Every finding on record at Integrity HC of Marion

Based on interview and record review, the facility failed to ensure sufficient staff to meet residents' needs in a timely manner. This has the potential to affect all 108 residents currently residing at the facility. Findings Include:1. R9's admission Record documented an original admission to the facility on [DATE] and included diagnoses of acute respiratory failure, diabetes mellitus 2, anemia, anxiety disorder, and cognitive communication deficit. R9's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R9's current Care Plan includes the following Focus areas of, 1. R9 has a functional self-care deficit related to impaired balance, muscoskeletal impairment related to left femur fracture, pain and activity intolerance. R9 is dependent on staff for some functional tasks. Goal for this focus area is that R9 will maintain current level of function in transfers as evidenced by functional score through the next review date of 7/15/26. Interventions for this focus area include using a mechanical lift for all transfers for increased safety and encourage R9 to use call bell for assistance. On 7/1/26 at 10:45 AM, R9 stated the call light system is not working currently so they have given her a whistle to use when she needs assistance. R9 stated she has fractured her back and is currently using a bed pan due to pain when transferred. R9 went on to state she cannot remember the exact dates, but she has had incontinence episodes due to prolonged wait time for staff to respond to her whistle. R9 stated she feels the longest wait times for staff response time is after dinner and through the midnight hours. 2. R12's admission Record documented an initial admission to the facility on 8/29/25 and included diagnoses of cerebral infarction, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominate side, major depressive disorder and cognitive communication deficit. R12's MDS, dated [DATE], documented R12 has moderate cognitive impairment with a BIMS score of 8. This same MDS documented R12 is dependent on staff for toileting hygiene and is frequently incontinent of bladder and bowel. R12's current Care Plan documents a Focus area of R12 having a functional self-care performance deficit related to history of cerebral vascular accident with left sided weakness and left sided neglect and cognitive deficits. The goal for this problem area is that R12 will maintain current level of function as evidenced by functional score through the next review date of 9/4/26. Interventions for this problem area include: encourage R12 to use call bell for assistance and to use mechanical sling for all transfers. On 7/1/26 at 11:30 AM, R12 stated she does have to wait longer times in the evening and overnight when she uses her call light. R12 also added weekends seem to have less staff available, which makes them take longer to assist her when she needs help. At this time, V25 (Family Member) stated the staff they have work hard but they just do not have enough, especially on 'second shift' during the week and then the weekends seem to be low staffed overall. 3. R8's admission record documents an original admission date to the facility of 3/4/2024. This document includes the following diagnosis: anemia, muscle weakness, and need for assistance with personal care. R8's MDS, dated [DATE], documented a BIMS score of 15, indicating that R12 is cognitively intact. This same MDS also documents that R8 is occasionally incontinent of the bladder. R8's care plan documents a focus area of functional self-care performance deficit related to low endurance, activity intolerance, impaired balance, and oxygen dependence and weakness. The goal for this problem area is that R8 will improve current level of function in transfers as evidenced function score through the review date of 9/12/26. The interventions include that R8 to use the call bell for assistance and to check for incontinence and wash, dry, perineum and change clothing as needed after an incontinence episode. On 7/1/26 at 1:00 PM, R8 stated her call light system does not work, and she has been given a dinner bell to use when she needs assistance. R8 stated in the evening overnight hours, they do not have enough staff to answer the call timely. R8 stated she needs help with her incontinence brief and has to wait longer lengths of time 30 minutes or more. On 7/1/26 at 4:45 AM, V5 (Certified Nurse Assistant/CNA) stated she is working 2AM-8AM this morning per volunteer due to staff needed to cover a shift. V5 stated she is the only one assigned to the 200 hall. V5 went on to state 5 CNA's total are currently working on night shift, including supervisor. V5 stated she has only been able to check 4 rooms since getting here a little before 2AM and has 8 rooms or 11 residents who haven't been able to check on yet on her hall since she arrived.On 7/1/26 at 9:30 AM, V23 (Registered Nurse) stated she is predominately day shift, but she hears from staff and residents both that nights and weekends do not have enough CNA's to answer call lights timely and get to all the resident care needs. On 7/1/25 at 10:30 AM, V1 (Administrator) stated they have advertisements out to hire for Certified Nurse Assistants (CNA's) for nights and weekend shifts. V1 stated these shifts seem to be the hardest shifts to fill and retain. V1 went on to state in an attempt to assist the evening and midnight shift staffing for CNA's when they are not fully staffed due to call in/no shows, and as the census keeps growing, they have started a 2-week rotation where administrative staff come in later in the morning and stay through 8 PM. If these staff that stay late to assist nursing staff are not licensed/certified they are still able to assist in preparing beds, passing water and answering call lights. V1 stated they like to staff the CNA's with 4 CNA's on the 100/200 halls and 3 on the 300/400 halls. V1 went on to state the self-scheduling has caused CNA's to work a combination of all hours in a shift. Some CNA's work 12 hours, some work 8 hours and some just pick up hours that work for their schedule. On 7/1/25 at 12:15 PM, V21 (CNA Supervisor) stated that nights and weekends are harder to cover with enough CNA staff. V21 stated the day shift is covered almost in excess, but then not many want to pick up the evening or weekend shifts. V21 stated they are getting ready to change the way they self-schedule and instead of over scheduling on day shift and sending staff home early, they will reduce the CNA's scheduled due to having office/administrative staff along with hall monitors, and then the evening hours available will be the only way for staff to get adequate hours to keep their full-time status. V21 stated currently V21 she and the other CNA supervisor work to cover the shifts that are open due to call in or no shows, but when several shifts are open at the same time, they just try to float around the facility and help everyone get their jobs done and resident care needs met. V21 stated the 200 Hall has a lot of 2-person assistance due to mechanical lifts, so optimal staffing would be two CNA's on all shifts. This would allow for each CNA to take a side of the hall and then they can then get the residents up more quickly when 2 people are required. V21 stated there is a 'get up' list of residents for the night shift CNAs, and that is to keep them from having to get every resident up on that hallway for the morning. This is used to ensure the night shift is required to get all the residents up and ready for the day prior to clocking out. This list was determined by doing a survey with the residents on preference of preferred time to be gotten up and ready for the day. Resident council meeting minutes from 6/18/26 documents there are not enough CNA's on the weekends. A resident grievance form, dated 4/6/26, documents R5 complained she did not get a shower due to being short staffed. The facility CNA daily staffing for 7/1/26 shows 6 CNA's were scheduled on night shift. 1 CNA scheduled on 200 Hall, 2 CNA's on 200 Hall, and 3 CNA's between 300-500 halls. The facility was unable to provide this surveyor with a staffing policy. A census with a print date of 7/2/26 documents 108 residents reside in the facility.

Based on interview and record review, the facility failed to conduct a thorough investigation and report factual information of an injury of unknown origin that resulted in R1's death and failed to investigate allegations of sexual abuse for 3 of 6 residents (R1, R3, R10) reviewed for abuse in a sample of 46. The facility's failure has the potential to affect all 114 residents residing in the facility by failing to protect them from potential abuse.The Immediate Jeopardy began on [DATE] at 12:00 PM when R1 was found expired in the floor next to her bed with her head in a trash can and a plastic trash bag covering her face. V1 (Administrator) and V3 (Regional Clinical Director) were notified of the Immediate Jeopardy on [DATE] at 1:00 PM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:1.R1's admission Record documents an admission date of [DATE], with diagnoses of Malignant Neoplasm of Unspecified Bronchus or Lung, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Adult Failure to Thrive, and anxiety disorder. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R1's cognition is intact. Section GG-Functional Abilities documents R1 required set up or clean up assistance for eating, partial/moderate assistance for oral hygiene and toilet transfers, substantial/maximal assistance to roll from left and right, and was dependent on staff for toileting hygiene, shower/bath, upper and lower body dressing, putting on /taking off footwear, personal hygiene, sitting to lying on side of bed, sit to stand, chair/bed to chair transfers, and tub/ shower transfers. R1's Care Plan documents R1 had an increased risk of falls related to weakness and deconditioning. Documented interventions include: anticipate and meet R1's needs, be sure R1 has call light within reach and encourage her to use it for assistance as needed, ensure R1 is wearing appropriate footwear nonskid socks and or shoes when mobilizing in wheelchair, R1 needs a safe environment with : floors free from spills and or clutter; adequate light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach, follow facility protocol, and PT evaluate and treat as ordered as needed all initiated [DATE]. R1's Care Plan also documents that R1 has admitted to hospice for end of life care with an initiation date of [DATE]. R1's Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification report was received by IDPH via email from V3 (Regional Clinical Director/ RCD) on [DATE]. This report documents the incident date and time of [DATE] at 12:30 PM. The description of the incident documents, On [DATE], (R1) was noted to be in floor next to her bed. The nurse immediately assessed the resident. Only obvious injuries were skin tears to left and right elbows. Resident on hospice with no previous falls noted. Residents BIMS is a 13. Hospice notified and gave orders to put resident back to bed and place oxygen. Resident passed away shortly after. Hospice notified. Resident has no POA (Power of Attorney) and is her own responsible party. Comprehensive investigation was initiated and a final report to follow in 5 business days. Under Type of Incidents', the box is marked as other and documents Death occurred shortly after being found on the floor. R1's Progress Note, dated [DATE] at 12:30 PM authored by V9 (Licensed Practical Nurse/LPN), documents CNA's (Certified Nurse Assistant's) notified this nurse that resident was on floor beside bed. Once this nurse entered the room resident noted to be laying on her stomach with resident not responding to staff. Faint pulse noted with contact made to (name of hospice company) to place O2 (oxygen) on resident and assist back to bed at this time with resident assisted. During process of assisting resident to bed x 3 staff resident noted to not have noted VS (vital signs) at this time. Hospice notified of resident's passing. Hospice nurse stated that resident had no family with the exception of (family member) with MR (mental retardation). Requested for name of funeral home to contact for body to go. On [DATE] at 2:39 PM, V4 (Hospice Clinical Services) was asked for contact information for the nurse on call for the facility on [DATE] at the time of R1's incident. V4 stated V7 (Hospice Registered Nurse/ RN) was on call, and she will reach out to her to call this surveyor. V4 stated, This is a mess with what happened to (R1). V4 stated R1's Hospice notes document a call from V8 (Licensed Practical Nurse/ LPN) stating R1's head was in the trashcan and R1 had suffocated. V4 stated R1 did not die from her cancer, she was doing good. V4 stated she called the coroner to inform him of R1's death and the coroner reported to her that he was not told by the facility (unsure of who called) about a fall, he was just told R1 died from cancer. V4 stated the coroner stated he was going to have an autopsy done on R1 because there may be a different cause of death. V4 stated the coroner was getting ready to have R1 cremated and was thankful V4 called and explained the situation with the fall. R1's hospice notes titled Telephone Contact Note authored by V7 document the following: [DATE] at 12:45 PM: (V8) called and stated pt (patient) appears to have rolled out of bed, found pt with head in trash can and trash bag wrapped around pts face. Appears she has suffocated. Initially they did not think she had a pulse but they put her back in bed and think they feel a faint pulse. Advised to place O2 (oxygen) on pt and observe. I am an hour away, will call my partner and see if she is closer and can arrive sooner than I can. [DATE] at 1:00PM: Called (V8) back to inform him (name of hospice nurse) will be on her way from (name of town). (V8) states pt has passed. Asked time of death and he originally stated 1235 but nurse (V9) corrected him and stated it was 1245. (V8) states they will notify coroner, funeral home and pts family. He feels no further needs from us. Will call (name of hospice nurse) back and tell her she is not needed. [DATE] at 1:15PM: Nurse (V9) called back and states they have notified coroner and family but they are not sure of funeral home. Funeral home is (name of funeral home and phone number). Asked if they need any other help from me, they state no everything else has been taken care of. R1's hospice note titled Death Summary authored by V7 documents a date and time of death of [DATE] at 12:45PM. The note documents, (V8) called and pt was found in floor beside of bed with head in trash can and trash bag was over pts face and the believe pt suffocated on trash bag. It was wrapped around pts head. Under observation at the time of death documents, (V8) states when she was found she had very slow faint pulse, it lasted approx (approximately) 3 min (minutes) after pt was found. Pt passed at approx 1245. No family or staff around. On [DATE] at 4:00 PM, V7 (Hospice Nurse) stated she received a call from V8 (LPN) on [DATE], stating R1 was found beside her bed with trash bag wrapped around her face then they got her back into bed and put oxygen on her. V7 stated that is what she directed them to do at that time. V7 stated she told V8 to call the family and see if they wanted R1 sent out to the hospital. V7 stated if a resident is receiving hospice services and the family wants them sent to the hospital, that is ok. V7 stated she was not R1's regular nurse so she told V8 that she was going to call R1's regular nurse and see what she thinks should be done. V7 stated when she called V8 back approximately 15 minutes later, V8 reported that R1 had passed. V7 stated R1 wore oxygen off and on as needed. V7 stated when she had seen R1 last she had to help her turn over in bed because she could not do it by herself. V7 stated she asked if the nursing home called the coroner and family and V7 stated that V8 told her that they had called both. V7 stated she ended up calling the funeral home around 3:00 PM because the nursing home stated they did not know which funeral home R1 preferred. On [DATE] at 3:52 PM, V3 (Regional Clinical Director/ RCD) stated he was not present in the facility on [DATE] at the time of R1's death. V3 stated V1 (Administrator) called him at 12:50 PM and informed him R1 rolled out of bed and hospice told them to put her to bed and put oxygen on R1 and then R1 passed away. V3 stated V1 said R1 possibly hit trash can on her way down. V3 stated the nurses' stories are all jacked up. V3 was asked if he verified nurses' notes and he stated, they are messed up. V3 stated the nurses working were V8 (LPN) and V9 (LPN). V3 stated it sounds like at 11:45 AM, R1 was checked on and set up in bed for lunch. Then at 12:30 PM, a CNA went in to give R1's roommate her tray and noticed R1 was not in her bed so the CNA went out and asked the other CNA where R1 was. That is when both CNA's went in to R1's room and saw R1's feet on the other side of bed and R1 was lying on her stomach and the trash can was over her head. V3 stated the CNA's were not sure about a trash bag. V3 stated they called V9 (LPN) to the room and V8 (LPN) came to help. V3 was asked if R1 had side rails and V3 stated he was not sure. V3 was asked if they ever call the ambulance for hospice residents and V3 stated no we call hospice and the family to see if they want the resident sent out. V3 stated he wasn't sure if the doctor was called but he knew hospice was called. V3 stated he had been in the facility investigating this incident yesterday ([DATE]) and continues on today ([DATE]). V3 stated, I believe she had a faint pulse, but I am not sure if they should have called the ambulance. V3 stated he was not sure who wanted an autopsy and V1 had talked with the coroner. V3 stated R1 was dependent on staff for all of her care except she could feed herself. V3 stated R1 required the staff to turn and reposition her every 2 hours. V3 stated R1 never had any falls. On [DATE] at 4:41 PM, V1 (Administrator) stated she was not in the facility when R1 fell and passed away, but she did receive a call from V8 (LPN). V1 stated she came to the facility and got staff interviews/statements and started an investigation. V1 stated it was around 12:50 PM and she arrived just a couple minutes after the call. V1 stated she was told R1 was in her bed when her nurse, V9 (LPN), went and checked on her around 11:30 AM. V1 stated V9 said R1 appeared ok at that time. V1 stated at 11:45 AM, R1's roommate's (R3) call light was activated, and a CNA went in to help the roommate (R3) then got R1 ready for lunch. V1 stated the CNA's started passing the noon time meal trays. V1 stated V17 (CNA) took R3's tray into the room and noticed R1 was not in her bed. V1 stated V17 saw R1's feet and went and got the other CNA and stated R1 was lying on the floor on her belly with her left arm up against the wall and had a skin tear to her arm. V1 stated they moved the trash can and moved R1 on her side. V9 was in the room at this time and noted R1 to have a faint pulse. V1 stated V8 went to check on R1's code status and called hospice and hospice said R1 was comfort care and to put R1 back to bed and apply oxygen. V1 stated the staff then lifted R1 back to bed and applied the oxygen and they felt a pulse at that time and V11 (CNA) told V1 she saw R1 breathing. V1 stated the trash can was against the wall, and the staff said R1's head was in the trashcan. V1 stated she looked in the trash can and there was a plastic bag in the trash can with a large hole in the bag. V1 stated she is not sure who wanted an autopsy. V1 stated she instructed the staff not to call R1's family as they are only emergency contacts and they never came to see R1, and she did not know them. V1 stated R1 was under APS (Adult Protective Services) so she wasn't sure if the emergency contact persons were involved with all of that. V1 stated they have been investigating the incident but are not sure how R1 fell out of bed. On [DATE] at 10:00 AM, V17 (CNA) stated she was working on [DATE] on a different hall but went down to R1's hall to help get ready to pass the noon time meal trays. V17 said she answered R1's roommate's (R3) call light. V17 stated she really didn't pay attention to R1 as she was helping R3 with her oxygen concentrator as she needed to use the bathroom. V17 stated she went back out and was starting to pass meal trays and when she came to R1's room she noticed R1 was not in bed, so she went and asked CNA's (V11 and V13) where R1 was. V17 stated she and V11 then went into R1's room and she saw R1 on the floor. V17 stated V11 got down on the floor with R1, and she (V17) summoned for more help. V17 stated she stood back out of the way once she came back to R1's room and she didn't know if they put R1 to bed using a sheet or how they put her back to bed. On [DATE] at 2:40 PM, V3 (Regional Clinical Director/ RCD) was asked if R1 had side rails and V3 stated he was not sure. V3 was asked if he came in to investigate R1's death and V3 stated he came in on the following Monday ([DATE]). V3 was asked to take this surveyor to R1's room. V3 went to V2 (Director of Nursing/ DON) at the nurse's station and asked what room was R1's room. V3 and this surveyor went to the room and looked at the room. R1's roommate, R3, was asked if she heard anything going on when R1 had the fall and R3 stated, No, I was too busy getting that dirty old man (R2) out of my room. R3 stated, He (R2) came in my room and started pulling his pants down and exposed himself to me and I yelled and told him to get out. R3 stated she then went to the bathroom and had her oxygen concentrator nearby and she did not hear anything. R3 stated before she went into the bathroom R1 was sitting up in bed and in the middle of the bed getting ready for lunch. R3 stated she was in the bathroom for a long time and when she was coming out she saw about 5 people running in the room and they were on the other side of R1's bed. R3 stated she could not see R1. R3 stated she had no idea what happened. V3 was present and witnessed this interview with R3. On [DATE] at 10:15 AM, V9 (LPN) stated she was the charge nurse for R1 on [DATE]. V9 stated she had given R1 her medications that morning and again at about 11:30 AM and R1 was ok. V9 stated she was summoned to R1's room by staff due to R1 being on the floor. V9 stated she ran to check and see if R1 was a DNR (Do Not Resuscitate) and then ran to the room. V9 stated when she got to the room the trash can and trash bag had already been removed from her head. V9 stated another nurse ran and called hospice. V9 said she didn't know how R1 got on the floor as R1 could not move the lower part of her body. V9 stated V1 got to the facility quickly and started interviewing people. On [DATE] at 1:10 PM, V9 (LPN) was asked if she called the emergency contacts for R1 upon her death and V9 stated, I was going to but (V1) told me not to call them because they never came out to see her (R1). V9 was asked to clarify if R1 had a pulse or was breathing while R1 was lying on the floor and V9 stated, We checked her vital signs with the vital sign machine while she was on the floor and there were no vital signs to obtain. V9 stated they checked R1's vital signs once she was moved to bed and still there were no vital signs at all, no blood pressure, no pulse, no respirations, and pulse oximeter did not show anything. V9 stated R1's temperature was like 95 degrees. V9 was asked if she called the physician (V12) and V9 stated no she just sent him a message through the electronic notification system. V9 stated, I just know it was crazy, and I don't understand how (R1) rolled out of bed and landed in the trash can and the bag up over her head like they told me it was. On [DATE] at 2:33PM, V11 (CNA) stated she and V13 (CNA) were the CNA's on R1's hall and had cared of R1 on [DATE]. V11 stated we got R1 repositioned and ready for lunch. R1 was placed on her back in a sort of sitting position with her bedside table over her. V11 stated normally R1 could only move her hands a little bit but not her lower extremities. V11 stated R1 had no complaints and was her normal self and this was about 11:30 AM. V11 stated she was passing trays and heard V17 (CNA) ask V13 where R1 was and V13 stated she is in her bed and V17 stated no she is not. Someone said she is on the floor and is bleeding. V11 stated she and V17 went in the room and R1 was lying on the floor, and her head was inside with the trashcan, and the trash bag was up against her face. V11 stated she took her hand under the bag and removed it and then gently moved back the trashcan. V11 stated R1's face was blue and so was her hands. V11 stated she tried to feel a pulse and thought she felt one so V8 (LPN) came in the room and he tried to check for a pulse and thought he felt a faint pulse. V8 ran to call hospice and V9 (LPN) was in the room and was checking on R1. V8 returned and said hospice said to put R1 in bed and apply oxygen. V11 stated there was a lot of blood on the floor, wall, and the outlet that was from R1's left arm that had a big skin tear. V11 stated when they moved R1 to the bed she thought she saw R1 take a breath. On [DATE] at 2:10PM, V8 stated he was working on a different hall on [DATE], and he was coming back from break and noticed staff running at the end of (R1's hall) so he went down there. V8 said V9 was the charge nurse, and she was running up to check R1's code status. V8 stated when he entered the room, he saw R1 on the floor and noted blood on the wall, floor, and plug in and R1 had a skin tear to her left arm. V8 stated V11 told him R1's head was in the trashcan with the bag around her head. V8 stated V11 asked him to help check for a pulse. V8 stated he checked the jugular (neck), and apical (chest) for a pulse and did not get a pulse. V8 said he checked the radial pulse and thought he felt a faint pulse. V8 stated R1's body temp was 95.8. V8 said he ran to call the hospice nurse. V8 stated he called, and the hospice nurse said to put R1 to bed and apply oxygen. V8 stated they checked for vitals and there were no vitals. V8 stated when he first called hospice, he did not tell hospice about the trashcan but when hospice called back, he told them R1 was deceased , and he told them about the trashcan. V8 stated he told V9 to call the family, funeral home, and the physician and if she needed any help he would help her. V8 stated he has no idea how R1 got to the floor. R1 never moved an inch except her hands and her head. V8 was asked if he ever sends hospice about patients to the emergency room and V8 stated it is on a case-by-case basis. On [DATE] at 1:00 PM, R1's investigation file was requested for review and provided by V1. The file contained the Initial IDPH Incident and/or Abuse Notification report, dated [DATE], typed witness statements, R1's admission Record, R1's Physician Order for Life Sustaining Treatment (POLST), and R1's Care Plan. The typed witness statements included in R1's investigation file did not include the witness/ staff members signatures. The typed witness statements document the following: Interview with V9 LPN at 12:50PM [DATE]: Resident on the floor when this nurse entered room. Resident was lying toward the window on her left side of her face. (Left) arm had a skin tear fresh blood, resident was warm and had a faint pulse. Assisted resident back to bed and called hospice, they stated to apply oxygen she's a Do Not Resuscitate (DNR). At 11:30AM she was sitting up in bed this nurse seen. Interview with V11 on [DATE] at 1:25PM: Roommate had her call light on, I went to see what she needed. It was about 11:45AM, making sure R1 was ready for lunch. Then they said she was on the floor, I went in to help V17. I moved the trash can. R1 was lying on her belly. The nurse helped me put a sheet under her and we put her back to bed. I felt a pulse, and I saw her breathing. Interview with V8 [DATE] at 1:33PM: This nurse went down to resident's room she was on the floor. I asked if there was a pulse and she said yes. I checked her pulse it was faint on her left wrist. Went to check IDPH Uniform Practitioner Order for Life Sustaining Treatment (POLST) she was a DNR. I called hospice and they said there was nothing we could do, she was comfort focused, and we put her back to bed and applied oxygen as instructed by hospice. On [DATE] at 1:58 PM, V11 was reinterviewed and stated she was working on R1's hall on [DATE] when R1 was found in the floor. V11 stated she had just been in R1's room around 11:30-11:45 AM getting her ready for lunch. V11 stated R1 was dependent on staff for all ADL's (Activities of Daily Living) except she could feed herself after set up. V11 stated R1 did not like disposable undergarments on while she was in bed. V11 stated R1 could not use her legs at all. V11 stated, (V17) yelled and I went into (R1's) room and noticed (R1) was in the floor with her head in a trash can with the trash bag covering her face. V11 stated there was also blood from the skin tear to R1's left elbow. V11 stated R1's head was positioned in the trashcan with her head to the side on her left side. V11 stated R1 would have had a hard time breathing with the trash bag over her face like it was. V11 stated she gently removed the trash bag and trashcan and noticed R1's face and hands were blue. V11 stated R1 was nonresponsive. V11 stated she thought she felt maybe a faint pulse but V8 checked it and said he did too. V11 stated R1 never regained consciousness. V11 stated, We put her to bed and there were no vitals at that time. V11 was shown her typed witness statement provided by V1 and V11 stated, this is incorrect. V11 was asked when she gave her statement to V1 did she include the details of the trashcan and trash bag and V11 stated, Yes, I told her exactly all about that. V11 was asked if she knew why it was not in the typed statement and V11 stated, No, I have no idea. V11 was asked if she had seen the typed statement and V11 stated No. V11 was asked if R1 was still breathing and V11 stated, No, but I may have seen a breath when we moved her but not really breathing. V11 was asked if her typed statement was correct and V11 stated, It is incorrect. On [DATE] at 2:10PM, V1 stated, I tried to call the police on Monday [DATE] to get a report run number like that we get when we have to call in abuse and get a number that proves we have called them. The woman (police dispatcher) said that they don't give us numbers for this stuff and so I got mad and hung up on her. V1 stated she then called and talked to the assistant police chief and stated she told them that had died and fell out of bed. V1 was asked if she told them about R1's head being in the trashcan with a trash liner (plastic bag) over her face, V1 stated, No I did not tell them that. V1 was asked why she did not include that information when reporting to the police and V1 stated, I felt that was too much information to give them. V1 was asked if she typed out the witness statements from the staff and V1 stated, yes, I did. V1 stated, I came in when they called and I sat at the front desk and took their statements and wrote them out, then I typed them because my writing was so bad. V1 was asked why V11's typed witness statement did not include the part about the trash can and the plastic bag. V1 stated, I guess I just left that part out. V1 was asked why that was left out and V1 stated, I don't know. V1 was asked why she put that V11 stated R1 was still breathing when R1 was on the floor and V1 stated, I know (V11) told me that. V1 was asked if she went to R1's room when she got to the facility and V1 stated, not for a while. V1 said she came in and sat at the front desk and did interviews with all of the staff. V1 said she went to the room later on, but they had cleaned up and R1 was in bed. V1 was asked if she directed the staff to not call the Emergency Contacts for R1 and V1 stated, Yes, I did tell the nurse not to call the Emergency Contact persons because they never came out to see (R1) and (R1) had Adult Protective Services involved in her case, so I was not sure how or if they were involved with anything. V1 stated, I would do it all over again if I had a do over. V1 began crying and stated, I don't want you to think I am a liar or that I am trying to hide anything with this situation. V1 asked why she waited until Monday, [DATE], to call the police and V1 stated, I was just doing what my boss told me to do, and she thought there was no regulation to force us to call the police. V1 was asked if she was aware of a part of her abuse policy that directs them to call the police when this type of incident happens and V1 stated, Well, I did not know at the time and again I was following what my boss told me. V1 was asked why information was not being disclosed throughout this investigation and V1 stated, I was controlling the investigation and protecting the facility. V1 confirmed that her boss was V31 (Chief Executive Officer/ Operations Consultant). On [DATE] at 10:30 AM, V1 presented this surveyor with the witness statements that were handwritten by V1 on [DATE] and were signed by the witness/staff making the statements. V1 stated she then typed out the statements and they were included in R1's investigation file that was provided to this surveyor on [DATE]. V1 stated she typed them out because what she had written (on [DATE]) was chicken scratch and nobody could read them. V1 stated these hand written statements were sent to V31 as well. The handwritten witness statements were reviewed and compared to typed statements that were in the R1's investigation file. The handwritten witness statements document the following: V9's (LPN) statement dated [DATE] at 12:50 PM: girls came down hall. Girls said head in trash can, girls had pulled her out and bag was around her head. Nurse did not see this. Resident on floor when nurse entered room towards the window on left side of face. Left arm big skin tear, fresh blood. Still warm faint pulse. On hospice DNR. At 11:30AM she was sitting in bed nurse seen. This statement is signed by V9. V9's typed witness statement did not document the details regarding the trash can and bag. V11 (CNA) statement dated [DATE] at 1:25PM: Passing lunch trays. (V17) asked where (R1) was, and I told her room and bed. (V17) said she didn't see her. Someone went in the room and said she was on the floor bleeding. Me and (V17) went together. I pulled trash can and bag was in her mouth. She was sweating. Bed check about 11:30AM. 11:30-11:45AM roommate had call light on and (R1) was leaning to the right, I pulled up and to middle of bed. Called into the room about 12:30PM (V8 LPN) and (V9 LPN) and I put a sheet under her and put her back onto the bed. I felt a pulse, and I saw breathing. (V9) said get vital signs. This statement is signed by V11. V11's typed witness statement did not include the details regarding the trash can and the trash bag being in R1's mouth. V8 (LPN) statement dated [DATE] at 1:33PM: (V8) went down, (R1) was in the floor. Asked if (V9 LPN) checked for a pulse. (V9) said she couldn't feel anything, I checked and found a very faint weak pulse on her left wrist. Ran to check DNR and she was a DNR. Hospice called said if she has a pulse, apply oxygen and went back down and (V9) said no pulse. We put her back in bed. On [DATE] at 9:32 AM, V31 (Chief Executive Officer/ Operations Consultant) stated she was made aware of the incident with R1 on the day of the incident, [DATE]. V31 was asked if she discussed calling the police when this occurred and V31 stated, Yes, but it was a little bit after the fact. V31 stated, I thought and expect my team to know the structural details of investigations, reporting, processes of abuse, and this was unknown origin situation. V31 stated she realized on Monday, [DATE], that the police were not notified so she instructed the team to do so and spoke with and educated V3 (Regional Clinical Director), so V3 then educated V1 about the policy and processes and a QAPI (Quality Assurance and Performance Improvement) was done. V31 was asked if during the investigation, when statements are being obtained, do you expect the investigator to summarize statements and leave important parts out? V31 stated it is perfectly legal for statements to be summarized but not to leave out important details. V31 stated she reviewed the statements and did a 2nd interview with V11, and she stated V11 stated the trash bag was over part of R1's face. V31 was informed that the whole part about the trash bag was left out of V11's typed statement and V31 stated she was not aware of that part. V31 stated the initial statements were like chicken scratch and needed to be summarized. V31 was asked if she was aware that R1's family was not notified, V31 stated, Yes, I was made aware of that and (V3) did a QAPI on that and educated (V1) as well. V31 stated they did a QAPI on reporting and investigating of abuse as well. On [DATE] at 10:24AM, V12 (Physician) was asked if he was aware of R1's recent death. V12 reviewed the electronic notification system and stated he has a notification that Resident found in floor beside bed with altered breathing. Hospice contacted with ordered to place in bed with oxygen. Resident expired at 12:45PM. V12 stated this notification is time stamped for [DATE] at 2:39 PM. V12 was asked if he was told about R1 having a trash bag over her face when she was found in the floor. V12 stated, I was not told anything about this at all and what did the police say. I explained the police were not called until the following Monday, [DATE], and the incident happened on Saturday, [DATE]. V12 stated, This was a crime scene and who knows what happened to this lady. V12 stated, How does anyone know this was not a homicide? V12 stated he feels this should be reported immediately to the police department so it can be looked at even though the crime scene has been disrupted. V12 stated, I feel like this was an intent to hide something. The electronic notification system documentation to V12 dated [DATE] at 2:39PM for R1 documents, Resident found in floor beside bed with altered breathing. Hospice contacted with ordered to place [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse for 2 (R3 and R10) of 6 residents reviewed for abuse in a sample of 46. This failure resulted in R10 feeling intimidated and scared for her safety.Findings include:1. R10's admission Record documented an admission date of [DATE], with diagnoses including depression, major depressive disorder, and anxiety disorder. R10's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.R4's admission Record documented an admission date of [DATE], with diagnoses including vascular dementia. R4's [DATE] MDS documented a BIMS 9, indicating moderate cognitive impairment.On [DATE] at 11:20 AM, R10 was sitting in the dining room and was alert and oriented to person, place, time, and situation. R10 said about a week prior to this interview, unsure of exact date, R10 was lying in bed, and a man had crawled in bed with her and was rubbing her legs. R10 said she started screaming and told him to leave. R10 said she was not sure of the man's name but could point him out. R10 said the man was not currently in the dining room but R10 had seen him earlier in the day. R10 stated she was intimidated and scared by being woken up by a strange man in my room with his hand under my covers rubbing me. R10 was asked if she had reported this incident to any staff and R10 said she had reported this incident to that dark haired lady (V1, Administrator) earlier that morning when that dark haired lady was asking if R2 had exposed himself to R10.On [DATE] at 11:46 AM, R10 was still sitting in the dining room. R10 was asked if the man that had touched her was also in the dining room and R10 pointed at R4. R4 was pleasantly confused and not a reliable historian. R10 confirmed that dark haired lady was V1.On [DATE] at 1:00 PM, R10 was asked if R10 used her call light for assistance when R4 was in her room and R10 said no she had just started screaming at R4. R10 said after she started screaming at R4, R4 got back in his wheelchair and left her room.On [DATE] at 9:15 AM, R10 was alert and oriented to person, place, time, and situation. R10 said she had spoken to V1 again and had been asked about the incident with R4. R10 said she told V1 R10 was asleep and that man, the one I pointed out in the dining room (R4) was in my room with his hand under my covers rubbing my legs. R10 was asked if R4 got in bed with R10 and R10 said she was not sure if R4 was in bed with her or on the side of the bed because R10's bed was not very big. R10 stated, Who knows what he would have done if it hadn't woken me up. R10 said she started screaming and must have scared R4 because R4 got back in his wheelchair and left R10's room. R10 said the incident occurred during the night but the light over R10's door was on and that is how R10 was able to see R4.R4's [DATE] MDS documented R4 required partial/ moderate assist with lying to sitting on side of bed, dependent with sit to stand and chair/bed-to-chair transfer, and not applicable with walking 10 feet.On [DATE] at 2:04 PM, R4 was observed independently walking to the bathroom in his room. R4 was redirected back to bed by staff. After staff left R4's room, R4 was observed to independently get out of bed and start walking back to the bathroom in his room.On [DATE] at 1:08 PM, V13 (Certified Nursing Assistant/ CNA) said R4 was able to get up and transfer himself to his wheelchair or to the bathroom. V13 said she had seen R4 wandering into other residents' rooms and R4 had to be redirected.On [DATE] at 11:26 AM, V1 said R10 did not tell V1 R4 had inappropriately touched R10. V1 said R10 had only told V1 R4 had patted R10 on the leg in the dining room.R4's care plan did not document any behavioral plan of care.R10 and R4's [DATE] Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification final report documented, On [DATE] at 1126 am Administrator went to (R10) to get a statement from her on another reportable. (R10) stated a man come into her room. Administrator asked (R10) is the man in the dining room and (R10) looked around and stated no. Administrator told (R10) that she would return at lunch to see if she can point out the resident. Then surveyor reported to the administrator (R10) stated (R4) got into her bed and touched her leg. Administrator explained to surveyor what (R10) had just told her. Administrator went back to (R10) and asked her what surveyor just told Administrator and she said yes it was (R4). During the interview with (R10) she stated to the Administrator I don't think he actually got into my bed, I just felt his hand and arm in my bed. (R10) said [sic] she jerked away and hollered. The roommate did verify this incident happened upon interview. Both (R10) and her roommate confirm in interview that (R4) left the room without difficulty or incident. The next morning while the nurse was giving (R10) her meds (R10) seen (R4) and she asked (R4) about him touching her leg and (R4) stated I just wanted to say hi. (R4) has a Bims of 3. (R10) said there has been no other incidents since then and the roommate did verify (R4) has not been back into their room. The ADON assessed (R10) with no emotional distress noted. The facility does find the incident occurred but cannot determine if the conduct was of sexual intent. The facility did interview other residents and staff and no one has reported any other incidents with (R4). 2. R3's admission Record documented an admission date of [DATE], with diagnoses including difficulty in walking, anxiety disorder, and major depressive disorder. R3's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact.R2's admission Record documented an admission date of [DATE], with diagnoses including Alzheimer's disease and dementia. R2's [DATE] MDS documented a BIMS score of 3, indicating R2 was severely cognitively impaired.On [DATE] at 9:48 AM, R3 was alert and oriented to person, place, time, and situation. R3 said on the day R1 expired ([DATE]), R2 came into R3's room and placed his dirty socks on my bed, pulled down his pants, and was feeling around in his underwear. R3 said she got loud with R2 telling him to leave and to get his dirty socks off her bed. R3 said after getting loud with R2, R2 pulled up his pants, picked up his socks, and left her room. On [DATE] at 10:18 AM, R3 said on the day R1 expired ([DATE]), R3 told V1 about the incident with R2 earlier that day.On [DATE] at 1:28 PM, V2 (Director of Nursing/ DON) said 2 to 3 weeks prior to this interview, a person from R2's Assisted Living Facility came to the facility to screen R2 for readmission. V2 said this person had asked if R2 had been taking his clothes off and V2 told her no. V2 said the person acted like she was surprised. V2 said the facility was not aware of R2 having any behaviors prior to R2's admission.On [DATE] at 11:06 AM, V26 (Registered Nurse/ RN) said she had seen R2 pulling his pants down in the hallway once before being redirected by staff and assisted to the bathroom. V26 said R2 wanders into other resident rooms and has to be redirected. V26 said R2 will go in and out of any door he could find while constantly wandering. On [DATE] at 11:01 AM, V36 (Assisted Living Social Services Director) said she had gone to the facility to screen R2 for readmission. V36 said R2 had a history of undressing in common areas and wandering into other resident rooms and undressing. V36 said no one from the facility had contacted her to inquire about R2's behavioral history.On [DATE] at 11:14 AM, V37 (Assisted Living RN) said R2 would disrobe in public and in other resident's rooms. V37 said R2's disrobing behavior had worsened prior to discharge. V37 said R2 was very handsy in a loving way not really a sexual way.R2's care plan documented no behavioral plan of care. R2 and R3's [DATE] Final IDPH Incident and/or Abuse Notification documented, On [DATE] a resident (R3) made an allegation of a resident being inappropriate by lowering his pants down in front of her. Upon more through [sic] investigation the facility has found the alleged resident (R2) did not expose himself to (R3). The alleged resident has a diagnosis of Alzheimer's and has a BIMS of 3. (R2) does not recall the allegation. There has not been any other allegations of this type of behavior. The facility has conducted interviews with other staff members and residents and this behavior has not been noted. The facility finds the allegation unsubstantiated. No further incidents of this behavior has been noted.R2 and R3's [DATE] Final IDPH Incident and/or Abuse Notification documented, ADDENDUM On [DATE] a resident (R3) made an allegation to our Regional Clinical Director (RCD) and a State Surveyor of a resident coming into her room only to the bathroom area being inappropriate by lowering his pants down in front of her. (RCD) asked the resident (R3) did he expose himself to you and (R3) stated no he did not he had underwear on. She told him to leave the room and (R2) left the room. (R3) further stated in this interview that (R2) has never been aggressive toward her and that he left the room without any complications. During the facilities [sic] thorough investigation the facility has found the alleged resident (R2) did drop his pants and exposed his (incontinence brief) in the presence of (R3) but he did not expose his genitals or buttocks to (R3), however the facility is unable to dietermine [sic] if this was sexual in nature. The alleged perpetrator does has [sic] a diagnosis of Alzheimer's and has a BIMS of 3 and does not recall the allegation. The facility has conducted interviews with other staff members and residents and this behavior has not ever been displayed by (R2) prior to this occurrenc [sic] or since this incident.On [DATE] at 9:32 AM, V31 (Chief Executive of Operations/ CEO) stated she expected staff to know the structural details of investigations and reporting allegations of abuse. The facility's [DATE] Abuse and Retaliation Policy Prevention Program documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of good and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment.

