14 and took over care from E6. She said she reported it to the nurse but didn't recall which nurse. E6's employee file was reviewed. There was a employee warning notice dated [DATE], five days after R14 had made the grievance/abuse allegation against E6. It documented the type of offense was neglect of resident and documented "You left a resident in his wheel chair and had the curtain pulled around him. The resident normally requests to be put in bed early evening. He was exhausted. You did not relay to staff that he was still up in chair. You need to do walk through and give the next shift information as to who still needs to be put to bed. You need to be a team player. If another complaint of this nature you may be suspended. Progressive discipline will occur." E6 refused to sign the employee warning notice and then did not show up for work. On [DATE] the facility sent E6 a letter documenting " You are considered to have abandoned your position at (name of facility) due to the fact that you clocked out and left on [DATE] after one hour of working when you were scheduled for eight hours that day. In addition you did not show up or call on your scheduled days to work on [DATE], [DATE], or [DATE]. E6's time report was reviewed for [DATE]-[DATE]. She worked 8.5 hours on [DATE] the day after the first allegation of mistreatment, 8.25 hours on [DATE]/11, 8.5 on [DATE], and 1 hour on [DATE] the day of the second allegation. No further documentation was provided concerning E6's employee warning for neglect. 2. During the review of the facility's grievances, a grievance documented that on [DATE] R15 had a concern that someone on the midnight shift told her to go ahead and urinate in bed since it was already wet. No staff was identified. It stated that the concern was reported to E7, Licensed Practical Nurse (LPN). Actions to resolve the concern was to type a written inservice to read and sign. Review of the inservice dated [DATE] documented being kind to residents and included " NEVER, NEVER tell a resident that they can go and wet or soil the bed / brief when they are requesting to go to the bathroom even if they are wet or soiled." R15's MDS dated [DATE] under cognitive patterns scored 11 out of a possible 15 points answering most questions correctly. On [DATE] at 12:05 PM, E7 said that R15 had reported to her daughter that an aide had told her to go ahead and wet the bed since it was already wet. She said the daughter told her the concern. She said she reported it to E5, Social Services, who no longer works at the facility. At 11:50 AM on [DATE], E1 stated she recalled the grievance / allegation and stated that the resident could not identify the staff and that no staff would admit to it. She was asked for documentation of the investigation and none was produced during the survey. The only documentation was a written inservice for staff to read and sign. The Department was not notified of the allegation. 3. During an interview with Z1, family member of R2, on [DATE] at 11:30AM, Z1 stated she had witnessed E8, CNA, acting inappropriately with 2 residents on two different occasions. a) The first incident was in the Dining Room when a male resident (R34) stepped away from his walker and fell . "It was an accident." E8 was talking mean to the resident and stated loudly that the resident needed to be seated at the "feeder table". Z1 stated she didn't remember exactly when, about ,[DATE] months ago. Z1 stated she reported it to the E5, SSD. b) Z1 stated the second incident, concerned R12 in the Dining Room. R12 was on a liquid diet and didn't want to finish her liquids. R12 started to leave the Dining Room in her wheel chair. E8 pulled the wheel chair back to the table and told R12 she was not leaving until she finished her dinner and she would not put R12 to bed until she finished drinking her liquids. Z1 stated she reported this to E1. On [DATE] at 12:10PM, E1 was interviewed about the incident of a resident falling and E8 talking mean to the resident and stating loudly that the resident needs to eat at the feeder table. E1 stated she was not aware of the incident but it should be in the Grievance Log. E1 stated she was not informed of the complaint by E5 and that no investigation was conducted concerning the allegation. E1 stated E8 had been written up in the past and suspended for a day due to her conduct towards residents. Review of the facility Grievance Log shows no GRIEVANCE/COMPLAINT REPORT was documented concerning complaint of E8 being mean to a