Based on observation, interview, and record review, the facility failed to report abuse timely to the State Agency and to local law enforcement for 2 (R1 and R3) of 6 residents reviewed for abuse out of a sample of 46. This failure has the potential to affect all 114 residents residing in the facility.Findings include:1. R1's admission record documents an admission date of [DATE] and includes diagnoses of Malignant Neoplasm of Unspecified Bronchus or Lung, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Adult Failure to Thrive, and anxiety disorder. R1's Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 13, indicating R1's cognition was intact. R1's Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification report was received by IDPH via email from V3 (Regional Clinical Director/ RCD) on [DATE] at 4:04PM. This report documents the incident date and time of [DATE] at 12:30 PM. The description of the incident documents, On [DATE] (R1) was noted to be in floor next to her bed. The nurse immediately assessed the resident. Only obvious injuries were skin tears to left and right elbows. Resident on hospice with no previous falls noted. Residents BIMS is a 13. Hospice notified and gave orders to put resident back to bed and place oxygen. Resident passed away shortly after. Hospice notified. Resident has no POA (Power of Attorney) and is her own responsible party. Comprehensive investigation was initiated and a final report to follow in 5 business days. Under Type of Incidents', the box is marked as other and documents Death occurred shortly after being found on the floor.R1's Final IDPH Incident and/or Abuse Notification report by V3 documents the following: On [DATE] at 1230, (R1) was noted to be on the floor next to her bed. The nurse immediately assessed the resident. Only obvious injuries were skin tears to left and right elbow. Resident on hospice with no previous falls noted. Residents BIMs is a 13. Several staff members were interviewed for the investigation. A complete reenactment was conducted with staff present at the time resident was found. Resident was noted to be in the middle of the bed at 1145. Resident was sitting up at that time to get ready to eat lunch. Staff went to give resident her lunch tray and resident was noted to be on the floor at 1230 laying on her stomach with her head in the nearby trash can. Trash can had a liner in with no other trash noted. Trash can liner noted to have a hole in it. Staff immediately removed trash can and nurse came to assess. Nurse thought they felt a radial pulse. Hospice notified and gave orders to put resident back in bed and place resident on oxygen. Resident is a DNR/comfort focused treatment. Vitals were taken with resident on the floor with no vitals noted. Hospice notified. Funeral home was notified of residents passing. Residents' roommate interviewed for the investigation and stated I didn't hear anything, I was in the bathroom. I didn't hear her yell or anything. At this time, we do not know what caused the resident to fall out of bed or the cause of death. An autopsy is being performed. Resident is dependent with care, transfers and has no history of falls prior to this incident. Prior to fall at 11:45, resident was able to move head and arms and respond to staff per baseline. Resident dependent for most functional and bed mobility tasks. (Name of city) police department was notified on [DATE] of the incident. Resident had no POA or responsible party. Emergency contacts called the facility on [DATE] in the evening and had been notified by the Coroner.On [DATE] at 1:10 PM, V1 (Administrator) stated she tried to call the police on Monday [DATE] to get a number like a run number that we get when we have to call in abuse and get a number that proves we have called them. V1 stated the woman said that they don't give us, the facility, numbers for this stuff and so I got mad and hung up on her. V1 stated she then called and spoke to the Assistant Chief of Police and stated she told them R1 had died and fell out of bed. V1 was asked if she told them about R1's head being in the trashcan with a trash liner (plastic bag) over her face. V1 stated, No I did not tell them that. V1 was asked why she did not include that information and V1 stated, I felt that was too much information to give them. V1 was asked why she waited until Monday (two days later) to call the police and V1 stated, I was doing what my boss told me to do, and she thought there was no regulation to force us to call the police. V1 was asked if she was aware of a part of her abuse policy that directs them to call the police when this type of incident happens and V1 stated, Well, I did not know at the time and again I was following what my boss told me. 2. R3's admission Record documented an admission date of [DATE], with diagnoses including difficulty in walking, anxiety disorder, and major depressive disorder. R3's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact.R2's admission Record documented an admission date of [DATE], with diagnoses including Alzheimer's disease and dementia. R2's [DATE] MDS documented a BIMS score of 3, indicating R2 was severely cognitively impaired.On [DATE] at 2:40 PM, R1's roommate R3 was asked if she heard anything going on when R1 had the fall and R3 stated, No, I was too busy getting that dirty old man (R2) out of my room. R3 stated, He (R3) came in my room and started pulling his pants down and exposed himself to me and I yelled and told him to get out. This interview was conducted with V3 (Regional Clinical Director) present.On [DATE] at 9:48 AM, R3 was alert and oriented to person, place, time, and situation. R3 said on the day R1 expired ([DATE]), R2 came into R3's room and placed his dirty socks on my bed, pulled down his pants, and was feeling around in his underwear. R3 said she got loud with R2 telling him to leave and to get his dirty socks off her bed. R3 said after getting loud with R2, R2 pulled up his pants, picked up his socks, and left her room. On [DATE] at 10:18 AM, R3 said on the day R1 expired ([DATE]), R3 told V1 (Administrator) about the incident with R2 earlier that day.An Initial IDPH Incident and/or Abuse Notification report was received by IDPH via email on [DATE] documenting: On [DATE] at approximately 3:50 PM a resident made an allegation of a resident possibly being inappropriate lowering his pants. Resident was immediately removed from her and put on 15 min checks. Resident was assessed, with no findings of injury or emotional distress. This report documents R2 for the name of the resident but does not document R3's name on the report or identify R3 as the victim. This report documents police was notified at that time ([DATE]).The facility's [DATE] Daily Census documented 114 residents residing in the facility.The facility's [DATE] Abuse and Retaliation Policy Prevention Program documented, Any allegation of abuse, retaliation, or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to decide whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time. If classified as an injury of unknown source, the person gathering facts will document the injury, the location and time it was observed, any treatment given, and notification of the resident's physician, responsible party. The Department of Public Health will be notified. Time frames for reporting and investigating abuse will be followed. When an allegation of abuse, exploitation, neglect, mistreatment, retaliation, or misappropriation of resident property has been made, the administrator, or designee, shall notify the Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported to the administrator and is being investigated. The facility shall also contact local law enforcement authorities. in the following situations. sexual abuse of a resident by a staff member, another resident, or visitor. when a resident death has occurred other than by disease process. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to local law enforcement and IDPH immediately. If a reportable incident or allegation results in the death of a resident, this facility shall, after contacting law enforcement, notify the IDPH Regional Office by phone. This means that this facility will speak with a Department representative who confirms over the phone that the requirement to notify the Regional Office by phone has been met. If unable to contact the Regional Office, this facility will notify the Department's toll-free complaint registry hotline at [PHONE NUMBER].