male resident who had fallen and stated loudly that he needs to eat at the feeder table. On [DATE], at 10AM, E1 stated she was able to determine that R34 was the resident who fell in the Dining Room. E1 stated she did interviews with staff, residents and family during the investigation. On [DATE], during meeting at 12:10PM, E1 was interviewed about the incident with E8 and R12. E1 stated Z1 had called her and told her of the incident. Z1 was upset. E1 provided a piece of paper with Z1 and E8's name on it with documentation, "R12 you will drink before you leave this table I'm not putting you to bed till you finish your dinner R12 looked sad was not crying Feels she is embarrassed. Very inappropriate..." During interview E1 stated E8 admitted she did it and E8 was suspended. When asked if she considered it abuse, E1 stated "It is abuse." E1 stated she felt if she suspended E8 she would know she is being watched. E1 stated she followed up by asking the Nurses how it was going with E8. E1 confirmed she did not document the allegation on the Grievance Form. Employee Warning Notice of [DATE] documents first warning for being disrespectful to a resident. Description of Infraction is documented, "It was reported that you spoke to a resident in a disrespectful manner in the dining room on [DATE]. It was reported on [DATE]. You were very unkind in your treatment of [REDACTED]." The Employee Warning Notice documented E8 was suspended for a day. 4. The facility's CMS-672, Resident Census and Conditions of Residents, dated [DATE] documented the facility's census as 46. The Immediate Jeopardy was identified to have begun on [DATE] when it was determined that R15 had a concern that someone told her to go ahead and urinate in the bed since it was already wet and the facility did not investigate the allegation of potential abuse. E1 and E2 were notified of the of Immediate Jeopardy on [DATE] at 1:15PM. The facility took the following actions to remove the Immediacy: 1. On [DATE] at 3:35 PM, 67 employees from all three shifts and all departments were inserviced by the Administrator on the abuse prevention program and proper reporting. Emphasis was placed on immediately reporting of suspected abuse to the Administrator; the definition and identification of suspected abuse and neglect; the investigation policy addressing the immediate barring from further contact with residents until the matter is properly investigated and resolved.. 16 staff members who could not attend the inservice, were inserviced over the phone on [DATE]. 2. On [DATE], the Administrator and Director of Nursing reviewed the facility Abuse Policy which addressed the reporting of abuse, investigation of abuse allegations, need to immediately remove the employee, family member or visitor from the facility for suspected abuse and the need to document the investigation as per their Policy and Procedure on abuse. 3. On [DATE], the Administrator was interviewed to ensure she understood the importance of immediately reporting an allegation of abuse to the Illinois Department of Public Health; removing a staff, family or visitor from the facility during an investigation; interviewing staff, which may include different shifts, family and residents to determine if allegation can be substantiated; termination of staff member if allegation is substantiated; and documentation of the investigation. B) Based on record review and interview the facility failed to investigate a how a displaced [MEDICAL CONDITION]/fibula occurred for 1 resident (R16) in the supplemental sample. Findings include: R16's MDS dated [DATE], under cognitive patterns she scored 4 out of a possible 15 answering most questions incorrectly. R16's MDS dated [DATE] documents that she is dependent on staff for transfers, hygiene/bathing, and needs extensive assist from staff for dressing, and eating. She expired at the facility on [DATE]. Based on the facility's occurrence report of [DATE], R16 sustained an injury of unknown origin to the right lower leg. The documented resident statement was "It hurts. I don't know what happened." Other actions to be taken were to continue to make sure side rails are padded . Cradle right lower extremity with bath blanket for comfort. Minimize movement. The report documented that there was pain when range of motion was performed, transfers with a mechanical lift and she was independent in bed mobility. The facility's narrative report dated [DATE] documented "R16 is a [AGE] year old female resident first admitted to