Based on interview and record review, the facility Administrator failed to follow policy and procedures to effectively and efficiently investigate an incident resulting in the death of 1 of 3 residents (R1) reviewed for death in a sample of 46. This has the potential to affect all 114 residents living in the facility.Findings include: R1's Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification report was received by IDPH via email from V3 (Regional Clinical Director/ RCD) on [DATE]. This report documents the incident date and time of [DATE] at 12:30 PM. The description of the incident documents, On [DATE] (R1) was noted to be in floor next to her bed. The nurse immediately assessed the resident. Only obvious injuries were skin tears to left and right elbows. Resident on hospice with no previous falls noted. Residents BIMS is a 13. Hospice notified and gave orders to put resident back to bed and place oxygen. Resident passed away shortly after. Hospice notified. Resident has no POA (Power of Attorney) and is her own responsible party. Comprehensive investigation was initiated and a final report to follow in 5 business days. Under Type of Incidents', the box is marked as other and documents Death occurred shortly after being found on the floor.R1's Progress Note, dated [DATE] at 12:30 PM authored by V9 (Licensed Practical Nurse/LPN), documents, CNA's (Certified Nurse Assistant's) notified this nurse that resident was on floor beside bed. Once this nurse entered the room resident noted to be laying on her stomach with resident not responding to staff. Faint pulse noted with contact made to (name of hospice company) to place O2 (oxygen) on resident and assist back to bed at this time with resident assisted. During process of assisting resident to bed x 3 staff resident noted to not have noted VS (vital signs) at this time. Hospice notified of resident's passing. Hospice nurse stated that resident had no family with the exception of (family member) with MR (mental retardation). Requested for name of funeral home to contact for body to go.On [DATE] at 2:39 PM, V4 (Hospice Clinical Services) stated R1's Hospice notes document a call from V8 (Licensed Practical Nurse/ LPN) stating R1's head was in the trashcan and R1 had suffocated. V4 stated R1 did not die from her cancer, she was doing good. V4 stated she called the coroner to inform him of R1's death and the coroner reported to her that he was not told by the facility (unsure of who called) about a fall, he was just told R1 died from cancer. V4 stated the coroner stated he was going to have an autopsy done on R1 because there may be a different cause of death. V4 stated the coroner was getting ready to have R1 cremated and was thankful V4 called and explained the situation with the fall.On [DATE] at 4:41 PM, V1 (Administrator) stated she was not in the facility when R1 fell and passed away, but she did receive a call from V8 (Licensed Practical Nurse/LPN). V1 stated she came to the facility and got staff interviews/statements and started an investigation. V1 stated she instructed the staff not to call R1's family as they are only emergency contacts and they never came to see R1, and she did not know them. V1 stated R1 was under APS (Adult Protective Services) so she wasn't sure if the emergency contact persons were involved with all of that. V1 stated they have been investigating the incident but are not sure how R1 fell out of bed.On [DATE] at 1:00 PM, R1's investigation file was requested for review and provided by V1. The file contained the Initial IDPH Incident and/or Abuse Notification report dated [DATE], typed witness statements, R1's admission Record, R1's Physician Order for Life Sustaining Treatment (POLST), and R1's Care Plan.V11's typed witness statement, dated [DATE] at 1:25PM, included in R1's investigation file documents the following: Roommate had her call light on, I went to see what she needed. It was about 11:45AM, making sure R1 was ready for lunch. Then they said she was on the floor, I went in to help V17. I moved the trash can. R1 was lying on her belly. The nurse helped me put a sheet under her and we put her back to bed. I felt a pulse, and I saw her breathing.On [DATE] at 2:33PM, V11 (CNA) stated she and V17 (CNA) went in the room and R1 was lying on the floor, and her head was inside with the trashcan, and the trash bag was up against her face. V11 stated she took her hand under the bag and removed it and then gently moved back the trashcan. V11 stated R1's face was blue and so was her hands. V11 stated she tried to feel a pulse and thought she felt one so V8 (LPN) came in the room and he tried to check for a pulse and thought he felt a faint pulse.On [DATE] at 1:58 PM, V11 was shown her typed witness statement provided by V1 and V11 stated this is incorrect. V11 was asked when she gave her statement to V1 did she include the details of the trashcan and trash bag and V11 stated, Yes, I told her exactly all about that. V11 was asked if she knew why it was not in the typed statement and V11 stated, No, I have no idea. V11 was asked if she had seen the typed statement and V11 stated, No. V11 was asked if R1 was still breathing and V11 stated, No, but I may have seen a breath when we moved her but not really breathing. V11 was asked if her typed statement was correct and V11 stated, It is incorrect.On [DATE] at 2:10PM, V1 stated she tried to call the police on Monday [DATE] to get a report run number like that we get when we have to call in abuse and get a number that proves we have called them. V1 stated, The woman (police dispatcher) said that they don't give us numbers for this stuff and so I got mad and hung up on her. V1 stated she then called and talked to the assistant police chief and stated she told them that R1 had died and fell out of bed. V1 was asked if she told them about R1's head being in the trashcan with a trash liner (plastic bag) over her face, V1 stated, No I did not tell them that. V1 was asked why she did not include that information when reporting to the police and V1 stated, I felt that was too much information to give them. V1 was asked if she typed out the witness statements from the staff and V1 stated, yes, I did. V1 stated, I came in when they called and I sat at the front desk and took their statements and wrote them out, then I typed them because my writing was so bad. V1 was asked why V11's typed witness statement did not include the part about the trash can and the plastic bag. V1 stated, I guess I just left that part out. V1 was asked why that was left out and V1 stated, I don't know. V1 was asked why she put that V11 stated R1 was still breathing when R1 was on the floor and V1 stated, I know (V11) told me that. V1 was asked if she went to R1's room when she got to the facility and V1 stated, not for a while. V1 said she came in and sat at the front desk and did interviews with all of the staff. V1 said she went to the room later on, but they had cleaned up and R1 was in bed. V1 was asked if she directed the staff to not call the Emergency Contacts for R1 and V1 stated, Yes, I did tell the nurse not to call the Emergency Contact persons because they never came out to see (R1) and (R1) had Adult Protective Services involved in her case, so I was not sure how or if they were involved with anything. V1 stated, I would do it all over again if I had a do over. V1 began crying and stated, I don't want you to think I am a liar or that I am trying to hide anything with this situation. V1 asked why she waited until Monday, [DATE], to call the police and V1 stated, I was just doing what my boss told me to do, and she thought there was no regulation to force us to call the police. V1 was asked if she was aware of a part of her abuse policy that directs them to call the police when this type of incident happens and V1 stated, Well, I did not know at the time and again I was following what my boss told me. V1 was asked why information was not being disclosed throughout this investigation and V1 stated, I was controlling the investigation and protecting the facility. V1 confirmed that her boss was V31 (Chief Executive Officer/ Operations Consultant).On [DATE] at 9:32 AM, V31 (Chief Executive Officer/ Operations Consultant) stated she was made aware of the incident with R1 on the day of the incident, [DATE]. V31 was asked if she discussed calling the police when this occurred and V31 stated, Yes, but it was a little bit after the fact. V31 stated, I thought and expect my team to know the structural details of investigations, reporting, processes of abuse and this was unknown origin situation. V31 stated she realized on Monday, [DATE], that the police were not notified so she instructed the team to do so and spoke with and educated V3 (Regional Clinical Director), so V3 then educated V1 about the policy and processes and a QAPI (Quality Assurance and Performance Improvement) was done. V31 was asked if during the investigation, when statements are being obtained, do you expect the investigator to summarize statements and leave important parts out? V31 stated it is perfectly legal for statements to be summarized but not to leave out important details. V31 stated she reviewed the statements and did a 2nd interview with V11 and stated V11 stated the trash bag was over part R1's face. V31 was informed that the whole part about the trash bag was left out of V11's typed statement and V31 stated she was not aware of that part. V31 stated the initial statements were like chicken scratch and needed to be summarized. V31 was asked if she was aware that R1's family was not notified. V31 stated, Yes, I was made aware of that and (V3) did a QAPI on that and educated (V1) as well. V31 stated they did a QAPI on reporting and investigation of abuse as well. On [DATE] at 10:24AM, V12 (Physician) was asked if he was aware of R1's recent death. V12 reviewed the electronic notification system and stated he has a notification that Resident found in floor beside bed with altered breathing. Hospice contacted with ordered to place in bed with oxygen. Resident expired at 12:45PM. V12 stated this notification is time stamped for [DATE] at 2:39 PM. V12 was asked if he was told about R1 having a trash bag over her face when she was found in the floor. V12 stated, I was not told anything about this at all and what did the police say. It was explained the police were not called until the following Monday, [DATE], and the incident happened on Saturday, [DATE]. V12 stated, This was a crime scene and who knows what happened to this lady. V12 stated, How does anyone know this was not a homicide? V12 stated he feels this should be reported immediately to the police department so it can be looked at even though the crime scene has been disrupted. V12 stated, I feel like this was an intent to hide something. On [DATE] at 12:12 PM, V6 (Pathologist) stated he did the autopsy and saw where R1's cancer was bad, but he was unsure about why she fell out of bed unless she passed away and fell over. V6 stated that without the police involvement during the incident, it is hard to rule out anything. V6 stated the police should have been called and they could have shed some light on this incident. V6 stated he will have to put cancer as the primary cause of death, but he will make a note in the file that this death was suspicious of suffocation, but no police report was made to that effect.On [DATE] at 11:20AM, V15 (Family Member/ Emergency Contact) was asked if she was notified of R1's fall and death on [DATE] by the nursing facility. V15 stated, No, the funeral home called us and told us he had (R1) and I stated this must be a mistake because (R1) is in a facility and we had not heard anything. V15 stated the funeral home apologized and said he was sorry but R1 had fallen and was deceased . V15 told the funeral home that this is not possible as R1 would not move herself in the bed. V15 stated she called the facility and the night nurse answered and said she did not know why they were not called and told us that R1 was good the night before and she showed no signs of upcoming death. V15 stated she can't understand why they did not call the family. V15 stated the coroner called (another family member) on Monday, [DATE], and informed her that he needed to do an autopsy due to a suspicious death of possible suffocation. V15 stated hospice told them that before R1's death that she showed no signs of impending death before the incident.R1's Final IDPH Incident and/or Abuse Notification report by V3 documents the following: On [DATE] at 1230, (R1) was noted to be on the floor next to her bed. The nurse immediately assessed the resident. Only obvious injuries were skin tears to left and right elbow. Resident on hospice with no previous falls noted. Residents BIMs is a 13. Several staff members were interviewed for the investigation. A complete reenactment was conducted with staff present at the time resident was found. Resident was noted to be in the middle of the bed at 1145. Resident was sitting up at that time to get ready to eat lunch. Staff went to give resident her lunch tray and resident was noted to be on the floor at 1230 laying on her stomach with her head in the nearby trash can. Trash can had a liner in with no other trash noted. Trash can liner noted to have a hole in it. Staff immediately removed trash can and nurse came to assess. Nurse thought they felt a radial pulse. Hospice notified and gave orders to put resident back in bed and place resident on oxygen. Resident is a DNR/comfort focused treatment. Vitals were taken with resident on the floor with no vitals noted. Hospice notified. Funeral home was notified of residents passing. Residents' roommate interviewed for the investigation and stated I didn't hear anything, I was in the bathroom. I didn't hear her yell or anything. At this time, we do not know what caused the resident to fall out of bed or the cause of death. An autopsy is being performed. Residents are dependent with care, transfers and has no history of falls prior to this incident. Prior to fall at 11:45, resident was able to move head and arms and respond to staff per baseline. Resident dependent for most functional and bed mobility tasks. (Name of city) police department was notified on [DATE] of the incident. Resident had no POA or responsible party. Emergency contacts called the facility on [DATE] in the evening and had been notified by the Coroner.On [DATE] at 6:45PM, V11, CNA, was asked if she remembers when the reenactment was done in regard to R1's incident. V11 stated they did a reenactment on the day it happened. V11 was asked who was present for the reenactment, V11 stated it was just her (V11), V13, CNA, and V1. V11 stated she just showed V1 how R1 was positioned on the floor. V1 was asked if she mentioned the trash can and the trash bag during the reenactment, V11 stated, Yes, I explained all of that. V11 stated the trash bag was in R1's mouth. The facility's Administrator job description dated 2003 under Purpose of Your Job Position section documents, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal. Stated and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Under the Duties and Responsibilities section documents the following: Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures, Maintain an adequate liaison with families and residents, Inform the Medical Director of all suspected or known incidents of resident abuse, Review accident/incident reports (e.g. falls, injuries of an unknown source, abuse, etc.), and Monitor to determine the effectiveness of the facility's risk management program.The facility policy titled Abuse and Retaliation Prevention Program, dated 1/2026, under section VII. Internal Investigation documents, 3. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to decide whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time. If classified as an injury of unknown source, the person gathering facts will document the injury, the location and time it was observed, any treatment given, and notification of the resident's physician, responsible party. The Department of Public Health will be notified.8. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following:. Facts determined during the process of the investigation, review of the medical record, and interview of witnesses, Conclusion of the investigation based on known facts. Under section VIII. External Reporting documents 1. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment, retaliation, or misappropriation of resident property has been made, the administrator, or designee, shall notify the Department of Public Health's regional office immediately by telephone or fax. This report shall be made immediately. Informing Local Law Enforcement: The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations: When a resident death has occurred other than by disease processes. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to local law enforcement and IDPH immediately. If there is a reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement as soon as possible, but within 24 hours of when the suspicion was formed. The resident or resident's representative will also be immediately informed of the report of an occurrence of potential abuse, neglect, exploitation, mistreatment, retaliation, or misappropriation of resident property, and that an investigation is being conducted.The facility's [DATE] Daily Census documented 114 residents residing in the facility.

Based on interview and record review, the facility failed to timely and factually notify family and the physician of an incident of injury of unknown origin resulting in death for 1 of 6 (R1) residents reviewed for abuse in of a sample of 46.Findings include:R1's admission record documents an admission date of [DATE] and includes diagnoses of Malignant Neoplasm of Unspecified Bronchus or Lung, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Adult Failure to Thrive, and anxiety disorder.R1's Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 13, indicating R1's cognition was intact. Section GG-Functional Abilities documents R1 required set up or clean up assistance for eating. R1 required substantial/maximal assistance to roll from left and right. R1 was dependent on staff for toileting hygiene, shower/bath self, upper and lower body dressing, putting on /taking off footwear, personal hygiene, sitting to lying on side of bed, sit to stand, chair/bed to chair transfers, and tub/ shower transfers. R1's care plan documents R1 had an increased risk of falls related to weakness and deconditioning. Interventions included anticipate and meet R1's needs [DATE], be sure R1 has call light within reach and encourage her to use it for assistance as needed [DATE], ensure R1 is wearing appropriate footwear nonskid socks and or shoes when mobilizing in wheelchair [DATE], R1 needs a safe environment with : floors free from spills and or clutter; adequate light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach [DATE], follow facility protocol [DATE], and PT evaluate and treat as ordered as needed [DATE].On [DATE] at 11:20 AM, V15 (R1's Great [NAME], #2 Emergency Contact) was asked if she was notified of R1's fall and death on [DATE] by the nursing facility. V15 stated, No, the funeral home called us and told us he had (died), and I stated this must be a mistake because (R1) is at the facility and we had not heard anything. V15 stated the funeral home man apologized and said he was sorry but R1 had fallen and was deceased . V15 said she told the funeral home man that this is not possible as R1 could not move herself in the bed. V15 stated she called the facility and the night nurse answered and said she did not know why we were not called and said R1 was ok the night before and R1 showed no signs of upcoming death. V15 stated she can't understand why they did not call the family. On [DATE] at 1:10 PM, V1 (Administrator) was asked if she directed the staff to not call the Emergency Contacts for R1. V1 stated, Yes I did tell the nurse not to call the Emergency Contact persons because they never came out to see (R1) and (R1) had Adult Protective Services involved in her case, so I was not sure how or if they were involved with anything. V1 stated, I would do it all over again if I had it to do over.On [DATE] at 10:24 AM, V12 (Physician) was asked if he was aware of R1's recent death. V12 stated, Well, let me pull up my notifications. V12 stated, I have a notification that resident found in floor beside bed with altered breathing. Hospice contacted with ordered to place in bed with oxygen. Resident expired at 12:45 PM. V12 stated this notification is time stamped for [DATE] at 2:39 PM. V12 was asked if he was told about R1 having a trash bag over her face when she was found in the floor. V12 stated, I was not told anything about this at all and what did the police say. This surveyor told V12 the police were not called until the following Monday and the incident happened on a Saturday. On [DATE] at 10:00 AM, V9 (Licensed Practical Nurse/ LPN) stated, I had talked to (V1) about calling family (Emergency Contacts) and I was told not to call them. I normally call them.On [DATE] at 2:39 PM, V4 (Hospice Clinical Services) stated she called the coroner to inform him of R1's death and the coroner reported to her that he was not told about a fall, he was just told R1 died from cancer. V4 stated then the coroner stated he was going to have an autopsy done on R1 because there may be a different cause of death.On [DATE] at 11:00 AM, V1 was asked in the presence of V3 (Regional Clinical Director) if she told staff to not contact R1's emergency contacts and V1 stated, Yes, I told them not to call those bi****s, and they never came to see her (R1). V3 stated he educated V1 on this subject. R1's Progress Notes document on [DATE] at 10:36 AM, V40 (Licensed Practical Nurse /LPN) documented V39 (R1's Emergency Contact #1/[NAME]) was given update of V41 (Wound Physician), wound care visit on [DATE] site #3. Right posterior calf improved continue with same orders. On [DATE] at 12:45PM, V40 documented V39 was given an update on V41's wound care visit on [DATE]. Site #3 right posterior calf a skin tear has been resolved, V12 (Physician) notified. On [DATE] at 7:53 AM, V42 (LPN) documents during skin assessment this nurse noted scabbed area to right elbow and small skin tear to right lower leg. V41 notified and orders betadine every shift to right elbow and Silvadene, calcium alginate and dry dressing for skin tears, dressings applied per MD orders no pain or discomfort noted. This nurse notified hospice and emergency contact V39. On [DATE] at 3:24 PM, progress notes document this V29 (Social Service Director) spoke with resident about moving her bed next to the window in her room. No concerns at this time. Emergency Contact was made aware via voice mail.R1's [DATE] at 8:36 PM progress note authored by V38 (LPN) documented, This nurse received a call from (V15 R1's 2nd Emergency Contact) regarding (R1's) passing. Very upset at the fact that they had to find out from the funeral home of resident passing. Questioning why facility had not made contact with them. This nurse looked up (R1's) profile and noted that this caller was emergency contact number 2 and her mother was listed as emergency contact 1. This nurse confirmed that resident had passed and explained it was very unexpected. (V15) stated they did not receive a call from hospice either. Stated they would contact management on Monday to discuss matter. This nurse apologized, condolences given, and call ended. (V2 Director of Nursing/DON) and (V16 Assistant Director of Nursing/ADON) and (V1) notified of this encounter.The was no reproducible evidence located in R1's clinical record that documented R1's family/emergency contact was called on [DATE] and made aware R1 had expired.Policy titled Change in Resident's Condition or Status, dated revised 2021, documented, .our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Under Policy Interpretation and Implementation . #2 A significant change of condition is a decline or improvement in the resident's status that . b. Impacts more than one area of the resident's health status . 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when . The resident is involved in any accident or incident that results in an injury including injuries of unknown source .

Based on interview and record review, the facility failed to notify the physician with a critical lab value in a timely manner for 1 of 3 (R4) residents reviewed for labs in a sample of 6.The findings include: R4's admission Record documents an admission date of 8/22/2025, and includes diagnoses of Acute on Chronic Systolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Peripheral Vascular Disease, Obesity class 2, Difficulty Walking, Anxiety, Major Depressive Disorder, Osteoarthritis, Hypo-osmolality, and Hyponatremia. R4's Progress Notes document on 4/3/26 at 2:05PM, R4 was seen by Cardiology and had new orders to discontinue Lasix and Bumex (medications used to reduce the amount of fluid within the body), have a Complete Metabolic Panel (a blood test measuring electrolytes, liver and kidney function and glucose levels) and Natriuretic Peptide Test (or BNP which is a blood test used to monitor heart failure status) and to follow up in the office in one week. R4's Lab Result Report with a received date of 4/9/2026 at 9:06AM documented a BNP value of 761. This was flagged as a High High (HH) value with normal ranges between 1-100. R4's Progress Note from 4/9/2026 at 11:59PM stated the physician was notified via a secure messaging application by V14, Licensed Practical Nurse (LPN). On 4/21/2026 at 11:31AM, V14 (Licensed Practical Nurse/LPN) stated she was on break and another person answered the phone and relayed the lab value to her for R4's BNP. V14 stated she sent V7 (facility's Physician), a message in a secure messaging application as she had seen that he was just on the application. V14 stated she did not hear back from V7 with any orders. V14 stated she may have tried to call him but maybe the phone was not working right. V14 was not sure. V14 stated she did not notify R4's Cardiologist. On 4/17/2026 at 10:20AM, V7 (Physician) stated he remembers receiving a critical lab notification via the secure messaging application for R4 with a BNP value of 761 on 4/9/2026 at 11:24PM, but he did not see the lab until the next morning and he did not respond with any orders. V7 stated he did not receive a call at that time from the facility about the critical lab. V7 stated the value was about baseline for R4. V7 stated they should call critical labs to the physicians. On 4/21/2026 at 11:10AM, V6 (Regional Clinical Nurse/RCN) stated, They should always call in a critical lab. V6 stated the labs should be called in to the ordering physician too. On 4/21/2026 at 11:00AM, V2 (Director of Nursing/DON) stated the nurses have to call these labs to the physicians. V2 stated they know the nurses have sent some via the secure messaging application, but they are educating on this issue. On 4/17/2026 at 2:05PM, V5 (LPN) stated they very seldom get a critical lab, but when they do they notify the Physician immediately. I just keep trying to call until I get them. On 4/17/2026 at 2:46PM, V10 (LPN) stated when receiving a critical lab they always call the physician, fax, use the secure messaging application, and if there are new orders they process them. On 4/17/2026 at 2:53PM, V11 (LPN) stated I call the doctor with any critical lab and fax the results. (V7) is usually through the secure messaging application and call the office. The policy titled, Change in Condition, with a review date of 2022, documents the protocol for notifying the attending physician of changes in resident's medical/mental condition. 1) The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been; e) a need to alter the resident's medical treatment significantly, a significant change in the resident's physical/emotional/mental condition. A lab policy was requested but was not presented.

Based on interview and observation, the facility failed to provide access to drinking water at the bedside for 4 (R18, R19, R20, R21) of 5 residents reviewed for access to drinking water in a sample of 29. On 3/31/26 at 2:28 PM, there were no water pitchers for R18 and R19 on or near their overbed tables in their room. There were empty cups sitting on the overbed tables of both R18 and R19 with only drops of clear liquid in the bottom.On 3/31/26 at 2:33 PM, there were no water pitchers or cups for R20 and R21 on or near their overbed tables in their room.On 4/1/26 at 8:50 AM, there were no water pitchers for R18 and R19 on or near their overbed tables in their room. There were also no empty or full cups of liquid on or near the overbed table of R18 and R19.On 4/1/26 at 8:55 AM, there were no water pitchers or cups on or near the overbed tables in the room of R20 and R21.On 4/1/26 at 245 PM, V4 (Certified Nurse Aide/CAN) stated all residents should have access to drinking water at their bedside unless they are on a fluid restriction or on thickened liquids.On 4/1/26 at 3:40 PM, V12 (CNA) stated all residents should have access to drinking water at their bedside unless they are on a fluid restriction.On 4/2/26 at 1:46 PM, V25 (CNA) stated all residents should have access to drinking water at their bedside.On 4/6/26 at 9:12 AM, V21 (CNA) stated all residents should have access to water at bedside unless they have some sort of dietary restriction, like thickened liquids. V21 stated for those residents on dietary restrictions, she tries to offer them drinks frequently to make sure they get enough fluid intake.On 4/6/26 at 9:56 AM, V22 (CNA) stated she could not think of any resident that is not supposed to have access to drinking water in their room.On 4/6/26 at 1:51PM, there were no water pitchers or drinking cups at bedside in the rooms of R18-R21.On 4/6/26 at 1:51 PM, V26 and V27, both CNAs working the hall, were asked if there was any fluid restriction or reason R18, R19, R20 and R21 had no water pitchers or drinking cups at their bedside. V26 and V27 could give no reasons why the above residents had no water pitcher or drinking cup at their bedside. V26 and V27 both stated the above residents were not on any type of fluid restriction or thickened liquids.On 4/6/26 at 2:01PM, V2 (Director of Nurses) visited the rooms R18, R19, R20 and R21. At that time R18, R19, R20 and R21 had no water pitchers or drinking cups at their bedside. V2 stated he will check why they don't have any.On 4/6/26 at 2:17 PM, V2 stated there was no reason the above residents shouldn't have had water at the bedside. V2 stated water pitchers with ice water have been provided to the above residents at this time.On 4/7/26 at 2:53 PM, V2 stated residents should always have access to fluids of their choice to help with hydration maintenance. V2 stated if the resident is on some type of dietary restriction, then fluids should be offered at least every two hours, when medications are administered, and at meals depending on their order for fluid restriction. V2 stated he is not sure how often water is passed on the wing but believes it should be done at least daily. V2 stated, I know it's part of the hall checks. The hall monitors are supposed to let us know if everyone has water.On 4/7/26 at 3:25 PM, V1, Administrator, stated residents should have constant access to drinking fluids. V1 stated ice water is passed every shift, but fluids are also offered at every meal, when CNAs do bed checks, and during medication administration times. V1 stated R18, R19, R20 and R21 should have had water pitchers in their rooms. V1 stated the facility does not have a written policy for hydration maintenance for the residents.

Based on observation, interview, and record review, the facility failed to secure medications at the bedside for 1 (R22) of 3 residents reviewed for medications secured at the bedside in the sample of 29.Findings include:On 4/2/26 at 9:58 AM, R22 was sleeping soundly in her bed. R22 responded to her name with a moan/grunt but was not easily awakened. R22 had a medicine cup sitting on her overbed table containing 7-8 tablets of unknown medications. R22 never wakened while this surveyor was in the room.On 4/2/26 at 12:02 PM, R22 who was alert to person, place, and time, stated it was her fault her medications were left on her overbed table. R22 stated the nurse had brought them into her when she was awake, but she fell back to sleep before taking the medication. This surveyor did observe 1 unidentified pill left in her medication cup. R22 stated she was going to take the pill in just a minute. On 4/2/26 at 4:37 PM, V28 (Licensed Practical Nurse/LPN) verified he was the nurse who was supposed to have administered R22's medications. V28 stated it was not safe or appropriate for him to leave R22's medications at bedside and not verifying the medications were administered before leaving the room. V28 stated he should have made sure medications were administered before leaving R22's room.On 4/7/26 at 2:53 PM, V2 (Director of Nurses) stated V28 should not have left R22's medications at bedside without first making sure R22 had been administered the medications. V2 stated one of the main reasons for this is for safety purposes to make sure another demented resident doesn't wander into the room and swallow the medications, or the resident who they are prescribed for doesn't horde them up and take them all at once.On 4/7/26 at 3:25 PM, V1 (Administrator) stated medications should not be left at the resident's bedside at all. V1 stated the main reason for not doing this is because of safety. V1 stated demented residents may wander into a room and swallow the medications by mistake, or if the resident could possibly horde the medications up and take too many at the same time.Facility's medication administration policy, with a revision date of December 2012, documents, Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering medications must verify the resident's identity before giving the resident his/her medications. Medications cannot be prepared for administration until the resident is present and ready to take the medication.