this facility on [DATE]. She had been living in her daughter's home. Review of her history and physical reveals a history of advanced [MEDICAL CONDITION]'s chorea, major [MEDICAL CONDITION] and anxiety. The primary medical doctor was updated as well as well as her responsible party and hospice nurse." It goes on to document that "On [DATE] the charge nurse noticed bruising to the the right lower leg, and updated the medical doctor who ordered a x-ray. Mobile x-ray was able to get the x-ray the same day and results revealed displaced fractures of the tibia and fibula. The report goes on that R16 is typically up in a reclining chair for all meals and then repositioned back in bed. R16 may have struck her lower leg on the edge of the table before the discovery. The report did not mention if staff were interviewed or how they came up with the possibility of her hitting her leg on the table. In an interview with E1 on [DATE] at 10AM, she confirmed that the one investigation that was reviewed was the complete investigation.

Based on interview, observation and record review, the facility failed to seek timely treatment for [REDACTED]. This failure resulted in a no treatments and decline in R1's coccyx pressure ulcer that included tunneling within one week of admission. Findings include: 1. According to the Admission Record, R1 was transferred to the facility from another nursing home on 11/22/11 with multiple pressure ulcers. He has diagnoses, in part, of [MEDICAL CONDITION] with [MEDICAL TREATMENT], Diabetes Mellitus, Dysphagia, gastrostomy tube and Decubitus ulcers. physician's orders [REDACTED]. Current physician orders [REDACTED]. The Interim Care Plan dated 11/22/11 under Skin Issues identifies the goal as "I will have no further skin issues" with interventions for lotion daily and keep clean/dry but neglects to include specifics to care including treatment of [REDACTED]. The facility's pressure ulcer assessments documented on the back side of the November 2011 Treatment Record by E33 shows R1's wound measurements on admission: 1) Stage I left outer aspect foot 3cm x 0.8cm red, 2) Ball of right foot 1.1cm x 0.7cm black/unstagable, 3) Ball of left foot 1.5cm x 1.5cm black/increased soft tissue, 4) Right outer aspect of foot stage I 3cm x 1.5cm red, 5) Right heel unstagable 4cm x 2.5cm black/red, 6) Coccyx .3 x .3cm, no depth, stage IV flesh colored. On 11/30/11 at 9:40am, E33 stated she assessed R1's pressure ulcers on admission and stated R1 had the wounds previously which were treated by a wound specialist. E33 stated "she tried to get orders and called yesterday (11/29/11)." E33 confirmed she received no orders on admission and she thought R1's physician, Z4, wanted him to see the nurse practitioner (NP) before orders were given. E33 stated the facility requested an order for [REDACTED]. E33 provided no documentation that she contacted the physician for orders on R1's admission. A Communication Fax form dated 11/23/11 to Z4, MD from the facility includes a statement "Need order Specialized Wound Management" with "NO" written beside it but include no treatment orders to be used in the interim as they waited for the Nurse Practitioner to come. There is no documentation present in the clinical record that Z4, MD was made aware R1 had no current treatment orders on admission and no evidence that he was notified of the status of the pressure ulcers on admission. There is no further communication from the facility between 11/23/11 and 11/28/11 when Z4 was faxed a form that requested an order for [REDACTED]. A wound assessment dated [DATE] showed a slight decline in R1's coccyx ulcer in depth only and was measured at that time as being 0.1cm deep. 0.3cm x 0.3cm. All other areas showed improvement. The nurses notes dated 11/29/11 at 4:15pm show a new order received from Z4 for R1's coccyx ulcer and the unstagable ulcers on both feet with a note that R1 will be seen by Z4's nurse practitioner who will address the wounds on 12/1/11. The new orders included an order to turn and reposition every 1 to 2 hours and Cleanse the coccyx ulcer with normal saline (NS), apply Santyl lightly pack c (with) Calcium Alginate cover c 4 x 4 and Allevyn dressing change every day and as needed. The treatment sheets from 11/22/11 through 11/29/11 do not reflect any treatments or care being done to any of R1's pressure ulcers. On 12/1/11 at 9:25am E32, LPN stated R1 had not been seen by the nurse practitioner yet and stated she knew he had no orders for his pressure ulcers since