Based on interview and record review, the facility failed to answer call lights timely for 6 (R2, R10, R11, R12, R13, R14) of 6 residents reviewed for call lights in the sample of 14. Findings include:R2's admission record, dated 1/28/26, documents an admission date of 8/25/25. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 is cognitively intact.On 1/27/26 at 12:03 P.M., R2 stated upon his arrival back from his hospital admission, they moved R2 into a new room. R2 stated his sheets and mattress were wet, so his daughter initiated the call light to have someone come and change the sheets and dry the mattress. R2 stated he could not remember the exact amount of time it took for staff to answer the call light, but it took well over 15 minutes. On 1/27/26 at 2:09 P.M., V24, Family Member, stated when her father, R2, had been moved into a new room from his return from a hospital admission a couple of weeks ago, she noticed the sheets and the mattress of his bed were wet. V24 stated she then initiated the call light system to get fresh sheets. V24 stated to determine how long it took staff to answer the call light she timed them according to her phone's watch. V24 stated she hit the call light button at 8:20 P.M., and the staff did not answer the call light until 9:00 P.M. V24 stated she does remember the day; it was January 13th, a Tuesday, when this happened. V24 stated she tried to get hold of the Administrator to report her concern about call light wait times but was never successful in reaching her. V24 stated she played phone tag with the Administrator a few times, and then eventually stopped trying.R14's resident grievance form, dated 11/13/25, documents resident feels like it takes a long time for staff to answer call lights on night shift.R12's resident grievance form, dated 11/18/25, documents resident feels like Certified Nurse Aides are not answering her call light in an appropriate amount of time.R13's resident grievance form, dated 12/1/25, documents resident stated nursing staff were not timely in answering his call light .R10's resident grievance form, dated 1/11/26, documents, resident stated his call light takes over 30 minutes to be answered and when someone comes, they turn it off and never come back to address the issue.R11's resident grievance form, dated 1/21/26, documents residents Power of Attorney called the facility complaining his mother had soiled herself because her call light had not been answered in 4 hours. On 1/29/26 at 9:13 A.M., V2, Regional Director of Clinical Operations/Acting Director of Nurses, stated he has not received any recent complaints of call lights being answered timely. V2 stated, I did look back at the grievances you talked about, and it looked like they were addressed and resolved. V2 stated he thought call lights should be answered as quickly as possible. V2 stated when asked about how long it should take to answer a call light, he stated he didn't want to give a time limit because it would depend on what's going on down the hall, but would consider fifteen minutes to be an appropriate maximum amount of time to answer a call light. V2 stated the facility does not have a call light policy.On 1/29/26 at 9:36 A.M., V1 stated she has not been made aware of complaints of call lights being answered timely. V1 stated she believes call lights should be answered as quickly as possible depending on what's going on down the hall. V1 stated she did not want to give a maximum time limit for appropriate time limit to answer a call light because it would all depend on what was going on and what was the situation that would take precedence. V1 stated the facility doesn't have a call light policy.

Based on interview and record review, the facility failed to clean a newly admitted resident's room after one resident was moved out and he was moved in for 1 (R2) of 3 residents reviewed for environment in a sample of 9. Findings include:R2's admission record, dated 1/28/26, documents an admission date of 8/25/25. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 is cognitively intact.On 1/27/26 at 12:03 P.M., R2 stated upon his return from a hospitalization in the middle of January, he was moved into a different room than the one he originally had because he was on isolation for influenza or something else (can't remember). R2 stated the beds in the new room were dirty and didn't appear to have been cleaned prior to the former occupant being moved out and himself moving in. On 1/27/26 at 2:09 P.M., V24, Family Member, stated the new room the facility placed her father in did not appear to have been cleaned or sanitized upon last resident's exit. V24 stated there was dirt on the floor, what appeared to be used oxygen tubing laying in the chair, there was a cupcake in a container on the overbed table, and the empty bed next to R2 had what appeared to be food crumbs on it. V24 stated when she entered the private bathroom for this room, it appeared the toilet had not been cleaned prior to the last resident's exit. V24 stated there were brown stains like feces on the porcelain of the bowl of the toilet.On 1/29/26 at 8:18 A.M., V5, Housekeeping Supervisor, stated the housekeepers do have a daily schedule for cleaning. V5 stated every resident room should be cleaned every day. V5 stated cleaning in the resident's room includes wiping down all high touch surface areas with sanitizer wipe or spray, sweeping, mopping of the floors, emptying trash cans, and cleaning private bathroom lavatories and toilets if they have one every day. V5 stated mattresses and bed frames are cleaned twice per week on resident's shower day when not in the resident is not in the bed. When asked about the room reportedly not cleaned before R2's placement in the room, V5 stated there was a miscommunication. V5 stated the housekeeper who was supposed to be responsible for cleaning the room thought she had more time to get it cleaned and went ahead and went to lunch. By the time the housekeeper got back and headed to clean the room, the resident, R2, had already been placed in the room. V5 stated they (housekeeping staff) thought they had more time to get the room clean, but the resident had come back sooner than expected from the hospital. V5 stated she thought the room had already been cleaned, but it had not between one resident moving out and the other R2 moving in. V5 stated the next day, the 14th, she went down and deep cleaned the room herself. V5 stated the room should have been cleaned prior to the resident, R2 being placed in the room.On 1/29/26 at 9:13 A.M., V2, Regional Director of Clinical Services/ Acting Director of Nurses, stated he had not received any complaints regarding facility cleanliness over the last month or so. V2 stated he had heard of a complaint about a room not being cleaned while he was on vacation the last part of December, first part of January, but didn't know the details of it. V2 stated he only heard about the complaint in passing. V2 stated he had not heard anything a room not being cleaned prior to this investigation but stated it should have been cleaned prior to the resident, R2, being placed in it. V2 stated he feels the facility should be kept very clean due to risk of transmitting infections and possible contamination. V2 stated the facility has been short on housekeeping staff in the past and have offered overtime to Certified Nursing Assistants to do housekeeping duties to make sure everything stays clean. When asked about rooms being cleaned daily, V2 stated he would expect the trash to be emptied, the floors swept and mopped , high touch surface areas wiped down with sanitizing wipes or spray, and the bathrooms cleaned.On 1/26/26 at 9:36 A.M., V1, Administrator, stated she has not recently received any complaints of the facility being dirty in general. V1 stated resident rooms should be cleaned daily including high touch surface areas wiped down with sanitizing wipes or spray and the bathrooms cleaned. V1 stated there was a complaint about the room that R2 was placed in upon his return from the hospital not being cleaned prior to him being placed in it. V1 stated, We got report that (R2) was coming back on isolation and that is the room we use for isolation and overflow if we have it. There was a miscommunication and one person thought another person had cleaned the room when actually no one had cleaned it prior to (R2's) entrance. It was an honest mistake. There should have been better communication between housekeeping staff. An undated Deep Cleaning a Room checklist documents the following to be done during the deep cleaning of a room. Take down privacy curtains, strip the beds, wipe down the mattress front and back, wipe down the bed frame, wipe off the control panel, wipe off the nightstands inside and out, wipe off the window seal, wipe down the over the bed table top to bottom, move the nightstands and clean behind them, move the bed and clean where it was sitting, wipe down the walls, move anything else that can be moved and clean where it was sitting, if the room has a bathroom deep clean it, wipe the trash cans inside and out, clean the A/C(air conditioner) (filter and vents), put privacy curtains back up, make the beds, put everything back where it goes.

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This failure has the potential to affect all 112 residents residing in the facility. Findings Include:On 11/21/25 at 2:19PM, R1 was alert and oriented and was asked how his meals were and if they were they served on time. R1 stated, It seems like we have a lot of reruns on the meals, but I think they try to follow the menu the best they can. R1 stated the meals are sometimes late and he wasn't sure why. When asked if the food and time the meals were served was ok, R1 stated, Well, that is debatable. On 11/21/25 at 3:30PM, V5 (Head Cook) stated there was a no call/no show for the shift so they are running way behind on everything. V5 said they usually have all the dishes from lunch done by now. V5 stated they are short staffed right now and are sometimes late with the meals.On 11/21/25 at 4:50PM, several residents were observed to be sitting in the big dining room awaiting the supper meal to be served. R4 was sitting in a recliner chair at a table in the dining room along with R5, who was sitting in the reclined position of a reclining wheelchair. At 5:15PM, several department heads and staff members gathered in the big dining room to help serve the supper meal. There were 14 staff members lined up waiting on trays to start to come out of the kitchen. R1 was sitting in the dining room waiting for supper and stated to this surveyor, Wow, I have never seen so many staff members here to help with any meals; I guess it is because you are here watching. The first tray went out at 5:37PM and was served to the 200 Hall. The hall trays were going out individually by staff, one at a time. The trays for the 100 hall started going out at 5:42PM. At 6:02PM, trays were being walked to the 300 hall. At 6:05PM, R6 left the big dining room and returned with a big bag of chips and was sharing them with R7. R6 stated, We are really hungry, so we have to eat chips for now. A cart with several trays went to the small dining room at 6:16PM. The first tray to be served in the big dining room was at 6:17PM.On 11/21/25 at 7:15PM, R1 received a tray containing fish, green beans, au gratin potatoes, and pudding. R1 stated, This is the way it normally goes lately, with the time of getting supper. On 11/21/25, R5 received a tray at 7:17PM. On 11/21/25 at 7:18PM, R8 was alert and oriented, sitting at the table in the big dining room with no tray, and was dressed with a jacket on and purse sitting on the table. This surveyor asked R8 if she was a visitor and R8 stated, No, I live here and I guess I won't get a tray again, so I am just going back to my room without supper again. This surveyor asked R8 to stay so she could get a tray. V6 (Regional Clinical Director) was sitting at the next table assisting residents and was notified R8 did not get a tray. V6 went to the kitchen door immediately and brought back R8 a tray. While V6 was at the door waiting on R8's tray, a CNA came up and told V6 that R9 did not get a tray either, and R9 needed a tray so she could get fed. V6 stated, I thought I saw that tray go out, but we will get her one right now. The last supper trays were served to R8 and R9 at approximately 7:20PM. On 11/23/2025 at 12:30PM, R1 was sitting in the big dining room waiting on his lunch tray. The first tray came out of the kitchen at 1:00PM. The hall trays were the first trays to go out. The trays in the big dining room were not started until 1:27PM with last tray out at 1:53PM. R1 did not receive a tray until 1:38PM. On 11/24/25 at 11:48AM, V17 (Certified Nurse Assistant/CNA) stated he was working 11/21/25 when the supper meal was very late. V17 stated that is not unusual for meals to be late. On 11/25/25 at 8:48AM, V12 (CNA/Supervisor) stated meals do run late at times. On 11/25/25 at 9:00AM, V13 (CNA) stated meals have been running late recently. On 11/25/25 at 9:30AM, V14 (Licensed Practical Nurse/LPN) stated there have been times that the trays were running late, and he was worried about the diabetics that get insulin, but so far, he has not had any issues. On 11/25/25 at 9:27AM, V18 (Registered Nurse/RN) stated she has noticed meals running late recently and she watches her diabetic residents closely, and does not give their insulin until the meal is ready to be served.A facility provided document titled Mealtimes documents Breakfast at 8:30AM, Lunch at 12:30PM, and Supper at 5:30PM.

Based on interview and record review, the facility failed to ensure a resident was free from intimidation/verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time of incident is listed as 11/17/25 at 6:30pm and location listed was the Kitchen. The description documents, Resident asked cook for a grilled cheese and (name of V11) told resident, I am not making any more f***ing grilled cheese. RN (Registered Nurse name) asked (V11) for sandwich as well and (V11) refused. V7's (Former Dietary Manager) signature was listed under Supervisor Signature with a date of 11/18/25 and a box marked Not Rehire-able was checked. Another Employee Action Form for V11 was marked Termination with an offense of Inappropriate conduct towards a resident with an incident date of 11/17/25 at 8pm and documented, (V11) was asked by a resident to make her a grilled cheese, and (V11) refused saying 'you got a normal f***ing tray, I am not making any more grilled cheese.' This language towards a resident is not acceptable and is subject to termination. This document is signed by V7 and dated 11/18/25. A third Employee Action Form for V11 was marked Termination with an offense of sleeping on duty with an incident date of 11/17/25 at 9pm in the kitchen.An untitled document appearing to be R11's written statement regarding the above incident documents, Resident asked cook, (V11) for a grilled cheese sandwich before dinner service began at 5:30PM. Cook, (V11) ignored resident's request throughout service and gave resident a normal tray without the grilled cheese. When resident approached the kitchen, (V11) said 'You got a normal f***ing tray, I am not making any more f***ing grilled cheese' and walked away. Resident asked once again for a sandwich and cook ignored resident's request. Resident immediately notified their nurse, and their nurse immediately notified Dietary Manager and Administrator of the incident. The statement was signed by R11 and dated 11/17/25.An untitled document appearing to be V19's (Licensed Practical Nurse/LPN) statement documented, resident (R11's initials) came up to this writer and reported that head cook was rude/disrespectful towards her. When asked what happened res (resident) stated me and my roommate had ordered burger and grilled cheese instead of our tray and I went to check in and see if it was ready and was told 'you guys got a tray, and you don't get anything else. I guess I'll make it but this is the last f***ing grilled cheese I make.' This nurse also noted that two other residents had not received their trays. Went to talk to kitchen staff about issue. [NAME] had a very bad attitude stating that she didn't know who I was talking about and that they had been done serving food for 45 minutes at this point and she didn't understand why things are being ordered now. This is not the 1st time these issues have been occurring with the same staff member. Kitchen Supervisor and Admin (Administrator) made aware of this. Staff member was sent home. This nurse was a witness along with floor hall monitor. This statement is signed by V19 (LPN) and dated 11/17/25.Another untitled document appearing to be V22's handwritten statement and dated November 17, 2025 documents, (V22) went to the kitchen to remind them (R2) had already asked for a hamburger. (V11) then said she has made all she is making and went outside. (R11) then asked about her food. (V22) went into the kitchen and made (R11) .and R2's sandwiches.while (V11) was in (V7's) office asleep in the chair. This statement is signed by V22. On 11/24/2025 at 10:39AM, V7 (Former Dietary Manager) stated he was aware of the incident that occurred on 11/17/25 regarding V11 and R11. V7 stated he received a call from a nurse reporting to him that one of his staff members (V11) cursed out R11 and refused to fix R11 a grilled cheese. V7 stated he notified V1 (Administrator) immediately and was directed by V1 to go to the facility and get statements and send V11 home. V7 stated he came to the facility and interviewed R11 and V11 and got statements from staff that heard the incident. V7 stated he sent V11 home. V7 stated he slid the statements under V1's door as he was told. V7 stated the next day he and V1 discussed the situation and V7 stated he wanted to fire V11 for verbal abuse to a resident and V1 stated to him, Don't fire (V11) for abuse because I will have to report the abuse to Public Health, and I don't want public health in my building over abuse. V7 stated this statement upset him because this was a situation of verbal abuse and should be treated as such. V7 stated he wrote up termination documents and added a reason was for V11 sleeping while at work because that had happened as well. V7 stated after this was all taken care of that day, he then quit and left the facility because as a manager, he didn't feel like he could handle the situation of abuse correctly and the way it should have been handled. On 11/24/2025 at 10:48AM, R11 was asked if she recalled the incident that occurred on 11/17/2025 involving V11 and R11's request for a grilled cheese. R11 stated, Oh yes I remember that evening well. R11 stated it was around 7pm and the meal that was served was not good at all, so she walked to the kitchen to ask for an alternate of a grilled cheese. R11 stated V11 was in the kitchen so R11 asked if V11 would please fix a grilled cheese for her. R11 stated that V11 said she already got a tray, and she was not going to fix me a f***ing grilled cheese. R11 stated V11 stated the f***ing kitchen is closed now and I will not fix you a grilled cheese. R11 stated the only staff that has talked to her about an investigation was V7. When asked how this made her feel, R11 denied this occurrence causing any type of emotional issues or fear, stating, No that didn't affect me in any way it just made me a little mad.On 11/26/2025 at 4:41PM, V19 (Licensed Practical Nurse/LPN) stated she was one of the nurses working on 11/17/2025 when the incident occurred with V11 and R11. V19 stated she was passing medications when R11 approached her and reported she had ordered a grilled cheese and went to the kitchen to get it, and V11 cursed at her and refused to make the grilled cheese. V19 stated she reported this to V7 and V7 called V1 (Administrator). V19 stated V7 came to the facility and sent V11 home for verbal abuse to a resident. V19 stated she talked to V1 as well and V1 informed her that V7 would be coming to the facility to get statements and V1 would review in the morning. V19 said V1 stated V7 was coming to send V11 home because this was verbal abuse. V19 stated there were a few other residents that had requested a substitute, so another staff member went to the kitchen and prepared food for all the residents that requested a substitute meal. V19 stated she filled out a report of what happened and turned it in to V7.On 11/24/2025 at 1:04PM, V1, Administrator, returned a call to this surveyor and was asked if she reported the incident of verbal abuse that occurred on 11/17/2025 between V11 and R11. V1 stated, No, I didn't report it because I felt it was more like a customer service issue. V1 was asked if she was the Abuse Coordinator, and V1 replied yes. V1 was asked if she was made aware of the situation when it occurred, and V1 stated, I knew there was an issue with a grilled cheese, but I still feel like it was a customer service issue. V1 was asked if she felt like a staff member cursing at a resident was verbal abuse, and V1 stated maybe, but again I felt it was customer service issue. V1 was asked if she did an investigation into the incident to determine if this was customer service or verbal abuse. V1 stated, No I did not investigate. V1 stated, I directed (V7) to get statements but honestly the only paperwork I reviewed was the 'Employee Discipline' paperwork. V1 was asked again if she was notified the night that this incident occurred and V1 stated, Yes I was notified by (V7) and (V19) the night it occurred.The facility's Abuse Prevention Program Policy, reviewed and updated 2022, documents, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The document contains the description of verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, families, or within their hearing distances, regardless of individuals age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to report an allegation of verbal abuse to the State Agency and local law enforcement within 24 hours for 1 (R11) of 3 residents reviewed for reporting alleged violations in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time of incident is listed as 11/17/25 at 6:30pm and location listed was the Kitchen. The description documents, Resident asked cook for a grilled cheese and (name of V11) told resident I am not making any more f***ing grilled cheese. RN (Registered Nurse name) asked (V11) for sandwich as well and (V11) refused. V7's (Former Dietary Manager) signature was listed under Supervisor Signature with a date of 11/18/25 and a box marked Not Rehire-able was checked. Another Employee Action Form for V11 was marked Termination with an offense of Inappropriate conduct towards a resident, with an incident date of 11/17/25 at 8pm, and documented, (V11) was asked by a resident to make her a grilled cheese, and (V11) refused saying 'you got a normal f***ing tray, I am not making any more grilled cheese.' This language towards a resident is not acceptable and is subject to termination. This document is signed by V7 and dated 11/18/25. A third Employee Action Form for V11 was marked Termination with an offense of sleeping on duty with an incident date of 11/17/25 at 9pm in the kitchen.On 11/24/2025 at 10:39AM, V7 (Former Dietary Manager) stated he was aware of the incident that occurred on 11/17/25 regarding V11 and R11. V7 stated he received a call from a nurse reporting to him that one of his staff members (V11) cursed out R11 and refused to fix R11 a grilled cheese. V7 stated he notified V1 (Administrator) immediately and was directed by V1 to go to the facility and get statements and send V11 home. V7 stated he came to the facility and interviewed R11 and V11 and got statements from staff that heard the incident. V7 stated he sent V11 home. V7 stated he slid the statements under V1's door as he was told. V7 stated the next day he and V1 discussed the situation and V7 stated he wanted to fire V11 for verbal abuse to a resident and V1 stated to him, Don't fire V11 for abuse because I will have to report the abuse to Public Health, and I don't want public health in my building over abuse. V7 stated this statement upset him because this was a situation of verbal abuse and should be treated as such. V7 stated he wrote up termination documents and added a reason was for V11 sleeping while at work because that had happened as well. V7 stated after this was all taken care of that day, he then quit and left the facility because as a manager, he didn't feel like he could handle the situation of abuse correctly and the way it should have been handled. On 11/26/2025 at 4:41PM, V19 (Licensed Practical Nurse/LPN) stated she was one of the nurses working on 11/17/2025 when the incident occurred with V11 and R11. V19 stated she was passing medications when R11 approached her and reported she had ordered a grilled cheese and went to the kitchen to get it and V11 cursed at her and refused to make the grilled cheese. V19 stated she reported this to V7 and V7 called V1 (Administrator). V19 stated V7 came to the facility and sent V11 home for verbal abuse to a resident. V19 stated she talked to V1 as well and V1 informed her V7 would be coming to the facility to get statements and V1 would review in the morning. V19 said V1 stated V7 was coming to send V11 home because this was verbal abuse. V19 stated she filled out a report of what happened and turned it in to V7.On 11/24/2025 at 11:00AM, V20 (Administrator at Sister Facility) was covering and present in the facility due to V1 (Administrator) not working. V20 was asked for the facility's reportable abuse incidents, and a report on the incident from 11/17/25 regarding V11 and R11 was not present. V20 checked and stated there were no reports for that date or any regarding V11 and R11. V20 and V6 (Regional Clinical Director) were presented with the statements that were retrieved from V11's personnel file. V6 and V20 reviewed the documents and V20 stated she would report this immediately to the State Agency and start an investigation. On 11/24/2025 at 1:04PM, V1 returned a call to this surveyor and was asked if she reported the incident of verbal abuse that occurred on 11/17/2025 between V11 and R11. V1 stated, No, I didn't report it because I felt it was more like a customer service issue. V1 was asked if she was the Abuse Coordinator, and V1 replied yes. V1 was asked if she was made aware of the situation when it occurred, and V1 stated, I knew there was an issue with a grilled cheese, but I still feel like it was a customer service issue. V1 was asked if she felt like a staff member cursing at a resident was verbal abuse, and V1 stated, Maybe, but I felt it was customer service issue. V1 was asked again if she was notified the night that this incident occurred and V1 stated, Yes I was notified by (V7) and (V19) the night it occurred.The facility's Abuse Prevention Program Policy, reviewed and updated 2022, documents under Purpose: Identifying occurrences and patterns of mistreatment, immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. Filing accurate and timely investigation reports. Section B., Internal Reporting documents Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.Reports will be documented and a record kept of the documentation. Section V., Reporting and Response documents: A. Representative and Physician. The administrator or designee will notify the resident's representative and physician of the alleged incident and the investigation. B. Police. The administrator or designee shall notify the local police of any suspicion of a crime or in the event of resident death other than by disease process.C. Initial Report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. i. Report contents. The initial report shall include: the name of the resident allegedly harmed; when the allegation was received; the time and date of the alleged incident; who was notified and when; and the steps the facility has taken in response to the allegation, including the steps to protect the resident. A copy of this initial report shall be maintained.D. State Agencies. If the perpetrator is an employee and the allegation is substantiated, the administrator or designee will report the employee to the appropriate licensing agency, as required by state law. E. Final Report & Follow Up. Within five days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken to respond to the allegation, will be sent to the Department of Public Health. i. Report Contents. The final report shall include the following, as appropriate: name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries); a summary of facts determined during the process of the investigation, review of medical record and interview of witnesses; and conclusion of the investigation based on known facts.