admission. E32 stated she worked days often since R1's admission and would cleanse all his wounds with normal saline but did not apply a dressing because she "had no order for it." E32 stated it was unusual to have no orders for so long but that she thought R1's physician wanted to wait for orders until he saw his nurse practitioner. E32 stated R1 came with no orders for pressure ulcer treatments and she acknowledged that she did not notifiy him to obtain any. The facility's policy and procedure entitled SKIN TREATMENT PROTOCOLS identifies that it is the policy of the facility to "use uniform treatment protocols for all wound types unless otherwise specifically ordered by physician." Under pressure ulcers, it identifies assessing the ulcers and providing "treatment as prescribed by physician" along with preventative measures that include turning/repositioning, 24 hour observation checklist for CNA's (Certified Nurses Aides) to monitor existing wounds, skin protectors, and "continue to document condition of area on treatment sheet, weekly wound sheet and "notify physician as further and/or different treatment may be required. The policy is dated 7/7/04. The policy entitled PROTOCOL FOR ASSESSMENT AND PREVENTION OF SKIN PROBLEMS/DECUBITUS is dated 8/8/01 and include directives to "follow the physician's orders [REDACTED]. On 12/1/11 at 10:20pm, R1 was in bed with the head of the bed elevated when Z3, NP, saw him. R1 had two cloth incontinent pads under him and his feet had protective boots and were resting tightly against the foot board of the bed. Z3 donned gloves and assisted R1 to roll to his right side. Z3 removed a [MEDICATION NAME] dressing off R1's coccyx area. His ulcer was a dimpled area which had white surrounding tissue. Z3 assessed the ulcer measurements with a tape measure and then using a q-tip end, assessed R1's wound to have 0.7cm tunneling present which had not been previously identified. Z3 then moved to assess R1's feet and without changing or removing her gloves, removed R1's boots then socks and assessed his ulcers on his heels. She then started to put his socks back on when asked about the black eschar area on the ball of his left foot. Z3 measured the eschar area and moved onto the other foot with the same gloves on. At 10:40am on 12/1/11, Z3 stated she had been on vacation the previous week and had not been out to see R1. She provided faxed communication sheets when asked if R1's physician had been notified on admission that he had no treatment orders. Z3 reviewed the sheets and stated the physician had no notification until 11/28/11 regarding treatment orders and that had he been told that R1 came with no orders, "he would have given an order, probably, to follow their protocol" until she got in to see him. When asked if the lack of treatment to R1's pressure ulcer could have contributed to its decline stated "yea" and agreed that a lack of treatment does not promote healing. Z3's progress note dated 12/1/11 documents R1's coccyx ulcer as 0.5 x 0.5cm with a 0.7cm depth, wound bed pink, small amount of exudate, surrounding area appears to be an area of healed wound, stage III. Z3 ordered Prototic 0.1% Topical Ointment Apply to wound and cover with [MEDICATION NAME] q (every) three days and as needed. On 12/14/11 at 11:45am, E33 was asked about the staging difference between her staging R1's coccyx as a stage IV on admission and the NP staging it a III on 12/1/11. E33 stated she staged it a IV because the wound was staged a IV at his prior placement and she didn't want to downgrade it. The policy for skin treatments identify a stage IV as a "full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone." The policy also indicates for stage II, III and IV's "Charge nurse or treatment nurse should assess and measure area. Document treatment sheets or infection control check sheets and/or in nurses notes regarding date, location, stage, size, appearance, depth, drainage (color), odor (amount), and signs and symptoms of infection. On 12/14/11 at 11:30am, E32, LPN stated R1 has been seen weekly by the Z23, NP and that his coccyx wound is deteriorating. E32 stated he sits for long periods of time in [MEDICAL TREATMENT] three times weekly and with the tube feeding, has to have the head of the bed elevated. Nurses Notes dated 12/14/11 at 730am document "decline in coccyx wound ^ (increased) in size to 0.7cm w x 0.5cm L x 0.4cm depth with scant serosanguinous drainage" 2. R3's Minimum Data Set, MDS, dated 10/21/11 identifies him to be