Based on interviews and record review, the facility failed to complete a thorough investigation in response to an allegation of staff to resident verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time of incident is listed as 11/17/25 at 6:30pm and location listed was the Kitchen. The description documents, Resident asked cook for a grilled cheese and (name of V11) told resident, I am not making any more f***ing grilled cheese. RN (Registered Nurse name) asked (V11) for sandwich as well and (V11) refused. V7's (Former Dietary Manager) signature was listed under Supervisor Signature with a date of 11/18/25 and a box marked Not Rehire-able was checked. Another Employee Action Form for V11 was marked Termination with an offense of Inappropriate conduct towards a resident with an incident date of 11/17/25 at 8pm and documented, (V11) was asked by a resident to make her a grilled cheese, and (V11) refused saying 'you got a normal f***ing tray, I am not making any more grilled cheese.' This language towards a resident is not acceptable and is subject to termination. This document is signed by V7 and dated 11/18/25. A third Employee Action Form for V11 was marked Termination with an offense of sleeping on duty with an incident date of 11/17/25 at 9pm in the kitchen.An untitled document appearing to be R11's written statement regarding the above incident documents, Resident asked cook, (V11) for a grilled cheese sandwich before dinner service began at 5:30PM. Cook, (V11) ignored resident's request throughout service and gave resident a normal tray without the grilled cheese. When resident approached the kitchen, (V11) said 'You got a normal f***ing tray, I am not making any more f***ing grilled cheese' and walked away. Resident asked once again for a sandwich and cook ignored resident's request. Resident immediately notified their nurse, and their nurse immediately notified Dietary Manager and Administrator of the incident. The statement was signed by R11 and dated 11/17/25. An untitled document appearing to be V19's (Licensed Practical Nurse/LPN) statement documented, resident (R11's initials) came up to this writer and reported that head cook was rude/disrespectful towards her. When asked what happened res (resident) stated 'me and my roommate had ordered burger and grilled cheese instead of our tray and I went to check in and see if it was ready and was told 'you guys got a tray, and you don't get anything else. I guess I'll make it but this is the last f***ing grilled cheese I make.' This nurse also noted that two other residents had not received their trays. Went to talk to kitchen staff about issue. [NAME] had a very bad attitude stating that she didn't know who I was talking about and that they had been done serving food for 45 minutes at this point and she didn't understand why things are being ordered now. This is not the 1st time these issues have been occurring with the same staff member. Kitchen Supervisor and Admin (Administrator) made aware of this. Staff member was sent home. This nurse was a witness along with floor hall monitor. This statement is signed by V19 (LPN) and dated 11/17/25.Another untitled document appearing to be V22's handwritten statement, and dated November 17, 2025, documents, (V22) went to the kitchen to remind them (R2) had already asked for a hamburger. (V11) then said she has made all she is making and went outside. (R11) then asked about her food. (V22) went into the kitchen and made (R11) .and (R2's) sandwiches.while (V11) was in (V7's) office asleep in the chair. This statement is signed by V22. On 11/24/25 at 10:39AM, V7 (Former Dietary Manager) stated he was aware of the incident that occurred on 11/17/25 regarding V11 and R11. V7 stated he received a call from a nurse reporting to him that one of his staff members (V11) cursed out R11 and refused to fix R11 a grilled cheese. V7 stated he notified V1 (Administrator) immediately and was directed by V1 to go to the facility and get statements and send V11 home. V7 stated he came to the facility and interviewed R11 and V11 and got statements from staff that heard the incident. V7 stated he sent V11 home. V7 stated he slid the statements under V1's door as he was told. V7 stated the next day he and V1 discussed the situation and V7 stated he wanted to fire V11 for verbal abuse to a resident and V1 stated to him, Don't fire (V11) for abuse because I will have to report the abuse to Public Health, and I don't want Public Health in my building over abuse. V7 stated this statement upset him because this was a situation of verbal abuse and should be treated as such. V7 stated he wrote up termination documents and added a reason was for V11 sleeping while at work because that had happened as well. V7 stated after this was all taken care of that day, he then quit and left the facility because as a manager, he didn't feel like he could handle the situation of abuse correctly and the way it should have been handled. On 11/24/2025 at 10:48AM, R11 was asked if she recalled the incident that occurred on 11/17/2025 involving V11 and R11's request for a grilled cheese. R11 stated, Oh yes I remember that evening well. R11 stated it was around 7pm and the meal that was served was not good at all, so she walked to the kitchen to ask for an alternate of a grilled cheese. R11 stated V11 was in the kitchen so R11 asked if V11 would please fix a grilled cheese for her. R11 stated that V11 said she already got a tray, and she was not going to fix me a f***ing grilled cheese. R11 stated V11 stated, the f***ing kitchen is closed now and I will not fix you a grilled cheese. R11 stated the only staff that has talked to her about an investigation was V7. On 11/26/2025 at 4:41PM, V19 (Licensed Practical Nurse/LPN) stated she was one of the nurses working on 11/17/2025 when the incident occurred with V11 and R11. V19 stated she was passing medications when R11 approached her and reported she had ordered a grilled cheese and went to the kitchen to get it, and V11 cursed at her and refused to make the grilled cheese. V19 stated she reported this to V7 and V7 called V1 (Administrator). V19 stated V7 came to the facility and sent V11 home for verbal abuse to a resident. V19 stated she talked to V1 as well and V1 informed her that V7 would be coming to the facility to get statements and V1 would review in the morning. V19 said V1 stated V7 was coming to send V11 home because this was verbal abuse. V19 stated there were a few other residents that had requested a substitute, so another staff member went to the kitchen and prepared food for all the residents that requested a substitute meal. V19 stated she filled out a report of what happened and turned it in to V7.On 11/24/2025 at 11:00AM, V20 (Administrator at Sister Facility) was covering and present in the facility due to V1 (Administrator) not working. V20 was asked for the facility's reportable abuse incidents, and a report on the incident from 11/17/25 regarding V11 and R11 was not present. V20 checked and stated there were no reports for that date or any regarding V11 and R11. V20 and V6 (Regional Clinical Director) were presented with the statements that were retrieved from V11's personnel file. V6 and V20 reviewed the documents and V20 stated she would report this immediately to the State Agency and start an investigation. On 11/24/2025 at 1:04PM, V1 returned a call to this surveyor and was asked if she asked if she was the Abuse Coordinator, and V1 replied yes. V1 was asked if she was made aware of the incident of verbal abuse that occurred on 11/17/2025 between V11 and R11. V1 confirmed she knew there was an issue with a grilled cheese, but she felt like it was a customer service issue. V1 was asked if she did an investigation into the incident to determine if it was customer service issue or Verbal Abuse, and V1 stated, No I did not investigate. V1 stated, I directed (V7) to get statements but honestly the only paperwork I reviewed was the Employee Discipline paperwork. The facility's Abuse Prevention Program Policy, reviewed and updated 2022, documented the following: Purpose: identifying occurrences and patterns of mistreatment, immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property, and mistreatment, and making the necessary changes to prevent future occurrences. Section IV., Investigation documents: As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident; The alleged victim (if the victim is unable to be interviewed, this shall be documented); The alleged perpetrator (if the alleged perpetrator is a resident who cannot be interviewed, this shall be documented); Any witnesses or potential witnesses to the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family or visitors; A review of the medical record, including care plan; A review of all circumstances surrounding the incident; and Physicians will be notified of any incident and any medical treatment will be done as ordered. The investigation shall conclude whether the allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation can likely be sustained. Records of the investigation shall be maintained.

Based on observation, interview, and record review, the facility failed to ensure timely incontinence care and repositioning services were provided for 3 (R4, R5, and R10) of 5 dependent residents reviewed for Activities of Daily Living (ADL) care in the sample of 13.Findings include:1. R4's admission Record documents an admission date of 5/11/22, and included diagnoses of Fracture of part of Neck of Right Femur, Type 2 Diabetes Mellitus, Unspecified Dementia, Convulsions, Anxiety Disorder, and Cognition Communication Deficit. R4's MDS (Minimum Data Set), dated 10/7/25, documented a BIMS (Brief Interview for Mental Status) score of 3, indicating R4 has severe cognition impairment. Under Functional Abilities and Goals, the MDS documents R4 is dependent for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer.2. R5's admission Record documented an admission date of 12/20/21, and included diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Osteoporosis, Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung, Hypertension, Hypothyroidism Anemia, Major Depressive Disorder, Anxiety, Drug Induced Dyskinesia, Scoliosis, and Cognitive Communication Deficit. R5's MDS, dated [DATE], documented a BIMS score of 12, indicating moderate cognitive impairment. Under Functional Abilities and Goals, the MDS documents R5 requires supervision or touching assistance for eating, and R5 is dependent on staff for oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer.On 11/21/25 from 4:50PM to 7:51PM, continuous observation was made of R4 and R5 in the big dining room while waiting to be served the supper meal. R4 was sitting in a recliner chair at a table in the dining room along with R5, who was sitting in the reclined position of a reclining wheelchair. During this time, R4 and R5 were not assisted with repositioning nor were they toileted or provided incontinence care. On 11/21/25 at 7:51PM, V3 (Assistant Director of Nursing/ADON) and V6 (Regional Clinical Director) were present and were asked how often residents are to be repositioned and checked for incontinence. V6 stated every 2 hours. 3. R10's admission Record documented an admission date of 12/22/23, and included diagnoses of Chronic Kidney Disease, Acute Kidney Failure, Unspecified Dementia, Failure to Thrive, Hypertension, Disorder of Kidney and Ureter, Weakness, and Difficulty Walking. R10's MDS, dated [DATE], documented a BIMS score of 11, indicating R10 has moderate cognitive impairment. Under Functional Abilities and Goals, the MDS documents R10 is dependent for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfers. Under Bowel and Bladder, the MDS documents R10 is always incontinent of bowel and bladder.On 11/24/25, R10 was observed throughout the day beginning at 8:00AM, at various frequent intervals being up in her wheelchair. At 3:00PM, R10 was up in her wheelchair with a sling under her in the wheelchair.On 11/24/25 at 3:10PM, V17 (Certified Nurse Aide/CNA) stated he was taking care of R10 today. V17 was asked if R10 had been laid down or changed throughout the day, and V17 stated he has not laid R10 down or changed her since he got here at 10:00AM. V17 stated he did push R10 down the hall around 10:00AM-10:30AM, but that was all. On 11/24/25 At 3:15PM, R10 was alert and oriented and was asked if she had been up in her wheelchair all day. R10 stated, Yes they got me up for breakfast this morning and I haven't been changed or checked since then. R10 stated, This is normal for the day. They will lay me down before supper and I will eat supper in bed. R10 stated she is incontinent of bowel and bladder. R10 was asked if she was wet and R10 stated, Well yes, I have not been changed all day. On 11/24/25 at 3:45PM, V9 (Certified Nursing Assistant/CNA) stated she was the other CNA working R10's hall for the dayshift and she was also taking care of R10. V9 stated she got R10 up for breakfast in the morning. V9 was asked if she had changed or repositioned R10 throughout the day and V9 stated, No I haven't. V9 stated they were waiting on the mechanical lift to transfer her. V9 was unsure of the exact time she got R10 up for breakfast. On 11/24/25 at 11:28 AM, V15 (CNA) stated there are usually plenty of CNAs to provide good care to the residents. V15 stated she feels like the staff have plenty of time to take good care of the residents. V15 stated she normally works the 200 hall, but she is familiar with R4, R5, and R10, and stated all 3 are incontinent of bowel and bladder. V15 stated all three require assistance with turning and repositioning. V15 stated, When meals are late, and they are very often, then the turning and repositioning schedules get all screwed up and the residents don't always get turned and repositioned every 2 hours and they don't get laid down as they should.On 11/24/25 at 11:35AM, V16 (CNA) stated she normally works 200 hall. V16 stated she is familiar with R4, R5, and R10, and she knows they are incontinent and require assistance with turning and repositioning. V16 stated when meals are very late, all of their routines are thrown off. V16 stated they try to keep the residents toileted and repositioned every 2 hours but the late meals make it hard to keep everything on schedule. V16 stated she has seen meals up to 2 hours late on several occasions.On 11/24/25 at 11:40AM, V9 (CNA) stated she normally takes care of R4, R5, and R10. V9 stated R4, R5 and R10 are all incontinent and require assistance with turning and positioning. V9 stated she normally tries to lay all of them down in between meals. V9 stated when the meals are late, she tries to make sure R4, R5, and R10 are comfortable. V9 stated she tries to maybe adjust them in their chairs in the dining room if they are getting uncomfortable while waiting on their meals. On 11/24/25 at 11:48AM, V17 (CNA) stated he normally works everywhere in the building, but often takes care of R4, R5, and R10. V17 stated residents should be repositioned every 2 hours and as needed for comfort. V17 stated there are times that the meals are late, and so he tries to make sure everyone is comfortable while they wait because they are having to sit in the dining room for an extended period of time. V17 stated he was working 11/21/25 when the supper meal was very late. V17 stated, It was crazy that night and we did not get repositioning done for the residents because we were trying to get trays out.On 11/25/25 at 8:48AM, V12 (CNA Supervisor) stated she expects the CNAs to turn or reposition residents at least every 2 hours. V12 stated if meals are running late and residents have been sitting in the dining area waiting for their tray and 2 hours have passed, then she expects the CNAs to reposition the residents that require assistance. On 11/25/25 at 9:00AM, V13 (CNA) stated just because the meals have been running late recently, we still should make sure the residents are repositioned.On 11/25/25 at 9:53AM, V2 (Director of Nursing/(DON) stated she expects the staff to turn/reposition and change residents every 2 hours.Policy titled Preventative Skin Care, dated June 2025, documents, To provide skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers.The facility did not provide surveyor a policy regarding ADL care.

Based on observation, interview, and record review, the facility failed to ensure interventions were developed and implemented for the prevention of pressure ulcers for 1 (R5) of 3 residents reviewed for pressure ulcers in the sample of 13.Findings include:R5's admission Record documented an admission date of 12/20/2021, and included diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Osteoporosis, Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung, Hypertension, Hypothyroidism Anemia, Major Depressive Disorder, Anxiety, Drug Induced Dyskinesia, Scoliosis, and Cognitive Communication Deficit.R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS Section GG (Functional Abilities and Goals) documented R5 is dependent on staff for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Section M documents R5 is at risk for pressure ulcer development. Under Skin and Ulcer/Injury Treatments Pressure reducing device for chair and Pressure reducing device for bed are marked. R5's Care Plan documents R5 is at risk for pressure ulcer development related to impaired mobility, decreased cognition, decreased strength, incontinent of bowel and bladder, and fragile skin (date initiated 9/16/2025). Corresponding interventions included: follow facility policies/protocols for prevention/treatment of skin breakdown dated 9/12/2025, skin checks as scheduled 9/12/2025, (Name of physician) wound specialist to evaluate and treat as indicated, assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process. Report improvements and declines to MD 9/12/2025. Other interventions include monitoring of nutrition, labs, medications, and monitor/document /report changes to the MD as needed for changes in skin status all dated 9/12/2025. R5's Care Plan did not document interventions including the use of pressure relieving devices for R5's chair or bed. R5's Braden's Assessments, dated 9/11/2025 and 11/5/2025, documented R5 was low risk for skin issues with a score of 15. R5's Weekly skin assessments for R5 dated 10/24/25, 10/31/25 and 11/14/2025 document no skin issues with no redness.On 11/21/2025 from 4:50PM to 7:51PM, continuous observation was made of R5. R5 was in the dining room in a reclining wheelchair with no repositioning provided to R5 during that time. V6 (Regional Clinical Director) and V3 (Assistant Director of Nursing/ADON) were informed that continuous monitoring had occurred for repositioning on R5, and she had not been repositioned for 3 consecutive hours. V3 and V6 were asked how often residents are to be repositioned and checked for incontinence and V6 stated it is every 2 hours. V6 was asked if R5's chair had a pressure relieving cushion, and V6 checked and stated none was noted. V6 instructed staff to place a pressure relieving cushion under resident when she is in her chair. On 11/23/2025 at 12:20PM, R5 was noted to be in the dining room waiting on lunch. R5 was sitting in her reclining wheelchair in the reclined position. R5 was noted to have pillows on each side for positioning. R5 still did not have a pressure relieving cushion under her in the reclining wheelchair. V6 was present and stated, Well (R5) does need one and I will make sure she gets one in her chair. On 11/23/2025 at 4:20PM, V8 and V9 (both Certified Nurse Assistants/CNA's) provided peri care to R5. R5 was noted to have a red coccyx and surrounding area as well as red areas to her ankle bones. The red area to R5's coccyx was slightly blanchable at this time and the red area to ankle bones was completely blanchable. V6 was present for the observation and instructed the nurse to get orders for boots and orders for cream (treatment) for R5's coccyx and surrounding areas. R5 was on a standard mattress at this time. On 11/24/2025 at 11:48AM, V17 (CNA) stated he normally works everywhere in the building, but he often takes care of R5. V17 stated all residents should have cushions in their chair, but he does know that since he has worked here, R5 has never had a cushion in her chair, and he is not sure why. On 11/25/2025 at 8:48AM, V12 (CNA/Supervisor) stated all the residents get and need a pressure relieving cushion unless they refuse them. On 11/25/2025 at 9:00AM, V13 (CNA) stated they try to keep pressure relieving cushions in all the residents' chairs. V13 stated, We are expected to change and reposition residents every 2 hours and we really try to make sure that happens. Meals have been running late recently, but we still should make sure the residents are repositioned.On 11/25/2025 at 9:30AM, V14 (Licensed Practical Nurse/LPN) stated he expects the staff to turn and position residents every 2 hours. V14 was asked what happens when residents have to sit longer than 2 hours in the dining room waiting on tray and V14 stated, I don't have an answer. On 11/25/2025 at 9:53AM, V2 (Director of Nursing/DON) stated she expects the staff to turn/reposition and change residents every 2 hours. V2 stated she expects cushions to be on every resident chair and more cushions were ordered yesterday. On 11/25/2025 at 9:27AM, V18 (Registered Nurse/RN) stated she was not aware R5 was without a cushion in her reclining wheelchair on 11/21/2020 and 11/23/2025. On 11/25/2025 at 3:15PM, R5's coccyx was observed with V12 (CNA) present. A red area was remaining to the coccyx approximately 2cm (centimeters) x 2cm with no noted open areas. The skin was peeling slightly over R5's coccyx bone areas. The area over R5's coccyx bone was non blanchable. The area right over the coccyx bone was discolored with prominent coccyx bone. R5 has prominent bone structures noted to buttocks, hips, back, legs, feet and arms as R5 is very thin in appearance with thin skin noted.On 11/25/2025 at 3:25PM, R5's physician orders and Treatment Administration Record were reviewed with no new orders present for treatment to coccyx. On 11/25/2025 at 3:20PM, V6 stated R5 should be a high risk for skin issues and the nurse that did her Braden Assessment did not do those correctly and he would do a new Braden assessment himself because she should not be a low risk for skin due to her medical conditions and her weights. R5's Braden Assessment, completed on 11/25/2025, documented R5 is a moderate risk for skin issues with a score of 13.On 11/25/2025 at 3:50PM, V6 (Regional Clinical Director) instructed V3 (Assistant Director of Nursing/ADON) to get a special air loss mattress put on R5's bed immediately.R5's document titled W- Initial Skin Alteration Record dated 11/25/2025 and authored by V6 documented a description of site to Coccyx of 3 x 3 red area to coccyx, area is blanchable. Date of onset: 11/25/2025. Wound size is 3 x 3 cm, red area to coccyx. Peri wound area is intact. Skin treatment is to provide relief on chair, relief on bed, turn and repositioning, nutritional/supplement, receives wound care and Ointments applied. Preventative Measures/Modifications marked include skin treatment done per MD (Medical Doctor) orders, Pressure reducing mattress, reposition every 2 hours and as needed, MD notified with new orders marked yes. Family notified yes. Treatment plan Zinc Oxide.On 11/26/2025 at 9:00AM R5's Physician orders were reviewed and noted an order for Zinc Oxide cream 10% topical, apply to peri area and coccyx topically every shift dated 11/25/2025. Previous order for Zinc Oxide dated for 9/1/2025.The facility policy titled Preventative Skin Care, dated June 2025, documents, to provide preventative skin through repositioning, and careful washing, rinsing, drying and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Any resident identified as being high risk for potential breakdown shall be turned and repositioned at a minimum of every 2 hours. Special mattress and/or chair cushions will be used on any resident identified as being at high risk for potential skin breakdown.

Based on interview and record review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for elopement risk in the sample of 15.This past noncompliance occurred from 10/19/2025 to 10/20/25.Findings include:R1's admission record documents an admission date of 9/13/25, with the following diagnoses: unspecified intellectual disabilities, paranoid schizophrenia, anxiety, unspecified, and difficulty in walking.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 13, indicating R1 is cognitively intact.R1's Elopement/Wandering Risk Assessment, dated 8/27/25, documents R1 is at risk for wandering and elopement.R1's Care Plan documents R1 is an elopement risk/wanderer related to impaired safety awareness, reports he is waiting for someone to come get him, frequently sits by exit doors with an initiation date of 9/15/25. Interventions listed include in part; Identify pattern of wandering.Intervene as appropriate.R1's Progress Note, dated 10/16/2025 at 6:03pm, Res (resident) has begun exit seeking stating, 'My brother is supposed to come pick me up. I'm going home today. That's what they told me.' Res has attempted to leave facility and was redirected multiple times; resident continues to bring his personal belongings to front door and sit in lobby chair staring out of the window. Res not combative or irritated, just pleasantly confused and able to be redirected, but this behavior is different from his normal baseline. UA (urinalysis) with culture if indicated order implemented per standing orders and to be obtained upon next void.R1's Progress Note, dated 10/19/25 at 4:47pm, documents, Around 1500 (3:00pm) this nurse noticed res was not in his bedroom or dining room. No door alarms sounding. Elopement drill immediately initiated. All staff checked the entire building inside and outside twice, unable to locate resident. Head count for the entire building completed, unable to locate resident. Attempted to call POA (Power of Attorney) two separate times, going straight to voicemail and voicemail box saying it is full. (local) Police Department called at 1600 (4:00pm), notified cops of missing resident. cops arrived at 4:10pm and took resident information from this nurse. Spoke with cops for roughly 10 minutes, cops stated they would begin attempting to locate res. Cop stated for facility staff to check entire building again. Facility staff searched the entire building and did a head count again. This nurse called POA again at 1625 (4:25pm), POA answered and stated cops had made contact with res. POA stated res is at his brother's house. POA requested to know when cameras show res leaving the facility and how he got out, this nurse informed POA that the facility does not have cameras. POA stated that res is stating that 'his roommates family member that was visiting today was saying hateful things to him' POA requested a meeting with the administrator ASAP, stated it must be this week to discuss. This nurse received a phone call from (local) Police Department who stated res had been located, safe and unharmed and that someone would be bringing him back to facility this evening. This nurse notified Regional Nurse about POA requesting a meeting with administrator, Regional Nurse stated POA could do meeting with the administrator whenever POA would like. This nurse called POA back at 1700 (5:00pm), POA did not answer but called this nurse back at 1710 (5:10pm).This nurse confirmed with POA again that res is at brother's house in (name of city) and that res left facility on his own and would be returning to facility this evening/tonight. POA stated '(R1) is at his brother in laws house which is in 9name of city) and his brother will be bringing him back to the facility later. POA also states he walked to his brother's house from the facility on his own.R1's incident description in the electronic health record tiled Elopement, dated 10/19/25, documents the above Progress Note dated 10/19/25 at 4:47pm. Under Immediate Action Take documents INT (intervention): Resident to have personalized redirection (paint, talk about the Steelers, call brother-in-law) when wandering and room change to make resident more comfortable. RCA (Root Cause Analysis): Resident states he was upset about his roommate's family being mean to him so he walked to his brother in laws house.Several attempts to interview R1 were made and unsuccessful throughout the survey. R1 did not respond to questions asked.On 10/30/25 at 1:45pm, V3 (Regional Director of Clinical Services) stated the was aware R1 completed a Brief Interview for Mental Status (BIMS) and staff were able to get a score of 13, but that is not typical for R1. V3 stated R1 usually does not say too much, but due to several factors, including mental health diagnoses, it all depends on his level of comfort with the person engaging in conversation with. V3 stated on 10/1925, R1's family reported his roommate's family was being mean to R1. V3 stated R1 has schizophrenia and previously lived at a sister facility. V3 stated often R1 would have to be moved to a room alone because he thought his roommate was out to get him. V3 stated R1 did not wear a electronic monitoring device prior to 10/19/25 because he did not try to elope.On 11/6/25 at 11:00am, V10 (family member) stated R1 just showed up at the house a little before the police came. V10 stated they did not pick R1 up from the facility. V10 stated they usually pick R1 up on Sundays for football, they just had not made their way to the home yet. V10 stated they did the same thing in the previous facility he lived in. V10 stated they hadn't let anyone know R1 was there yet because they were just trying to figure out what was going on. V10 stated R1 stated his roommate's family was being mean to him. V10 stated R1 has never tried to leave a facility prior to this incident.On 11/6/25 at 11:18am, V9 (CNA) stated V1 grew up about a mile away from the facility and the house he was found at was where he grew up. V9 stated she was here the day that R1 eloped. V9 stated staff searched the inside and outside of the building twice, she stated she told staff and police R1 grew up around here and where they might find him.On 11/6/25 at 1:54pm, V6 (Licensed Practical Nurse/LPN) stated on 10/19/25, she noticed prior to lunch R1 was very restless. V6 stated she remembered lunch was being served late that day and R1 did not normally eat in the dining room, but she got him to come out there. V6 stated at about 2:15pm, R1 came up to her and told her he still hadn't received a tray. V6 stated he does not normally talk to her much, especially when he is anxious, so she told them to get his tray as soon as possible. V6 stated she knew at about 2:30pm he received his tray, and she saw him eating it. V6 stated she was passing meds around the dining room and had observed him eating, she stated she noticed R1 had left the dining room around 3:00pm. V6 stated she did not see R1 leave the dining room and could not say what time he had left, but she would estimate it was about 20 minutes. V6 stated she immediately initiated the elopement protocol, which involves search the entire facility inside and out, and doing a head count. V6 stated she did this twice and then notified the police. V6 stated she tried to call R1's family twice and there was no answer, and their inbox was full. V6 stated they did not answer until after the police had located the resident and had already contacted the facility. V6 stated it was normal for R1 to go with family on Sundays to watch football, but no one had notified her that they were taking him. V6 stated to her knowledge the wander guard system was working but R1 was not wearing a wander guard at that time. V6 stated R1 was a risk for elopement, but he had never tried to leave the building before. V6 stated R1 would pack his things and say he was leaving with his family but never tried to exit. V6 stated his family brought R1 back later that evening.On 11/6/25 at 2:05pm, V7 (LPN) stated she was working 100 hall, and R1 was on 200 hall at the time of the elopement. V7 stated she remembered R1 asking for a tray, which was unusual and then about 20 minutes later they noticed he was missing. V7 stated to her knowledge the wander guard system was working.On 11/6/25 at 2:15pm, V8 (CNA/Certified Nursing Assistant) stated he was working the day that R1 eloped. V8 stated it was around 3:00pm the nurse noticed R1 was missing and made everyone check all the rooms and the outside of the facility multiple times and then the police were called. V8 stated V6 (LPN) had already had staff keeping an eye on R1 because he had been restless that afternoon.On 11/6/25 at 2:56pm, V3 (Regional Director of Clinical Services) stated they immediately reassessed R1's elopement risk, moved him from the 200 hall to the 400 hall and put a electronic monitoring device on him. V3 stated they had identified the problem and already had a plan of correction in place.The facility policy titled Elopements, with a revision date of 2/2025, documents in the section titled policy statement Staff shall investigate and report all cases of missing residents. Prior to the survey date, the facility took the following actions to correct the noncompliance:QAPI (Quality Assurance and Performance Improvement) committee met on 10/20/25 with V1 (Administrator), V2 (Director of Nursing), and V3 (Regional Director of Clinical Services) in attendance. The QAPI Ad Hoc form notes documents as follows:1. R1 was immediately located and returned safely to the facility. Resident was assessed head to toe upon return, no injuries were noted. Vital signs stable. Physician and responsible party were notified of incident.R1 elopement risk status and interventions have been updated.Counseling and education provided to all staff involved regarding elopement prevention and response protocols.2,The Social Services Director will conduct a facility-wide audit of all residents with elopement risk factors or active elopement care plans.Reviewing of staff rounding and supervision schedules in all high risk areas.3. Facility immediately re-educated of all staff on facility Elopement Prevention and Response Policy.Facility immediately initiated an elopement investigation and placed safety interventions and care plan updated for R1.Interdisciplinary team to review all elopement incidents and near misses during QAPI meetings to identify trends.4. V2 or designee will complete weekly audits 5 times a week for 4 weeks, then monthly x 3 months to ensure: Elopement risk assessments and care plans are current. Staff are following elopement interventions and protocols. If trends or concerns are identified, additional corrective actions and staff education will be implemented.5. Ongoing monitoring through QAPI tracking logs and Performance Improvement meetings to evaluate effectiveness and sustain improvement.