A [AGE] year old male admitted to the facility on 10/13/10 with diagnoses, in part, of Metabolic [MEDICAL CONDITIONS] and obesity. The MDS identifies him requires extensive assist of staff for bed mobility and is dependent on staff for transfers. According to the care plan dated 10/26/11, R3 is at risk for pressure ulcer development due to incontinence and decreased mobility and a history of ulcers. Interventions include turning schedule, monitor skin, position with pillows. On 11/29/11 during tour of the building at 9:20am, R3 was up in his wheelchair at bedside. He was identified by E33, to have a history of pressure ulcers. At 11am, R3 continued to be up in his wheelchair at bedside. At 11:07am, he was propelled by staff to the dining room and left at a table in his wheelchair. He remained in the wheelchair throughout lunch and at 12:32pm, was taken to his room. He was transferred via a mechanical lift to bed. There were 2 cloth incontinent pads on his bed.. He had deep red/white creases throughout his upper thighs and across his buttocks. His paper incontinent brief was saturated with urine. E36, Certified Nurse Aid, CNA provided poor incontinent care as E35 CNA, assisted in turning him. His coccyx area was red, scrotum red with discoloration. R3 had no protection on his feet and refused to float them when E36 attempted to do so. E36 stated R3 was transfered to his wheelchair between 9 and 9:30am. This was confirmed by E35. No fluids were offered. At 2pm, R3 was observed to be in the same position as he was at 12:20pm. 3. R4's Physician order [REDACTED]. There is an order documented on 10/13/11 to apply TAO to ulcer on 1st and 3rd toe on right foot daily after cleansing with Normal Saline and cover with dressing until healed. R4's Care Plan of 9/28/11 documents R4 has chronic reoccurring [MEDICAL CONDITION] of her lower legs with a [DIAGNOSES REDACTED]. Approach is to do skin assessment with daily care and weekly bath. Assess legs daily with care for blistering , redness, warm heat. Nurses Note of 10-9-11 documents R4's bilateral lower extremities are [MEDICAL CONDITION]. Right great toe has an open area. Residents says her shoes are rubbing this area...will see podiatrist Thursday. Nurses Note of 10-13-11 documents the Podiatrist here and gave orders for Keflex 500 mg TID (twice a day) x 7 days; X- ray right foot for [MEDICAL CONDITION] and open lesion on 1 and 3 toes of right foot; Cleanse ulcers with normal saline solution and apply TAO with dressing until healed; Use slipper to right foot until ulcers healed; Have MD (Medical Doctor) sign for diabetic shoes. Facility WEEKLY Pressure Ulcer Surveillance Report of 10-12-14 identifies R4 as developing an in house pressure sore on 10-9-11on her right great toe, a stage 2 measuring .9 cm wide x 1 cm long. On 10-20-11 Report identifies another Stage 2 facility acquired pressure sore on R4's 3rd digit of her Right foot measuring .6 cm long x 1 cm wide. Podiatrist report of 10-13-11 documents R4 has two open [MEDICAL CONDITION] for past few days may have been caused by tight shoes. Has diabetic shoes but they are tight and the Velcro is broke. On 11-29-11 at 1:35PM, R4 stated she developed pressure sores on her toes from wearing shoes that were too big and were rubbing. On 11-30-11 at 9:10AM, E7 LPN was observed to do treatment on R4's toes. E7 stated she had already took off the bandages before breakfast. E7 removed R4's socks and R4 did not have dressings on her pressure sores. R4's right great toe had an open pressure sore the size of a dime, red with white edges . The right middle toe had an open red pressure sore the size of a dime and red. R4's lower legs were [MEDICAL CONDITION]. E7 washed the pressure sore on the right great toe with soapy water, rinsed and dried. E7 placed TAO on gauze and then on R4's toe. E7 then put another gauze R4's right great toe. E7 used tape to adhere the dressing. E7 then proceeded to wash, rinse and dry the right middle toe. E7 placed normal saline on a gauze pad that had been sitting on the TAR, put on clean gloves and wiped the toe with gauze and normal saline. E7 put on new gloves and placed TAO on a gauze pad and administered to the toe with the gauze and then got another gauze pad and strips of tape and bandaged the right middle toe. On 12-14-11 at 11:30AM, E33, Treatment Nurse, stated CNA's should identify reddened areas. E33 confirmed R4's pressure sores were not identified until they were already open. 4. On 11-30-11, R17 was observed to be in an activity