Based on observation, interview, and record review, the facility failed to keep the dry storage free of contamination of rodents and rodent droppings. This failure has the potential to affect all 94 residents residing in the facility. Findings include:On 8/14/25 at 11:50 AM, in the dry storage room in the kitchen, there was a pile of small pieces of plaster/wood with a hole above it noted in the corner. Shelves containing food items around the outer perimeter of the room had several mouse droppings on them.On 8/14/25 at 12:04 PM, V1 (Administrator) said the pest control company had covered up 3 holes in the walls of the dry storage area they believed mice were getting in through, but was unaware the mice had chewed through one. V1 said she would have the Maintenance Director to fill the hole with steel wool and recover the hole.On 8/14/25 at 2:47 PM, V2 (Regional Clinical Director) said the facility did not have a dry storage area policy.The facility's revised May 2008 Pest Control policy documented in part . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The facility's 8/14/25 Midnight Census Report documented 94 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to ensure the facility was free of rodents. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 8/14/25 at 9:46 AM, R2 said she had seen a couple of mice in her room and had found a small mouse dead in her trashcan. R2 said she had seen a mouse in the room next to hers that was connected through a bathroom. R2 said she thought the mice may have been coming into her room from the room next door. R2's 5/19/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 was cognitively intact.On 8/14/25 at 9:45 AM, the room next to R2 connected by a bathroom had pieces of breakfast foods scattered around the floor and a black mouse bait box in the corner. On 8/14/25 at 10:15 AM, R3 said she had seen a mouse in the corner of her room earlier in the week. R3 said she had scared the mouse away and it ran out into the hallway. R3 said she had a box under her bed that she kept shoes in and it had a large amount of mouse droppings in it, but her daughter had cleaned it out a few days prior. R3's room had an overturned cup in the floor with milk spilled around and a few pieces of breakfast food scattered around the floor. R3's 6/8/25 MDS documented a BIMS score of 13, indicating R3 was cognitively intact.On 8/14/25 at 10:05 AM, R4 said she had a mouse that lived in her room in her dresser. R4 said she had seen the mouse that morning in the corner of her room behind her yarn basket and had saw him run back to the dresser. R4 pulled her yarn basket out of the corner and a large amount of mouse droppings were scattered on the floor. R4's room had an assortment of open snacks such as chips, crackers, and cakes. R4's bottom drawer of her nightstand had a large amount of mouse droppings scattered around the bottom. R4 said she had not seen any mouse traps in her room and did not want the mouse to be killed. R4 stated, He (the mouse) isn't hurting anybody. R4's 7/27/25 MDS documented a BIMS score of 12, indicating moderate cognitive impairment.On 8/14/25 at 1:38 PM, R5 said about a month prio, V3 (Certified Nursing Assistant/ CNA) had come into her room one night and turned on the light and started screaming because there was a mouse on R5's shoulder in the bed. R5 said the mouse had jumped off her bed onto the nightstand and went into an open bag of chips. R5 said the mouse then ran down her call light cord and jumped to the floor like a little acrobat. R5 said she had other mice in her room, but that was the only time one had been in bed with her, to her knowledge. R5's 5/26/25 MDS documented a BIMS score of 15, indicating R5 was cognitively intact.On 8/14/25 at 2:04 PM, V3 (CNA) stated she had not seen any mouse on R5's shoulder or on any residents. V3 said she had been asked by R5 if V3 recalled seeing the mouse in R5's bed, and V3 told R5 it must have been another staff member because it was not V3. V3 said she recently saw a mouse running down the hallway and into the shower room, but was unsure of the exact date. V3 was asked if she told anyone about the mouse running down the hallway and into the shower room, and V3 said she did not because there were mice all over the building.On 8/14/25 at 10:39 AM, V4 (CNA) stated. I have heard there is a mouse on 100 hall, I have never seen a mouse but there are signs of them on 100 hall. On 8/14/25 at 11:50 AM, in the dry storage room in the kitchen, there was a pile of small pieces of plaster/wood with a hole above it noted in the corner. Several mouse droppings were noted on the food storage shelves. On 8/14/25 at 11:55 AM, the door leading to the maintenance room off of the main dining room was left open to the outside with no one in the maintenance room.On 8/14/25 at 12:04 PM, V1 (Administrator) stated, That's new in dry storage area the mice have chewed through it, they were getting in in the other corner and they put steel mesh in and sealed it up so I guess we are going to have to put the steel mesh over here. He (Maintenance) shouldn't be leaving the door open. On 8/14/25 at 2:10 PM, V1 said the facility had been told by the pest control company the mouse bait boxes in the facility were not going to be effective as long as there were other foods for the mice to eat. V1 said she had ordered a large number of sticky traps in hopes they would be more effective than the mouse bait boxes. Pest Control Report, dated 8/11/25, documents in part, Service Description.Rodent- Interior Maintenance.Rodent Bait Station, With Activity: 2, Without Activity: 11.The facility's May 2008 Pest Control policy documented in part .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The facility's 8/14/25 Midnight Census Report documented 94 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to ensure pain was treated for 1 of 1 (R3) resident reviewed for pain in the sample of 19. This failure resulted in R3 experiencing severe pain with no treatment for the first 24 hours of admission, resulting in a lack of sleep and emotional distress. Findings Include:R3's facility admission Record, with a print date of 8/4/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include sacroiliitis, surgical aftercare, diabetes, asthma, anemia, restless leg syndrome, Alzheimer's disease, and radiculopathy of lumbar region.R3's Baseline Care Plan, dated 7/30/25, documents R3 is alert with cognitive impairment. This Care Plan documents, family states resident gets confused at times. Under Pain, this Care Plan documents R3 is in pain with no pain level documented.R3's Order Summary Report with Active Orders: Percocet Oral Tablet 7.5-325 MG (milligrams).Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 07/30/2025.R3's Medication Administration Record, dated 7/1/25 to 7/31/25, documents a physician order to Monitor and document pain level every shift. Start Date 07/30/2025 1800 (6:00 PM). On 7/30/25 under Pain Level Night and 7/31/25 Pain Level Day, there is an 8, indicating R3 was experiencing pain at an 8 out of 10 level. This same MAR documents a physician order of, Percocet Oral Tablet 7.5-325 MG (milligrams).Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 07/30/2025. There are no signatures indicating R3 received this medication on 7/30/25 or 7/31/25.R3's Progress Notes document the following.7/30/25 10:12 AM, report called from (name of regional hospital) .female with hx (history) of DM (diabetes mellitus), stroke, breast cancer, sleep apnea, Parkinsons, seizures, RLS (restless leg syndrome), liver failure, depression, GERD (gastroesophageal reflux disease), kidney stones. Resident c/o (complaints of) rt (right) leg pain, rx (prescription) for Percocet is being sent. Has lumbar laminectomy on 7/25 with a pain stimulator present.7/30/25 2:30 PM, Resident arrived via family personal car. Resident assisted into bed. Resident is A/O (alert and oriented) x (times) 4 at this time, with family at bedside.7/30/25 4:47 PM, Messaged MD (physician) for RX for Percocet as no scripts came with resident. Hospital stated they sent RX with her. Awaiting response.7/31/25 8:58 AM, Resident c/o pain 8/10. MD notified for PRN (as needed) pain pill Percocet 7.5/325 prn q (every) 6 (hours) signed script.7/31/25 9:53 AM, Tylenol offered for pian. Res (resident) refuses states it won't work. Awaiting response from MD for PRN Percocet script.7/31/25 5:22 PM, Pharmacy contacted for emergency release code for Percocet from (medication cabinet). Medication obtained and administered to patient.On 7/31/25 at 2:49 PM, R3 was laying in her bed covered with blankets. R3 stated she arrived at the facility yesterday morning and hasn't had any pain medication since her arrival. R3 stated she didn't get any medications until about an hour ago. R3 stated last night was rough, no sleep, just sat here crying in the blanket. When asked why she didn't get her medications including her pain medication, R3 stated they didn't get the order from the doctor and couldn't get it from the pharmacy.On 8/6/25 at 10:37 AM, V23 (Certified Nursing Assistant/CNA) stated she provided care for R3 on her day of admission. V23 stated R3 was independent and did say she was in pain. V23 stated she told the nurse (V26/LPN-Licensed Practical Nurse) and they said the hospital didn't send a prescription for the pain medication.On 8/6/25 at 10:59 AM, V25 (CNA) stated she provided care to R3 on her day of admission, and she was hurting that day. When asked what they were doing to treat the pain, V25 stated they were calling the pharmacy.On 8/6/25 at 10:23 AM, V26 (LPN/Licensed Practical Nurse) stated she was the nurse who admitted R3 to the facility. V26 stated she didn't remember what time R3 arrived at the facility. V26 stated she came in towards the end of her 6 am to 6 pm shift. V26 stated she complained of pain and V26 messaged the physician. V26 stated the hospital said they sent prescriptions for R3's pain medications, but R3 didn't have them. V26 stated she messaged R3's physician and he never responded.On 8/6/25 at 9:36 AM, V27 (RN/Registered Nurse) stated she was helping on R3's unit on her day of admission, 7/30/25. V27 stated she and V26 (LPN) were doing R3's admission together. V27 stated she left around 4:30 PM. V27 stated she did the charting and V26 put the medications in the system. V27 stated she could tell R3 was in pain, and she told V26 who was working on the orders. On 8/4/25 at 2:42 PM, V6 (Registered Nurse/RN) stated R3 admitted to the facility on [DATE], and her medications weren't available. V6 stated R3 was hurting, and it was an all-day event getting her pain medication. V6 stated towards the end of her shift (7/31/25), they were able to get in touch with R3's physician (V5), and got a prescription for her Percocet. V6 stated she had another nurse message V5 on their message app first thing that morning, since she didn't have access to the app yet. V6 stated V2 (Director of Nurses) got involved with it and V5 gave them the prescription they needed. When asked if there was a reason she didn't call V5 when he didn't respond to their messages, V6 stated it just went over my head. V6 stated she did offer R3 Tylenol, and she refused it. V6 stated they have issues with the pharmacy not always sending the medications. V6 stated if they don't get a medication from the pharmacy, they are supposed to get it out of the (medication cabinet) if they can and/or notify the physician.On 8/4/25 at 3:16 PM, V9 (Licensed Practical Nurse/LPN) stated he did a comprehensive pain assessment on R3, and she had pain in her femur that shoots down her right leg that can be a 7 out of 10 at times. V9 stated he gave R3 pain medications as needed all day on the days he provided care to R3, and he believed he gave her Tylenol also for breakthrough pain. V9 stated he assisted her with turning and repositioning as well. V9 stated if they don't have medications to administer to residents who newly admit, he calls the pharmacy, contacts the physician, and gets them from the (medication cabinet). V9 stated if he can't get them from the (medication cabinet) he calls the pharmacy and has them send the order to a local pharmacy so they can get a supply until their pharmacy can deliver them.On 8/4/25 at 4:02 PM, V10 (CNA/Certified Nursing Assistant) stated she assisted R3 with a shower on 7/31/25 or 8/1/25. V10 stated R3 appeared slightly confused and worried. V10 stated R3 complained of lower back pain when they transferred her.On 8/6/25 at 1:11 PM, V2 (Director of Nurses) stated she was aware R3 didn't get her pain medication until 7/31/25. V2 stated when R3 was admitted , the nurse reached out to V5 via the messaging app and didn't hear a response through the night. V2 stated after this surveyor spoke with her and V1 (Administrator) about the situation on the afternoon of 7/31/25, she reached out to V5, and he told her he had sent the order to the pharmacy at 9:30 AM on 7/31/25. V2 stated she called the pharmacy and got the emergency release code and pulled the prescription out of the (medication cabinet). V2 stated the nurse working did not realize she could pull the medications from the (medication cabinet) and they have educated her and all of the other nurses on what to do if they don't have the prescription and/or the medications are not delivered from the pharmacy.On 7/31/25 at 4:20 PM, V1 (Administrator) stated R3 came to them with no hard prescription for her pain medications and they had contacted R3's physician the morning of 7/31/25 and hadn't heard anything back at this time. When asked what the normal procedure would be if a resident didn't have the medications they needed, V1 stated they would get the order from the attending physician and/or medical director, contact the pharmacy, and it would be delivered. When asked if they had done that with R3's medications, V1 stated they had contacted the physician the morning of 7/31/25. When asked what the next step would be to ensure R3's pain was treated, V1 stated she guessed they would send R3 to the emergency room. V1 stated they did offer R3 Tylenol for the pain, and she refused it.On 8/5/25 at 2:37 PM, V5 (Physician) stated he got a text late afternoon on 7/30/25 related to R3 not having pain medication. V5 stated the actual prescription wasn't sent to the pharmacy until 7/31/25 at 9:30 AM, and then it went into a prior authorization bin, and that may have delayed it. V5 stated he wasn't sure how long it sat in the bin. V5 stated having the pharmacy call him for emergency medication is the safest way to get them. V5 stated he got messages on 7/30/25 at 4:40 PM that she admitted and needed scripts for the pain medication and on 7/31/25 at 8:57 AM he received a message R3 was in severe pain. V5 stated then they called him sometime that afternoon.The facility Pain Management Policy, dated 2022, documents, Purpose: To facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. General Guidelines: The facility will achieve these goals through: Promptly and accurately assessing and managing pain to the greatest extent possible. Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. Communication with the physician will ensure an appropriate individualized pain management plan.

Deficiencies at this level require more than one Deficient Practice Statements A. Based on interview and record review, the facility failed to prevent the development of unstageable ulcers, identify and assess newly developed ulcers, consistently implement interventions to promote healing of the ulcers, and implement physician orders to treat ulcers for 1 (R149) of 7 residents reviewed for ulcers in the sample of 52. This failure resulted in R149 developing unstageable ulcers to bilateral heels and subsequently being admitted to the hospital with diagnoses of sepsis, gangrene, and necrosis of the bone, tendon, and surrounding tissue. R149 underwent surgery to debride the ulcers on bilateral heels. Post surgery, R149 was placed on hospice and died on 6/9/25. The Immediate Jeopardy was identified to have begun on 4/17/25, when V27 (Wound Specialist) identified a monthly care goal to decrease odor in the right heel ulcer and indicated infected tissue was removed through debridement, without obtaining a culture of the wound and/or treating the underlying infection. This failure resulted in R149 being admitted to the local hospital with sepsis, gangrene, and required surgery to debride bilateral heels. R149 was placed on hospice after the surgery due to the extent of the injury to his bilateral heels and the severity of the infection. R149 expired at the hospital on 6/9/25, with cause of death listed as cardiorespiratory failure due to septic shock. V1 (Administrator), V2 (Regional Director of Clinical Services/Acting Director of Nurses), and V52 (Operations Consultant) were notified of the Immediate Jeopardy on 6/10/25 at 2:38 PM. The surveyors confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 6/11/2025, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R149's admission Record, with a print date of 6/5/25, documents R149 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, adult failure to thrive, diabetes, hypertension, peripheral vascular disease, and osteoarthritis. R149's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 09, which indicates a moderate cognitive deficit. This same MDS documented R149 was at risk for skin breakdown, no unhealed pressure ulcers, and two venous/arterial wounds. Under Skin and Ulcer/Injury Treatments, this MDS documents the following interventions, pressure reducing device for chair and bed, nutrition or hydration intervention, non-surgical dressings, ointments/medications, and dressings to feet. Turning and repositioning and pressure ulcer/injury care are not marked as interventions to implement. R149's current Care Plan documents, (R149) has potential for pressure ulcer development r/t (related to) Hx (history) of ulcers, impaired mobility, impaired circulation 03/06/2025 Site #22 arterial wound of R (right) heel 03/20/2025 Site #24 Arterial wound to L (left) heel. 03/20/2025 Site #25 End stage skin failure to R (right) buttocks (resolved 04/24/2025). 04/03/2025 Site #26 End Stage skin failure L (left) buttocks (resolved 04/24/2025) Date Initiated: 02/27/2024. This Focus area includes the following interventions, .03/06/2025 Tx (treatment) as ordered Site #22 arterial wound of R heel. EBP (enhanced barrier precautions) per facility policy. Date Initiated: 3/17/2025. 03/20/2025 Tx as ordered to Site #24 arterial wound to L heel. EBP per facility policy Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/27/2024. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 02/27/2024. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to MD (physician). Date Initiated: 02/27/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 02/27/2024. Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 02/27/2024. Low air loss mattress as ordered. Date Initiated: 03/14/2024. Monitor/document/report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Date Initiated: 02/27/2024. Nutritional supplements as per MD orders. Date Initiated: 02/27/2024. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/27/2024. Skin checks as scheduled. Date Initiated: 02/27/2024. (name of wound specialty) wound specialist to evaluate and treat as indicated. Date Initiated: 02/27/2024. This care plan does not document interventions to float heels and/or wear heal protection. R149's Braden Scale, dated 1/8/25, documents a score of 15, indicating R149 has a low risk of skin breakdown. R149's facility Progress Notes document the following: 5/14/25 1:50 PM, .Resident seems lethargic, able to wake up to voice but falls back asleep quickly. Temp. (temperature) 100.9, HR (heart rate) 116, BP (blood pressure) 96/60, O2 sat (saturation) 97% RA (room air). Blood sugar 355. V35 (Physician) office notified, waiting on call back from (V35) nurse for any new orders. 5/14/25 2:15 PM, .(V35) office called back and gave verbal order per (V35) to send resident to ER (emergency room). EMS (emergency medical services) transported resident to (name of local hospital). POA (Power of Attorney) notified. 5/15/25 5:08 AM, .admitted to (name of local hospital) ICU (intensive care unit) r/t (related to) sepsis. PT (patient) is currently receiving IV (intravenous) ABX (antibiotics) and fluids. R149's local hospital record documents on 5/14/25 under Chief Complaint: Patient presents with Altered Mental Status, Wound Check. 88 yo (year old) wm (white male) is brought to ER (emergency room) for eval (evaluation) of ams (altered mental status). As per nh (nursing home) staff, patient is confused, patient has fever, patient has low bp (blood pressure). Nh staff is concerning of sepsis. Patient has bil (bilateral) heel necrotic ulcers. Patient has no chest pain. No abd (abdominal) pain Pt (patient) arrives for AMS (altered mental status) EMS (Emergency Medical Services) reports we were called for AMS (altered mental status) that was worsening throughout the day. He has sores on both feet that are becoming necrotic. They are concerned he is becoming septic. His BP (blood pressure) was 95/40 .Pungent scent noted. Under Physical Exam, R149's hospital records document temperature of 100.2 degrees Fahrenheit, R149 is ill appearing, bed bound, with bilateral heel ulcers with necrosis. The CT (Computerized tomography) results dated 5/14/25 of the left foot documents under impression, Cellulitis. Deep soft tissue ulceration along the posterior plantar aspect at the calcaneal tuberosity with gas extending to the bone at that level. Erosive change/osteomyelitis involving the posterolateral portion of the calcaneal tuberosity at that level through the attachment the Achilles tendon with appearance concerning for underlying tendinosis/partial-thickness tear of the tendon and possible tendon infection The CT results dated 5/14/25 of the right lower extremity/foot documents the following under Impression, Cellulitis. Progressive, deep soft tissue ulceration overlying the calcaneal tuberosity with exposure the bone and underlying acute osteomyelitis. There is gas and ill-defined fluid throughout the underlying soft tissues at that level as well as gas within abscess cavity extending along the distal plantar fascia with possible infection with gas-forming organisms. Full thickness tear and osseous avulsion fracture involving the Achilles tendon with partial thickness tearing and abscess cavity extending more proximally along the tendon. Under Clinical Impression, R149's hospital record documents, Sepsis, due to unspecified organism .altered mental status .osteomyelitis of foot, unspecified laterality, unspecified . The hospital history and physical dated 5/14/25 documents, heel wounds. In ED (emergency department), patient met criteria for sepsis as patient was noted to have fever, tachycardia, tachypnea, elevated lactic acid, leukocytosis. Patient was started on broad spectrum IV (intravenous) antibiotics after imaging studies showing questionable osteomyelitis. ER provided consulted on-call podiatrist . R149's hospital record documents a physical exam, dated 5/14/25, under skin, the assessment documents, .Multiple healing abrasion/skin tears over extremities. Examination of right heel- on plantar aspect of right heel, large necrotic ulcer with foul-smelling ulcer base/eschar, 5.4 cm (centimeters), ankle swelling with erythema. Examination of left heel - on plantar out of left heel, large necrotic ulcer 3 x 2 cm with purulent base. V33 (Podiatrist/Surgeon) hospital consult note for R149, dated 5/14/25, documents under Assessment, (R149) is an 88 yo male with gangrene of heels, bilateral .Dakins wet to dry gauze applied bilateral. Plan for OR (operating room) debridement tomorrow and wound vac (vacuum) application. R149's Operation Note signed by V33 documents, Preoperative diagnoses: 1. Gangrene of bilateral heel with necrosis of bone. 2. Decubital ulceration, Stage IV, bilateral heel. Postoperative Diagnoses: 1. Gangrene of bilateral heel with necrosis of bone. 2. Decubital ulceration, Stage IV, bilateral heel. Under Description of Procedure the note documents, .Attention was first directed towards the posterior right heel. There was significant foul odor and necrosis of skin, soft tissue, and exposed necrotic bone within the wound cavity of the right heel. There was exposed necrotic bone within the wound cavity of the right heel. There was exposed necrotic Achilles tendon with purulent fluctuance at the Achilles tendon course .The bone at the plantar posterior margin of the calcaneus as necrotic in appearance .Attention was then directed towards the posterior left heel at full-thickness necrotic ulceration .Nonviable bone at the posterior dorsal lateral margin of the calcaneus was excised . The patient was then transported back to the ICU (Intensive Care Unit) on a ventilator with vital signs stable. Heel offloading boots were applied after repositioning the patient in the supine position. R149's hospital Progress Note, dated 5/18/25, documents under Plan for Today, Per discussion with intensivist and ICU RN (Registered Nurse): Plan to extubate later today. Continue management in ICU, as already discussed earlier today with intensivist (name) Prognosis is dismal and this has apparently been relayed to the family; patient remains full coder per his previously stated wishes at this point, per discussion with intensivist R149's hospital Progress Note, dated 6/1/25, documents, patient was made comfort care yesterday after family decided. Pending hospice evaluation tomorrow as per case management R149's three separate Initial skin Alteration Records, dated 1/8/25, document three separate shear wounds to buttocks, with treatments documented as provide relief on chair and bed, turning and repositioning, and dressing care with treatments documented as apply silver sulfadiazine (SSD), collagen, calcium alginate, and apply dry dressing. There is no documentation of any wounds/ulcers to R149's heels documented on this assessment indicating R149 returned to the facility on 1/8/25, with no ulcers/wounds identified on his bilateral heels. R149's skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review, dated 3/3/25, documents, Perform a visual assessment of the resident's skin when giving a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. This form documents a circle around the feet on body chart with no documentation of what was observed. This surveyor attempted to contact the CNA (Certified Nursing Assistant) who did this assessment, but she no longer works at the facility and didn't answer the phone and/or return this surveyors call. There is no documentation in R149's assessments and/or progress notes related to the abnormal areas indicated by a circle on the body chart on this assessment. R149's facility progress notes document on 3/6/25 at 12:18 AM, .this nurse was in the hallway standing at med (medication) cart during evening med pass when res (resident) daughter approached her stating that she saw blood coming through res white socks. At assessment, nurse observed a 6 cm (centimeter) x 5.8 cm wound to right heel. See skin assessment for details. Wound treated per wound doctor (V27/Wound Specialist) standing order. V27 and V3 ADON (Assistant Director of Nurses) notified to assess on wound rounds. R149's Weekly Skin Record, dated 3/6/25, documents, 3/6/25 - Right heel .full thickness tissue loss wound; 6 cm length x 5.8 cm width x 0.3 cm deep; no slough present. The assessment documents no tunneling, no undermining of the wound, no odor, irregular wound edges, and no pain verbalized. Under comments the assessment documents, Wound cleansed c (with) ns (normal saline); applied ssd/cp (collagen powder) mix et (and) covered c ca (calcium alginate) et dry dressing per standing order. (V27/Wound Specialist) and V3 (Assistant Director of Nurses/ADON) notified of the need to assess during wound rounds. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) note document the following: 3/6/25- .Chief Complaint: Patient has wounds on his upper scalp; right heel, anterior penis, right scalp .Examination of right lower extremities. Foot warm, moderate edema, wound present .Focused Wound Exam (Site 22) Arterial Wound of the Right Heel Full Thickness. Etiology .Arterial, Duration: > (greater than) 5 days, Objective .Healing/Maintain healing, Wound size (L (length) x W (width) x D (depth): 6.4 x 7.2 x 0.1 cm, Surface Area .46.08 cm² (squared), exudate Moderate Serous, Slough 30%, Granulation tissue 70% . Dressing Treatment Plan Primary Dressings: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days. Secondary Dressing: ABD (abdominal pad) apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days. Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents, Indication for Procedure: Remove necrotic tissue and establish the margins of viable tissue Procedure Note: the wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to excise 13.82 cm² of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed . 3/13/25- .Chief Complaint: Patient has wounds on his upper scalp; anterior penis; right heel; right scalp . Under Arterial wound of the Right Heel Full Thickness the assessment documents, Objective Healing/Maintain Healing, Wound Size . 6.4 x 7 x 0.1 cm, Surface Area 44.80 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 23 days; Betadine apply once daily for 23 days Under Site 22: Sharp Selective Debridement Procedure: Procedure Note: The wound was cleansed with normal saline and anesthesia, though not required, was achieved using topical benzocaine. Then with clean surgical technique, curette was used to selectively remove biofilm, remove devitalized epidermis and/or dermis, remove devitalized tissue at margins of a wound over the wound surface area of 44.8 cm². 3/20/25 - Chief Complaint: Patient has wounds on his upper scalp; anterior penis; right heel; right buttock; left heel; right scalp. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective .Healing/Maintain Healing, Wound size .6.2 x 7 x 0.1 cm, Surface Area 43.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 16 days; Betadine apply once daily for 16 days . Under Site 22: Sharp Selective Debridement Procedure the assessment documents, .Procedure Note curette was used to selectively remove biofilm, remove dried exudates or debris over the wound surface area of 43.4 cm² Goal primary to control infection risk in a chronic wound. Treating only the margins of an otherwise stable heel eschar. Under Focused Wound Exam (Site 24) the assessment documents, Arterial Wound of the Left Heel Full Thickness. Etiology: Arterial, Duration: > 3 days, Objective: Healing/Maintain Healing, Wound Size . 3.2 x 3 x 0.3 cm, Surface Area 9.60 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 100%. Dressing Treatment Plan: Primary Dressing: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days. Secondary Dressings: Gauze roll (kerlix) 4.5 apply once daily for 30 days. Reason For No Sharp Debridement: Non-infected heel necrosis. There is no documentation in R149's facility medical record when the ulcer to R149's left heel was first identified, an assessment of the left heel, or treatment of the area, prior to V27's assessment on 3/20/25. R149's Order Summary Report Active Orders as of 04/01/2025 includes the following orders, Left heel-cleanse with n/s (normal saline) or wound cleanser/pat dry/apply betadine/ca (calcium alginate) and wrap with kerlix daily and PRN (as needed) and Right heel- cleanse with n/s or wound cleanser and apply Betadine/ca and wrap with kerlix every day shift for wound, both orders have a start date of 3/20/25. R149's Order Summary Report does not document an order to treat the ulcer on the right heel from when it was identified on 3/6/25 until 3/20/25. R149's TAR (Treatment Administration Record), dated 3/1/25 to 3/31/25, includes the following orders, Left heel cleanse with n/s or wound cleanser/pat dry; apply betadine/ca and wrap with kerlix daily and PRN every day shift for wound and Right heel- cleanse with n/s or wound cleanser and apply Betadine/CA and wrap with kerlix every day shift for wound. Both physician orders have a start date of 3/21/25. This TAR does not document a physician order to treat the right heel ulcer from 3/6/25 until 3/20/25. On 6/7/25 at 10:55 AM, V2 (Regional Director of Clinical Services/Acting Director of Nurse) stated they were unable to find treatment orders from 3/6 to 3/21/25 for the ulcer located on R149's right heel, but he looked at the wound specialist notes, and the area was improving. V2 stated V3 (Assistant Director of Nurses/ADON) did rounds with V27 (Wound Specialist), and they saw R149 weekly. V2 stated V3 (ADON) remembered there being dressings on R149's right heel when she did rounds with V27 each week, but there was no order in the system for a treatment to the right heel. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) notes document the following: 3/27/25 - .Chief Complaint: Patient has wounds on his upper scalp; right heel; right buttock; left heel; right scalp; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective: Healing/Maintain Healing, Wound Size .: 6.2 x 6.4 x 0.1 cm, Surface Area .39.68 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area . Dressing Treatment Plan: Primary Dressing: Alginate Calcium apply once daily for 9 days; Betadine apply once daily for 9 days . Under Site 22: Surgical Excision Debridement Procedure the assessment documents .curette was used to surgically excise 3.97 cm² of devitalized tissue and necrotic subcutaneous level tissue along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. This same assessment documents under Focused Wound Exam (Site24), Arterial Wound of the Left Heel Full Thickness Objective . Healing/Maintain Healing, Wound Size .: 3 x 3 x 0.3 cm, Surface Area .9.00 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue 100%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 23 days; Betadine apply once daily for 23 days . Reason for No Sharp Debridement: Non-infected heel necrosis. 4/3/25 - .Chief Complaint: Patient has wounds on his upper scalp; right heel; left heel; left buttock; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective Healing/Maintain Healing, Wound Size .: 6 x 6.4 x 0.1 cm, Surface Area 38.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days . Under Site 22: Surgical Excision Debridement Procedure, the assessment documents, Procedure curette was used to surgically excise 2.30 cm² of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Under Focused Wound Exam (Site 24) this same assessment documents, Arterial Wound of the Left Heel Full Thickness .Objective Healing/Maintain Healing, Wound Size .: 3 x 3 x 0.3 cm, Surface Area 9.00 cm², Exudate None, Thick adherent black necrotic tissue (eschar) 100%, Wound Progress At Goal Dressing Treatment Plan Primary Dressing: Alginate Calcium apply once daily for 16 days; Betadine apply once daily for 16 days Reason for No Sharp Debridement: Non-infected heel necrosis. Under Site 24: Sharp Selective Debridement Procedure the assessment documents, .Procedure .curette was used to selectively remove devitalized tissue at margins of a wound, remove dried exudates or debris over the wound surface area of 9 cm² . 4/10/25 - .Chief Complaint: Patient has wounds on his right heel, upper scalp, right scalp, left heel, anterior penis, right buttock. Under Exam, this assessment documents Foot Warm, Moderate Edema, Wound present for bilateral lower extremities. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness, Etiology .Arterial, Duration: > 40 days, Objective Healing/Maintain Healing, Wound Size .: 5.6 x 5.3 x 0.8 cm, Surface Area 29.68 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 23 days; Betadine apply once daily for 23 days . Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents under Procedure Note, .curette was used to surgically excise 1.19 cm², of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 0.9 cm and healthy bleeding tissue was observed This same assessment documents under Focused Wound Exam (Site 24), Arterial Wound of the Left Heel Full Thickness Objective Healing/Maintain Healing, Wound Size 2.8 x 3 x 0.3 cm, Surface area 8.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 100%, Wound Progress .Improved evidenced by decreased surface area .Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 9 days; Betadine apply once daily for 9 days Reason No Sharp Debridement: Non-infected heel necrosis. 4/17/25 - Chief Complaint: Patient has wound on his right heel; upper scalp; left heel; right scalp; left buttock; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness Objective .Healing/Maintain Healing, Healing Potential Good, Estimated Time to Heal 2-4 months, Care goal(s) this month . Decrease Ulcer Area, Maintain Skin Integrity, Decrease Odor Wound Size .5 x 5.3 x 0.8 cm, Surface Area 26.50 cm², Exudate Moderate Serous, Thick adherent black necrosis tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area .Infection Assessment .No sign (s) of infection Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 14 days; Sodium hypochlorite solution (dakins) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days . Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents under Indication for Procedure, Remove Infected Tissue, Remove thick Adherent Eschar and Devitalized Tissue. Under Procedure Note this assessment documents, .curette was used to surgically excise 5.30 cm² of devitalized tissue and necrotic periosteum and bone along with slough and biofilm and removed at a depth of 1 cm and healthy bleeding tissue was observed . This same assessment documents under Focused Wound Exam (Site 24), Arterial Wound of the Left Heel Full Thickness . Objective: Healing/Maintain Healing, Healing Potential . Good, Estimated Time to Heal 2-4 months, Care goal(s) this month Decrease Ulcer Area .Wound size .2.2 x 3 x 0.3 cm, Surface Area 6.60 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) .100%, Wound Progress . Improved evidenced by decreased surface area Infection Assessment No sign (s) of infection) Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 30 days; Sodium hypochlorite solution (dakins) apply once daily and as needed: If saturated, soiled, or dislodged. For 30 days . Under Site 24: Surgical Excisional Debridement Procedure the assessment documents under Indication for Procedure, Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Under Procedure Note the assessment documents, curette was used to surgically excise 3.30 cm² of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.4 cm and healthy bleeding tissue was observed There is no documentation in R149's facility records of V27 (Wound Specialist) ordering a wound culture of the right heel ulcer to determine the cause of the odor documented under the care goals of the month, and no documentation of V27 ordering an antibiotic to treat the infected tissue referenced under the surgical debridement section of V27's progress note. There are no facility skin assessments or progress notes documented with assessments of the ulcers to R149's heels and/or assessments of his condition until 4/22/25, when R149's Weekly Skin Record documents, Right heel- measured 6 cm x 5.8 cm x 0.3 cm. Under Additional Narrative Description of Wound the assessment documents Full thickness tissue loss wound .no slough present. The assessment describes the wound bed as greenish/yellow, red/beefy with no odor, and purulent (brownish/yellow) drainage. The healing process is documented as no change. R149's facility Progress Notes document the following: 4/24/2025 12:26 PM, .res (resident) noted more lethargic than usual today, not responding verbally as he normally does but will make eye contact. When fed res is letting food fall out of and not swallowing. Vitals 98.9 t (temperature), 18 r (respirations) 96 p (pulse), 99% O2 (oxygen) on RA (room air), 62/46 b/p (blood pressure), lung sounds clear, bowel sounds present. Res presenting with non-productive cough. MD (physician) notified. MD gave orders for CBC (complete blood count) w/diff (with differential), CMP (comprehensive metabolic panel), TSH (thyroid stimulating hormone), Free T4, Ammonia, Lactic Acid and 2 view chest (sic) xray. Orders put into pcc (point click care), biotech and lab. 4/25/25 5:25 PM, .Sent chest x-ray and labs to (V35/Physician) New ant (antibiotic) Clindamycin 300 mg (milligrams) po (by mouth) TID (three times daily) for 10 days ordered. R149's Order Summary Report active orders as of 05/01/2025 includes the following orders, 4/29/25 Daily skin check every night, 4/12/25 heel protectors on while in bed. Every day and night shift. 4/25/25 Clindamycin 300 mg three times daily for ten days. There are no antibiotic orders documented for treatment to the ulcers on bilateral heels on R149's Order Summary Report from 4/25/25 until his hospitalization on 5/14/25. R149's Weekly Skin Records do not document assessments of the ulcers to bilateral heels on 4/28, 5/5, 5/9, and 5/13/25. The assessments document no new areas noted and/or no changes to current wounds. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) notes document the following: 4/24/25- .Chief Complaint: Patient has wounds on his right heel, left heel; right scalp; anterior penis; right buttocks; left buttocks. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness Objective .Healing/Maintain healing Healing Potential .Good. Care goal(s) this month. Decrease Ulcer Area, Maintain Skin Integrity, Decrease Odor .Wound Size 5 x 5.3 x 0.8 cm .Surface Area .26.50 cm² .Exudate Moderate Serous .Thick adherent black necrotic tissue (eschar) .70%. Slough 30% .Wound Progress .At Goal Infection Assessment .No signs of infection .Dressing Treatment Plan .Alginate Calcium apply once daily for 9 days; Sodium hypochlorite solution (dakins) apply once daily and as needed Under Site 22 Surgical Excisional Debridement Procedure the evaluation documents the indication for the procedure as Remove Infected Tissue, Remove Thick Adherent Eschar and Devitalized Tissue, Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Under Procedure Note the Evaluation documents, curette used to surgically excise 15.90 cm² of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 1 cm and healthy bleeding tissue was observed This same assessment documents under Focused Wound Exam (Site 24) Arterial Wound of the Left Heel Full Thickness .Objective .Healing/Maintain Healing Healing Potential .Good Care goal(s) this month .Decrease Ulcer Area Wound Size 2 x 3 x 0.3 cm Surface Area .6.00 cm² Exudate .Moderate Serous .Thick adherent black necrotic ti[TRUNCATED]

Based on interview, observation, and record review, the facility failed to manage pain for 1 of 2 residents (R81) reviewed for pain in a sample of 52. This failure resulted is R81 experiencing decreased mobility and participation in daily activities related to uncontrolled severe pain. Findings include: R81's admission Record documents an admission date of 05/14/24, with diagnoses including: polyneuropathy, injury of left ankle, bilateral primary osteoarthritis of knee, osteoarthritis, myalgia, depressive episodes, anxiety disorder, bipolar disorder, chronic pain, lumbago with sciatica on right side, and lumbago with sciatica on left side, age related osteoporosis, and anxiety disorder. R81's Minimum Data Set (MDS), dated [DATE], documents a Brief interview of mental status (BIMS) of 15, indicating cognitively intact with diagnosis including: polyneuropathy, unspecified injury of left ankle, myalgia, other chronic pain, lumbago with sciatica on right side, and lumbago with sciatica on left side. Section GG documents R81's sit to stand, chair/bed to chair transfer and toilet transfer as supervision or touching assistance- helper provides verbal cues or touching/steadying assistance as resident completes activity. R81's Care Plan documents a Focus Area of: R81 has potential for pain related to arthritis, neuropathy, and lumbago with an initiated date of 06/04/24 with intervention documented of: administer analgesia as per orders, monitor/document for probable cause of each pain episode, remove/limit causes where possible, monitor/record pain characteristics every shift and as needed: quality (example: sharp, burning);severity (1 to 10 scale); anatomical location; onset; duration (example: continuous, intermittent); aggravating factors; relieving factors; monitor/record/report to nurse any signs or symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing); monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; monitor/record/report to nurse resident complaints of pain or requests for treatment; notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care with interventions dates of 06/04/2024. R81's Order Summary Report documents her most current order for a Lidoderm external patch 5% on 08/29/24, with an end date of 08/29/24. R81's order summary report documents an order for acetaminophen oral tablet, give 1000 milligrams by mouth every 8 hours as needed for pain with an order date of 02/27/25, and an order status of active. R81's order summary report documents an order for gabapentin oral tablet 400 milligrams, give one tablet by mouth three times a day for pain with an order date of 05/28/25, and an order status of active. R81's order summary report documents an order for ibuprofen oral tablet 200 milligrams, give 2 tablets by mouth every 8 hours as needed for pain give 1 ibuprofen tab with 1 325 milligrams Tylenol, with an order date of 02/27/25, and an order status of active. R81's Pain Questionnaire, dated 02/17/25, documents: mental status with alert marked, ability to verbally communicate has able to communicate marked, routine medications ordered for pain with ordered and somewhat effective (moderate relief) marked, frequency of pain with intermittent/occasionally less than daily marked, conditions/diagnosis associated with potential for pain with one condition/diagnosis marked, intensity of pain with moderate pain marked, pain scale used with numeric observations of pain (non-verbal pain indicators) with no observations of pain marked. R81's Medication Administration Record (MAR), dated May 2025, documents an order for: monitor and document pain level every shift with a start date of 05/17/25, with zero documented for days 1-24 for day and night, day 25 has a 3 documented for night, day 26 has a 0 documented for day and night, day 27 documents a 2 at night, and days 28 - 31 documents a 0 for day and night. R81's MAR, dated May 2025, documents Acetaminophen 1000 milligrams given on 05/21, 05/22, 05/25, and 05/27 for the month of May. R81's Nurse's Note dated 05/28/25 at 8:17 PM, documents, Medical Doctor (MD) in the building and spoke with resident about concerns with her gabapentin making her feel unsteady since it had been increased from 300 mg (milligrams) three times a day to 600mg three times a day. MD gave new order to start gabapentin 400 mg three times a day. R81's Nurse's Note, dated 05/27/25 at 3:37 PM, documents: (Nurse Practitioner) assessed resident, resident voiced severe pain to hips to the point of not able to walk. Resident voiced she went to (hospital) after a fall and had an x-ray and CT scan with no findings. (NP) ordered to send referral to brain and spine for further evaluation. R81's order summary report documents an order for referral to brain and spine related to increase pain to back, hips, and leg with an order date of 05/28/25, and an order status of active. R81's MAR, dated June 2025, documents an order for: monitor and document pain level every shift with a start date of 05/17/25 with zero documented for days 1-8 for day and night. R81's MAR, dated June 2025, does not document any acetaminophen 1000 milligrams given 06/01 - 06/05. On 06/02/25 at 4:20 PM, R81 was observed sitting in her wheelchair, leaning to her side so her left hip area was not touching much of the chair. R81 was leaning more of her weight on her right elbow. R81 stated her hip and leg hurt, and she has a walker, but she cannot use it because of the pain, so she has to use this wheelchair. R81 stated she has been telling them it hurts. On 06/03/25 at 12:15 PM, R81 stated she has pain daily, and she has never told the nurses she did not have pain. R81 said she has never said it was a zero or a three when they have asked. She stated she would be happy if it was only a three. R81 said she believes she is supposed to have a scan of some kind to hopefully find out what is going on because she would like to use her walker and get around more. On 06/04/25 at 8:10 AM, R81 was observed lying in bed, with dark circles under her eyes and moving very slowly. R81 repositioned her leg with her hands and then started rubbing her hip. When she did this, she had a slight grimace on her face. R81 stated she has not got up yet, because the gabapentin makes her so tired and does not help much with the pain. R81 said she hopes to get up later and do something, her hip area is just really hurting, and she is in bed a little more than she would like. R81 stated the nurse has been asking if she has pain and she tells them yes, daily, and never says it is a zero or even a three. R81 stated there are days that she tells the nurses the pain is above ten on a one to ten scale. She stated even after the pain medication, which is just acetaminophen, ibuprofen, and gabapentin, she still has pain. The gabapentin does not seem to help the pain that much, it just makes her tired, but she takes the ibuprofen and the acetaminophen. R81 stated her pain is more than just moderate. R81 said she would like to have a little more tolerable pain so she could go to more activities and get up more, but she does not have the energy with the pain. On 06/16/25 at 11:27 AM, V35 (Physician) stated he was notified by the facility about her pain on 02/26/25 about her pain, but he believes that was after she had a fall. He has seen her in the facility and knows she has chronic pain and sometimes it is worse with the weather. He was unaware the pain assessments were not completed as more than a casual conversation; he would have expected the questions to be asked and assessed. He would expect the staff to be documenting her pain consistently on the MAR (Medication Administration Record). V35 stated, The upcoming scan is to gauge the progression of her diagnoses and to assist with gauging her pain. On 06/05/25 at 12:00 PM, V28 (Care Plan Coordinator/Minimum Data Set Coordinator) stated she does the pain assessments for the residents including R81's assessment. V28 stated if she was busy, she may have done the pain assessment by using the resident's chart. V28 stated she does not think R81 stated she has pain daily, but this was just a passing conversation with her, not an in-depth conversation. V28 stated when she does the pain assessments, it is not a sit-down process; she does not take the paper (the assessment) in with her and sit and ask her the questions; she has five of these a day. On 06/05/25 11:54 AM, V25 (Registered Nurse) stated she has asked R81 if she has had pain, and R81 has expressed she does have pain, and it bothers her. V25 stated she has been complaining of pain for the last couple months. V25 stated the doctor will not give R81 anything stronger for pain. On 06/05/25 at 1:10 PM, V20 (Registered Nurse) stated, (R81) has chronic pain. There is nothing they can do about her pain; she gets gabapentin and acetaminophen. (R81) had lidocaine patches in the past. What do you expect us to do? When V20 was asked if he knew what R81's diagnoses were, V20 stated No. The facility policy, dated 2022, titled, Pain Management documents: to facilitate resident independence, promote resident comfort and preserve resident dignity. The facility will achieve these goals through: promptly and accurately assessing and managing pain to the greatest extent possible, encouraging residents to self-report pain, increasing comfort and reducing to depression and anxiety in residents, optimizing the residents' ability to perform activities of daily living, monitoring treatment efficacy and side effects. A standard format for assessing, monitoring and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign at the facility, along with temperature, pulse respiration, and blood pressure. For the purposes of this policy, pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does.