at 10:30AM in the Dining Room and remained at the table in her wheel chair throughout the lunch meal. R17 was observed to get her food at 11:40AM and remained up in her wheel chair without being repositioned when observation was discontinued at 1:05PM. R17's MDS of 11-28-11 identifies R17 to be at risk for developing pressure sores; requiring extensive assistance of 1 for bed mobility; and requiring extensive assistance of 2 or more staff for toilet use and transfer. R17's Pressure Ulcer Care Area Assessment of 9-6-11 states R17 is at risk for developing pressure sores and requires assistance with mobility and hygiene. Assessment identifies R17 as being frequently incontinent of bladder and occasionally bowel; Participates in bladder program; Barrier cream is used; Cushion for wheel chair and therapeutic mattress for bed. There is nothing on the assessment that addresses repositioning. R17's Care Plan of 9-8-11 documents R17 is at risk for pressure areas. (There is nothing on the Care Plan addressing repositioning R17 or on the CNA Care Plan Guide. On 12-14-11 at 10:50AM, E31, Care Plan Nurse stated R17 is at risk for developing pressure sores and should be repositioned every 2 hours. E31 confirmed there was nothing on the Care Plan about repositioning R17 and how often. E31 stated it should be on the Care Plan.

Based on record review, observation and interview, the facility failed to assess, analyze the circumstances of falls, re-evaluate for effectiveness of interventions, attempt alternative interventions and supervise resident to minimize the risk for recurring falls and/or serious injuries for 3 of 9 residents (R7, R11, R12) reviewed for falls. This failure resulted in R12 falling during unsupervised toileting and sustaining a right arm fracture. . Findings include: 1. R12's Occurrence Report, dated 5-29-11, documented R12 fell during unsupervised toileting and was sent to a local hospital for an evaluation. R12's Radiology Report, dated 5-30-11, documented R12 received a two part fracture of the proximal humerus, right arm. E32, Licensed Practical Nurse (LPN), stated, on 12-14-11 at 8:40a.m., R12 did not have safety awareness and that she should not leave R12 alone during care. E2, Director of Nursing (DON), stated, on 12-14-11 at 8:50a.m., that R12 did not have safety awareness. E31, Care Plan Nurse, stated, on 12-14-11 at 8:55a.m., R12 did not have safety awareness and that she agreed R12 could not be left alone during toileting. R12's Minimum Data Set (MDS), dated [DATE], documented extensive assistance of one person physical assistance with mobility and toileting, unsteady balance and only able to stabilize with human assistance with, in part, from moving on and off toilet and bilateral lower extremity impairment. R12's Care Plan, dated 5-30-11, documented "staff to be inserviced of falls and importance of staying supervising resident during b/r (bathroom) visits." The facility's Fall Prevention Protocol, dated 8-27-09, documented if the resident has compromised sitting balance (check MDS) scoring and/or is cognitively impaired and/or attempts to rise from chair/bed without needed assistance, staff will be instructed and supervised to provide continuos up close supervision during toileting to prevent fall." 2. R7's Occurrence Report, dated 4-18-11, documented R7 fell in the beauty shop and received a forehead laceration. The facility's investigation, not dated, documented, in part, "Beautician stated she knew she should not leave the resident but only left her for a minute. Beautician was told that her services were no longer needed." R7's MDS, dated [DATE], documented R7 was cognitively impaired, extensive assistance of one person physical assistance with mobility, functional limitation in upper and lower extremities, unsteady balance only able to stabilize with human assistance with moving from seated to standing position and surface to surface transfer. R7's Fall Risk Assessment, dated 2-27-11, documented R7 was a high risk for falls. It was also noted "4-18-11 fall with with injury left unattended at beauty salon reprimanded stylist procedure protocol for res (resident) while in salon." R31 stated, on 12-14-11 at 10:45a.m., R7 did not have safety awareness. 3. R11'a MDS dated [DATE] identifies her to be totally dependent on staff for all aspects of mobility and has contractures upper and lower extremeties According to the care plan dated 10/26/11, R11 is at risk for falls due to poor posture and safety awareness. The goal is to have no falls through the next review. Interventions include 2 assist for transfers, personal alarm at all times, address immediately if sounding. According to the care plan, R11 had two falls within 9 days (4/29/11 and 5/7/11). An incident report dated 4/29/11 documents that R11 fell from her wheelchair while sitting at the dining room table. The incident report indicated at 10:40am, R11's alarm was sounding and R11 was found on the floor on her back laying toward the right side. R11 sustained 2 skin tears measuring 5cm x 2cm on her right arm. The only intervention implemented as a result of the fall is to have occupational therapy work with R11 for posture. There are no new interventions for direct care staff implemented at the time. On 5/7/11, R11 is documented in the care plan as falling again and sustaining a laceration of the forehead which required a trip to the emergency room for sutures. The Incident Report dated 5/7/11 indicates the alarm was "not sounding" when R11 was observed on the floor on her left side at 10:30am. The fall was unwitnessed. R11 had a "inverted "V" shape laceration 2.5cm x 2cm to middle of forehead." R11 was sent to the emergency room and returned with sutures. The facility implemented a lap cushion upon her return from the hospital. Although the report indicates that R11's personal alarm was not sounding at the time of the fall, there is no explanation/investigation as to why it wasn't. On 12/1/11 at 1:07pm, R11 was observed in her wheelchair asleep at the nurses station. She had a splint on her left elbow and a mechanical lift sling under her. R11 appeared totally dependent on staff.

Based on interview, observations and record review, the facility neglected to assess and treat multiple pressure ulcers for 1of 4 residents (R1) reviewed for pressure ulcer treatment and prevention in the sample of 12. This failure resulted in R1 having no treatment orders from admission on 11/22/11 until 11/29/11 for a stage III coccyx pressure ulcer which showed deterioration with tunneling on reassessment 12/1/11. Findings include: 1. According to the Admission Record, R1 was transferred to the facility from another nursing home on 11/22/11 with multiple pressure ulcers. He has diagnoses, in part, of [MEDICAL CONDITION] with [MEDICAL TREATMENT], Diabetes Mellitus, Dysphagia, gastrostomy tube and Decubitus ulcers. physician's orders [REDACTED]. The facility neglected to contact the physician regarding the need for treatment orders immediately following his admission to the facility. The Skin Condition Report completed by E33, Licensed Practical Nurse (LPN)/Treatment Nurse, on admitted d 11/22/11 identified 6 pressure ulcers ranging from stage I to IV and unstagable on his feet and coccyx. The Interim Care Plan dated 11/22/11 under Skin Issues identifies the goal as "I will have no further skin issues" with interventions for lotion daily and keep clean/dry but neglects to include specifics to current ulcers and the need for treatment of [REDACTED]. The facility's pressure ulcer assessments done on 11/22/11 E33 documented, on the back side of the November 2011 Treatment Record, shows R1's wound measurements on admission: 1) Stage I left outer aspect foot 3cm x 0.8cm red, 2) Ball of right foot 1.1cm x 0.7cm black/unstagable, 3) Ball of left foot 1.5cm x 1.5cm black/increased soft tissue, 4) Right outer aspect of foot stage I 3cm x 1.5cm red, 5) Right heel unstagable 4cm x 2.5cm black/red, 6) Coccyx .3 x .3cm, no depth, stage IV flesh colored. On 11/30/11 at 9:40am, E33 confirmed she assessed R1's pressure ulcers on admission and stated R1 had the wounds previously which were treated by a wound specialist. E33 stated "she tried to get orders and called yesterday (11/29/11)." E33 confirmed she received no orders on admission stating she thought R1's physician, Z4, wanted him to see the Nurse Practitioner (NP) before orders were given. E33 was unable to provide any documentation or evidence that R1's physician was aware of him having no treatment orders on transfer. A Communication Fax form dated 11/23/11 to Z4, MD from the facility includes a statement "Need order Specialized Wound Management" with "NO" written beside it but included no treatment orders to be used in the interim as they waited for the Nurse Practitioner to come. There is no further communication from the facility between 11/23/11 and 11/28/11 when the facility faxed a communication form to Z4's office with a repeated requested for an order for [REDACTED]. A wound assessment dated [DATE] showed a slight decline in R1's coccyx ulcer in depth only and was measured at that time as being 0.1cm deep. 0.3cm x 0.3cm. The treatment sheets from 11/22/11 through 11/29/11 neglect to reflect any treatments or care being done to any of R1's pressure ulcers. On 12/1/11 at 9:25am E32, LPN stated R1 had not been seen by the nurse practitioner yet and stated she knew R1 had no orders for his pressure ulcers since admission. E32 stated she worked days often since R1's admission and would cleanse all his wounds with normal saline but did not apply a dressing because she "had no order for it." E32 stated it was unusual to have no orders for so long but that she thought R1's physician wanted to wait for orders until he saw his nurse practitioner. E32 stated R1 came with no orders for pressure ulcer treatments and acknowledged that she did not notify him to obtain any. The facility policy and procedure entitled SKIN TREATMENT PROTOCOLS to ensure that R1 received treatment of [REDACTED]." Under pressure ulcers, it identifies assessing the ulcers and providing "treatment as prescribed by physician" along with additional preventative measures that include turning/repositioning and to "notify physician as further and/or different treatment may be required." The policy is dated 7/7/04. The policy entitled PROTOCOL FOR ASSESSMENT AND PREVENTION OF SKIN PROBLEMS/DECUBITUS is dated 8/8/01 and include directives to "follow the physician's orders [REDACTED]. This failure resulted in R1's coccyx wound deteriorating. On 12/1/11 at 10:20pm, R1 was in bed with the head of the bed elevated when Z3, NP, assessed his pressure ulcers. Z3 assessed the ulcer measurements as measuring 0.5cm x 0.5cm with a 0.7cm tunneling present which had not been previously identified, stage III. This shows a decline from the assessment done 2 days prior on 11/28/11. At 10:40am on 12/1/11, Z3 stated she had been on vacation the previous week and had not been out to see R1. She provided faxed communication sheets when asked if R1's physician had been notified on admission that he had no treatment orders. Z3 reviewed the sheets and stated the physician had no notification until 11/28/11 regarding treatment orders and that had he been told that R1 came with no orders, "he would have given an order, probably, to follow their protocol" until she got in to see him. When asked if the lack of treatment to R1's pressure ulcer could have contributed to its decline stated "yea" and agreed that a lack of treatment does not promote healing. Z3's progress note dated 12/1/11 documents R1's coccyx ulcer as 0.5 x 0.5cm with a 0.7cm depth, wound bed pink, small amount of exudate, surrounding area appears to be an area of healed wound, stage III. Z3 ordered Prototic 0.1% Topical Ointment Apply to wound and cover with [MEDICATION NAME] q (every) three days and as needed. On 12/14/11 at 11:45am, E33 was asked about the staging difference between her staging R1's coccyx as a stage IV on admission and the NP staging it a III on 12/1/11. E33 stated she staged it a IV because the wound was staged a IV at his prior placement and she didn't want to downgrade it, therefore, E33 neglected to accurately assess the current condition of R1's pressure ulcer at the time of admission. The policy for skin treatments identify a stage IV as a "full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone." The policy also indicates for stage II, III and IV's "Charge nurse or treatment nurse should assess and measure area. Document treatment sheets or infection control check sheets and/or in nurses notes regarding date, location, stage, size, appearance, depth, drainage (color), odor (amount), and signs and symptoms of infection. E33's documentation fails to reflect a stage IV ulcer on admission. On 12/14/11 at 11:30am, E32, LPN stated R1's coccyx wound is deteriorating. E32 stated he sits for long periods of time in [MEDICAL TREATMENT] three times weekly and with the tube feeding, has to have the head of the bed elevated. Nurses Notes dated 12/14/11 at 730am document "decline in coccyx wound ^ (increased) in size to 0.7cm w x 0.5cm L x 0.4cm depth with scant serosanguinous drainage" The facility's policy defines Neglect as "a failure in a long term care facility to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a resident or in the deterioration of a residents physical or mental condition. Neglect may or may not be intentional." The policy includes examples of neglect as "staff not providing medical care promptly."