Based on observation, interview, and record review, the facility failed to adjust the type and frequency of interventions and needed level of supervision for a resident with a history of self inflicted burns with hot liquids for one resident (R1) of four residents reviewed for incidents/accidents in the sample of four. This failure resulted in R1 spilling hot water onto his groin, sustaining second degree burns to nine percent of his body, causing pain and the need for increased pain medication, and requiring placement of an indwelling catheter to prevent urine from irritating the wounds. Findings Include: R1's Face Sheet documented an admitted [DATE], and listed Diagnoses including Spinal Stenosis with Fusion of the Lumbar Spine, Schizoaffective Disorder, and Diabetes Type 2. R1's Minimum Data Set, dated dated [DATE], documented R1 has no deficits in cognition, has impaired range of motion to both lower extremities, requires substantial/maximal assistance from staff for bed mobility, is dependent on staff for transfers, and requires set up or clean up assistance from staff for eating. R1's Care Plan, dated 12/30/24, documented a problem area, (R1) displays adverse behaviors. He has been educated to let staff get him hot water to prevent burns and he continues to be non-compliant with this, with corresponding interventions, Remind (R1) too let staff get his hot water for safety. Educate (R1) about the risk of burns. Provide appropriate non-spill cup for safety. R1's 2/4/25 Hot Liquid Burn Incident Report documented, Staff heard resident yelling, staff went in to assess resident, resident continued to yell, 'Help I spilled hot water on myself,' staff noted the bed sheets were wet with hot water. (R1) stated, 'I was trying to take the lid off the water pitcher with hot water in it and the lid popped off and the water went all over me. Injury type: Burn(s) to the coccyx, groin, right thigh (rear) and left leg (rear). Intervention: Non spill cup for hot water. R1's 2/6/25 Wound Evaluation and Management Summary documented, Patient has wounds on his left posterior leg, right posterior thigh, posterior scrotum, left thigh, left medial foot. Burn on the left medial foot resolved on 2/6/25. Follow up: Evaluation by (V12, Wound Care Physician) weekly, or sooner as needed, with further intervention as indicated based on response to current treatment plan. R1's 2/4/25 untitled note authored by V14, Nurse Practitioner, documented, Physical Examination: Burn. Acute. Patient spilled hot water for tea into his bed. (V12) has given orders for management. R1's 2/12/25 Nurses Notes documented: New order to increase oxycodone (as needed) to every twelve hours. February 2025 Physicians Orders (POS) documented a 1/21/25 order for oxycodone 5 milligrams (mg) one tablet every 24 hours for moderate pain. The same POS documented a 2/12/25 Pain Scale pain level of 7, and a 2/12/25 order to increase the oxycodone to 5mg one tablet every 12 hours for moderate pain. On 3/13/25 at 11:30am, R1 was alert and oriented to person, place, and time. R1 was observed to have an indwelling catheter draining clear straw colored urine. R1 stated on 2/4/25 at about 7:30am, he asked V9, Certified Nursing Assistant, to heat him up some water so he could make instant coffee. R1 stated V9 took his water pitcher and took it out of the room. R1 stated in a few minutes, V9 returned with hot water in the pitcher. R1 stated he was sitting up in the bed when V9 gave him the pitcher and left the room. R1 stated he was trying to get the lid off, when the lid suddenly came off and steaming hot water was spilled all over his crotch area. R1 stated he was in immediate pain and yelled for help. R1 stated one of the nurses came and got him out of the wet bed linens and assessed his burns. R1 stated he has since been treated weekly by V12. R1 stated he has burned himself previously in similar circumstances, although during those occurrences, he was able to walk to the dining room and microwave hot water himself. R1 stated he had spinal surgery in January, and as a result, has decreased sensation in both lower extremities. R1 stated initially, he did not have a lot of pain, but as time went on he did, and his pain medication had to be increased. R1 stated it has been effective, but has caused him to be more sleepy during the day. On 3/13/25 at 12:00pm, R4, R1's Roommate/Family Member, who was alert and oriented to person, place, and time stated she was woken up on 2/4/25 by R1 yelling that he had been burned. R4 stated R1 later told R4 that V10, Hall Monitor, had been the staff member who brought him the hot water. On 3/13/25 at 2:55pm, V12 stated R1 sustained second degree burns over nine percent of his body. V12 stated R1's wounds are healing, there were no signs of secondary infection, and R1 will not require skin grafts. V12 stated he has previously treated R1 for non intentional self inflicted burns in similar circumstances. V12 stated he has repeatedly told R1 to not handle hot water, but R1 will not comply. V12 stated R1 temporarily requires an indwelling catheter to prevent urine from irritating the wounds. On 3/14/25 at 8:40am, V9 denied giving R1 the hot water, and stated she does not know who did. V9 stated, I would not give him a pitcher of hot water and not supervise him with it. V9 stated she did not think there was any staff re-education after the incident. On 3/14/25 at 9:00am, V4, CNA Supervisor, stated after R1's 2/4/25 burns, staff were educated to make sure R1 is sitting up in his chair and not in bed when given hot water. On 3/14/25 at 10:40am, V10 stated she did not give R1 the hot water, and does not know who did. V10 stated, I wouldn't have, because everybody knows he spills it and he's not supposed to have it. V10 stated she did not recall getting re-educated after the incident. On 3/14/25 at 12:30pm, V3, Assistant Director of Nurses, stated on 2/4/25 at about 7:30am, she heard R1 yelling for help, and she and V1, Regional Nurse/Director of Nurses, responded. V3 stated they got R1 into dry linens and V3 assessed R1, noting he had areas of redness, peeling skin to his left posterior leg,right posterior thigh, posterior scrotum, left thigh, and left medial foot. V3 stated she notified V12 and sent him pictures of the burns, and V12 responded with treatment orders. V3 stated R1 has burned himself on hot liquids previously, and was treated by V12. V3 stated she does not know who gave R1 the hot water. V3 stated R1 did not have complaints of pain that morning past the time of the burn itself. V3 stated several days after the burns occurred, R1 complained of increased pain, and V15, Primary Care Physician, increased R1's pain medication. On 3/14/25 at 2:20pm, V1 corroborated V3's account of the incident as stated above. V1 stated when he investigated the incident, no staff members took responsibility for giving R1 the hot water. V1 stated staff should have put the water in a handled cup with a lid, not a water pitcher. V1 stated R1 has burned himself on hot liquids several times, when he ambulated to the dining room and microwaved the water himself. V1 stated as a result, the microwave was removed from the dining room, and R1 has been educated numerous times about the need for staff assistance with hot liquids. V1 stated on 2/5/25, staff were re-educated R1 is to get hot water in the handled cup with lid. A 2/5/25 State of Education for Employees Sign In Sheet documented, The following area of instruction were covered: We have got (R1) adult sippy cups for him to use. There is 2 cups-clear, with handles. The facility's Safety and Supervision of Residents Policy, dated July 2017, stated, Systems approach to safety: The facility oriented and resident oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk. factors, and then adjusts interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment. (such as construction) or if there is a change in the residents condition.

Based on interview, observation, and record review, the facility failed to develop and implement appropriate fall interventions for one of three residents (R2) reviewed for falls in the sample of 4. This failure resulted in a repeated fall for R2 on 3/28/24, resulting in a left patellar fracture. Findings include: R2's Face Sheet documented an initial admitted [DATE], a discharge date of [DATE], and a Readmitted [DATE]. This Face Sheet listed diagnoses including a history of CVA (Cerebral Vascular Accident) and TIA (Transient Ischemic Attack), Fibromyalgia, Peripheral Vascular Disease, and Cervical Disc Degeneration. R2's 12/6/23 (Re)Admission Minimum Data Set documents in section C, Cognitive Patterns, R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents R2 used both a walker and wheelchair, and requires supervision or touching assistance with sit to stand and walking 10 feet. R2's Nursing Progress Notes documented the following: 3/28/24 at 2pm by V5 (Registered Nurse): Res (resident) left facility via (transit) bus to go to (local hospital) for MRI (Magnetic Resonance Imaging). Res sent with copy of facesheet/orders. Res is clean and wearing appropriate clothing for weather. 3/28/2024 at 3:44pm by V5: Res returned to facility from appointment at this time. 3/28/24 at 5:00pm by V5: Late entry: Res approached this nurse stating they lost their balance while getting on the (name of transportation company) bus and caught themselves on the chair preventing a fall. Res appeared upset about how the bus driver responded to the situation. Res was touching knee during the conversation and stated their knee was against the seat when they caught themselves, this nurse assessed sites with no injuries or changes observed to bilateral knees. This nurse offered in-house imaging or hospital transfer but was refused by resident, res denied any new pain at that time. Res educated to notify staff if any new pain starts or if there are any concerns. Res verbalized an understanding. 3/29/24 at 1:51pm by V6 (Licensed Practical Nurse): Resident states, 'I fell yesterday on the bus outside of the facility. My shoulder is pretty sore, and I am having a tremendous amount of flank pain to my left side. It feels like my kidney is on fire. Could you please call an ambulance for me so I can go to the ER (emergency room )? I feel like something is wrong.' EMS (Emergency Management Services) notified and are en route. Copy of face sheet, orders, bedhold policy printed off to send resident. R2's Fall Incident Report dated 3/8/24 authored by V5, Registered Nurse (RN), documents an incident location of the Hallway and documents In conclusion to this fall investigation resident was not using walker and slipped and fell . The same report documents an intervention (INT) of resident educated to use walker at all times and a Root Cause Analysis (RCA) of Resident slipped and fell while not using walker. R2's Fall Incident Report, dated 3/29/24, authored by V6, Licensed Practical Nurse, documents self reported fall from 3/28/24 and a resident description of I guess I got tripped up on the bus during transport yesterday et (and) I fell on my LT (left) side et shoulder. The same report documents and intervention of, Resident educated to bring walker with her on outings and a Root Cause Analysis of Resident had a fall while on outings, did not have her walker with her. R2's Care Plan documented a problem area of,(R2) is at risk for falls related to deconditioning and gait/balance problems, with corresponding interventions, 3/8/24: Educated (R2) to use her walker at all times, and 3/29/24,Educate (R2) to take her walker with her on her outings. An Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification for R2, dated 3/29/24, stated, On 3/29/24, (R2) self reported a fall she had on 3/28/24 while on an outing via (transit bus). The nurse immediately assessed her. Per her interview she voiced, 'My shoulder is pretty sore, and I am having a tremendous amount of flank pain to my left side.' Medical Doctor notified and gave orders to send to the emergency room (ER) for evaluation. R2's Radiology Report, dated 3/29/24, for imaging of the left knee documents the following under findings: Calcification is noted in the distal quadriceps at the insertion with the patella. A hairline fracture appears to be present at the base of the calcified enthesophyte. On 4/23/24 at 11:05am, R2 was interviewed in her room. R2 was alert and oriented. There was a manual wheelchair observed in the room, but no walker. R2 stated on 3/28/24, she went out on the transit bus to an appointment. R2 stated while getting off the bus, she attempted to ambulate through the narrow aisle around a person in a wheelchair, lost her balance and fell , with her left knee and left side making contact with the floor. R2 stated additionally, she fell earlier in March 2024 in front of the soda machine in the hall. R2 stated she was not using a walker on either occasion, and stated, I have not used one the entire time I've been here, and I won't be using one. I took care of my Grandma and she was dependent on her walker, and I don't want to be dependent on anything for walking. R2 stated when she came back into the facility on the afternoon of 3/28/24, she notified V5, who looked at her knee and thought maybe she should go to the emergency room , but she didn't want to, and said she would wait and see if it got any worse. R2 stated V5 did not perform a full body assessment, and she is not sure if her Physician was contacted. R2 stated the following day, the pain in her left side and knee was worse so she told V6 (Licensed Practical Nurse) about it, who examined her and got orders to send her to the emergency room . R2 stated the hospital discovered her left patella was fractured. R2 stated, Even if I had my walker with me on the bus, I wouldn't have been able to use it because the aisle was too narrow. On 4/23/24 at 1pm, V5 stated R2 left on 3/28/24 on the bus at about 2pm. V5 stated R2, Did not have a walker with her which she never does, she refuses to use one, although we have educated her many times that she needs to use one. V5 stated when R2 came back a little bit before 4pm, she told V5, When she was on the bus and got up she lost her balance and caught herself on the seat. She did not really say she fell . I did not do a fall report or a nursing assessment. When I went down to give her her afternoon medications a few minutes later, she complained of her left knee hurting, so I looked at it, it appeared normal. I didn't assess any of the rest of the body as she had no complaints of anything else at that time. I said maybe we better send you out (to the ER) or at least get an x-ray of the knee but she refused. I said well at least keep us aware if the pain gets worse or you develop any other symptoms, and she agreed. I left for the day at about 6:30pm and she had had no further complaints that shift. I told oncoming staff during shift report about it. I heard they sent her out the next day. She's usually pretty compliant, except for not using a walker. V5 stated she did not notify R2's Physician. On 4/23/24 at 1:20pm, V6 stated on 3/29/24 at about 9am, R2 complained of pain to the left knee and left shoulder and told V6 she tripped and fell the previous day while on the bus. V6 stated he looked at the knee and the shoulder both of which looked ok, with normal range of motion. V6 stated he suggested she go out for an evaluation, but she refused. V6 stated that afternoon, R2 complained of the pain being much worse, so he obtained orders to send R2 out to the ER. V6 stated he initiated a Fall Investigation at that time. V6 stated R2 has a history of falls. V6 stated he was not aware of R2 having a walker as a fall intervention, as he has never seen her use one. On 4/23/24 at 3:20pm V4, Director of Therapy Services, stated after R2's 3/28/24 fall, therapy is now working with her on using a walker. V4 stated she does not recall previously assessing R2 for a walker, and if nursing feels a walker is needed, then the resident would be referred to therapy for assessment. R2's Physical Therapy Evaluation and Plan of Care, dated 4/3/24, documented, Start of care: 4/3/24. Short Term Goals: Patient will safely ambulate on level surfaces 150 feet using (wheeled walker) with supervised (ambulation) with reduced risk for falls and with minimal pain in order to increase independence with all functional ambulation. Prior device use: Walker. Current device use: Walker. On 4/24/24 at 8:35am, V2, Director of Nurses, stated R2 had a walker when she was readmitted to the facility and at some point they lost track of it. V2 stated he was not sure, but her previous roommate might be using it now. V2 stated R2 wouldn't use the walker even when she had it. V2 stated the 3/28/24 fall had caused a left Patella fracture. V2 stated after that fall, therapy has started working with her on using the walker, which the facility has provided. On 4/24/24 at 8:50am, V1, Administrator, stated R2 had her own walker upon readmission, and staff think maybe her previous roommate is using it. V1 stated R2 would not use the walker when she did have it. V1 stated therapy is working with R2 on using a walker, which the facility has provided. On 4/24/24 at 10am, V7, Minimum Data Set/Care Plan Coordinator/RN, stated the Care Plan intervention added after the 3/8/24 fall was to educate R2 to use her walker at all times, and the intervention added after the 3/28/24 fall was to educate her to use her walker on all outings. When the Surveyor told V7 that R2 told the Surveyor she refuses to use a walker, and the Surveyor asked V7 how effective that intervention would be, V7 stated, I don't think she refuses to use her walker per se, maybe she just forgets or doesn't use it for whatever reason, but I don't think she is actually refusing to use it. The facility policy titled Fall Management, dated 2019, documents, It is the policy of the facility to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary and The fall may be witnessed, reported by the resident, or an observer or identified when a resident is found on the floor or ground. An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person-this is still considered a fall.

Based on observation, interview, and record review, the facility failed to safely position a resident during a bed linen change for one of three residents (R2) reviewed for falls in the sample of three. This failure resulted in R2 rolling off the bed and sustaining a fractured left hip, and a laceration to the left side of the head requiring 4 staples. Findings include: R2's Medical Diagnosis List documented a diagnosis of [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)], affecting the left non dominant side. R2's [DATE] Care Plan documented a problem area, (R2) is at increased risk for falls related to generalized weakness and decreased mobility, with a corresponding goal, Will have falls/injuries minimized through management of risk factors while maintaining maximum independence/quality of life through next review. R2's [DATE] Minimum Data Set(MDS) documented R2 requires extensive assistance from at least one staff member for bed mobility and transfers and R2 has limited range of motion to the left upper and lower extremities. This MDS also documented a Brief Interview for Mental Status Score of 9, indicating R2 has moderate deficits in cognitive functioning. A Nurses Note, dated [DATE] at 2:07 am, documented, This nurse (was) called to residents room by CNA staff. Upon arrival to room resident noted to be laying on floor beside bed on left side. Puddle of blood noted under and around resident head. CNA staff stated that during full bed change that resident rolled off of the side of the bed. Resident complains of pain to head, left shoulder, and left hip. Emergency services called, and resident transported via ambulance to hospital. R2's Emergency Department Physician Documentation, dated [DATE], documents in part, HPI (History of Present Illness) 3:56 (pm) This [AGE] year white female presents to ED (Emergency Department) via EMS (Emergency Medical Services)- Ground with complaint of Fall injury. Details of fall: the patient fell from a supine position, out of bed. Onset: The symptoms(s)/episode began/occurred just prior to arrival. Associated injuries: The patient sustained left hip, deformity, painful injury, left side of the back of head, laceration 3cm(s) Laceration: 5:21(pm) Wound repair of 3 cm (1.2in) subcutaneous laceration to left side of the back of head. Distal neuro/vascular/tendon intact. Wound prep: simple cleansing, with chloroprep. Skin closed with 4 staples using staple gun Orders: 3:55(pm) Findings: Comminuted fracture involving the proximal left femur likely at the Trochanter. R2's [DATE] Fall Risk Assessment documented a score of 17, indicating R2 is at high risk for falls. On [DATE] at 12:40pm, V4, R2's Power of Attorney, stated on [DATE] at about 2:00am, R2 fell out of bed and was sent to the hospital. R2 was diagnosed with a fractured left hip and a laceration to the left side of her head, which required staples. V4 stated she was told by V1, Administrator, the fall occurred as a result of R2 falling asleep on the edge of the bed. V4 stated R2, however, told V4 one of the CNA's (Certified Nursing Assistants) who work on the midnight shift rolled R2 out of bed while she was changing her bed. V4 stated R2 is generally alert with some issues with short term memory. On [DATE] at 1:30pm, V1 stated she was unable to provide the Surveyor with R2's Fall Investigation, as it is considered an internal quality assurance document. On [DATE] at 8:40am,V2, Director of Nursing, was interviewed about the findings of the fall investigation. V2 stated R2 is at high risk for falls, and has a history of falls. V2 stated V3, CNA, was the staff member who was with R2 at the time of the fall. V2 stated V3 was by herself in R2's room changing R2's bed after an incontinence episode, and the fall investigation concluded R2 had rolled herself off the edge of the bed. V2 stated the root cause analysis of the fall was determined to be that R2 had decreased safety awareness, and as a result a quarter enabler rail was added to R2's bed as an intervention. On [DATE] at 9:05am, R2 was observed in her room lying in bed. R2's bed was noted to have a quarter enabler rail to the right side of the bed. R2 was alert and oriented to time, able to state her name and date of birth, and knew she was in a nursing facility but could not give the name of the facility. R2 had staples to her left forehead, as well as a surgical dressing to her left hip. R2 stated she was rolled out of bed about two weeks ago and fractured her left hip. R2 stated she asked a midnight shift CNA, whose name she does not know, to reposition her in bed. She stated the CNA rolled her too close to the edge of the bed, and she then rolled off the bed and onto the floor. R2 was tearful, and stated she is now in constant pain and requires round the clock pain medication, which is making her constipated. R2 stated, I'm miserable now. I wish I would have just died instead of having to go through this. On [DATE] at 10:20am, V3 stated she was working the midnight shift on R2's hall on [DATE]. V3 stated the other CNA working with her that morning was on break when she went in to check on R2 around 2am. V3 stated R2 was awake, and she had been incontinent of urine and the bed was soaked, necessitating a complete change of bed linens. V3 stated she was under the impression R2 only required the assistance of one staff for transfers and positioning. V3 stated she cleaned R2, changed her gown, and was in the process of changing the bottom sheet when she rolled R2 to the edge of the bed, with R2 lying on her right side. V3 stated the bed was approximately two and a half to three feet off the floor, and there were no siderails on the bed as R2 did not have siderails as an intervention. V3 stated R2 did not have a floor mat as a fall intervention, so there was no floor mat in place. V3 stated she positioned herself on the opposite side of the bed to pull the bottom sheet into place. V3 stated she was gently pulling the corner of the bottom sheet over the mattress, when R2 must have hunched her shoulder or something, and she rolled off the bed and onto the floor. V3 stated she yelled for nurse, and applied pressure to R2's head which was bleeding. V3 stated after the fall, she was re-educated by management that R2 was to always have the assistance of two staff for transfers and positioning. On [DATE] at 11:15am, V2 acknowledged V3 should have had another staff member present on the opposite side of the bed since R2 was positioned at the edge of the bed. V2 stated he educated V3 to have another staff with her on the opposite side of the bed if a resident was to be rolled to the edge of the bed, regardless of the amount of staff required for transfers and positioning. On [DATE] at 9:20am, V1 stated when she discussed R2's fall with V4, she told V4 a staff member had been changing R2's bed when R2 rolled off the bed. V1 stated she did not tell V4 R2 rolled off the edge of the bed while she was sleeping. A Fall Management Policy, with a review date of 2019, documented, It is the policy of the facility to have a fall prevention program to assure the safety of all resident(s) in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .Safety interventions will be implemented for each resident identified at risk using a standard protocol Facility staff are responsible for assuring ongoing precautions are put in place and consistently maintained.

Based on record review, interview, and observation, the facility failed to follow physician orders [REDACTED]. This failure resulted in R4 having an 11.87% (severe weight loss) over a 6 month time frame. Review of R4's admission record documents that R4 was admitted to the facility on [DATE]. The same admission record notes that R4 has [MEDICAL CONDITION], Unspecified dementia with behavioral disturbances, and [MEDICAL CONDITION] disorder, depressive type. R4's MDS (Minimum Data Set), dated 2/12/21, documents that R4 requires extensive assistance and one- person physical assist with meals. The same MDS notes that a BIMS (Brief Interview for Mental Status) should not be performed due to resident rarely/never understood. R4's electronic medical record documents the following weights over the last 6 months: 08/05/20: 87.6 pounds 09/02/20: 84.2 pounds 10/15/21: 79.6 pounds 11/04/20: 83.6 pounds 12/08/20: 79.9 pounds 01/12/21: 76.8 pounds 02/04/21: 77.2 pounds This represents an 11.87% weight loss over 6 months. A progress/dietary note by V12 (Registered Dietician/RD), dated 12/17/20, documents that R4 remains on 120 cc med pass tid (three times daily) for additional calories, with wt (weight) loss that continues and wts fluctuating below desirable, will suggest to change milk to whole when served and to increase med pass to 240 cc tid. continue to monitor intakes and wts and refer to RD as needed. V12's progress/dietary note, dated 1/26/21, documents R4's height is 62 inches and weight as of 1/12/21 was 76.8 pounds, BMI (body mass index) of 14.0. The note continues to state that in general R4's weights continue to show loss of 3.1 pounds in last month, 3.4 pounds in last 3 months, and 20.2 pounds (20.8%) in the last 6 months. V12 noted R4 continues at this time to remain well below desirable and below 80 pound range. The note continues to state there was a request from last month to change milk served to whole, increase med pass to 240cc tid was pending at this time, with weight loss again this month and recommendations were pending, no further recommendations were made. R4's care plan, dated 2/9/21, also documents that R4 is at risk for nutritional problems related to cognitive impairments, wandering behavior. Weight loss intervention documented on 12/23/21 noted to change milk served to whole milk and increase med pass to 240cc three times daily. R4's January and February 2021 physician's orders [REDACTED]. Upon review of R4's physician orders [REDACTED]. Review of the January and February MAR's (Medication Administration Records) indicate nursing is giving health shakes three times a day and med pass 90cc three times daily. On 2/16/21 at 1:05pm, R4 was observed sitting in her room and staff were noted to be assisting her with her lunch. R4's clothes were very loose fitting and her she appeared to be very thin. R4 was unable to respond to questions appropriately. On 2/17/21 at 10:00am, V8 (Primary Care Physician) said he is aware of R4's weight loss and there was not much that can be done about it due to R4's condition. V8 said he is at the facility now and is checking on (R4). On 2/18/21 at 10:30am, V1 (Administrator) was asked about the Registered Dietician recommendations noted above for R4 in December and she said she didn't have the answer for that, and said it just got missed. V1 was unable to produce any documentation of physician notification. On 2/22/21 at 10:10am, V11 (Dietary Manager) said the kitchen serves residents what is on their diet card. V11 said R3 is not getting supercereal at breakfast or fortified pudding at breakfast or supper. On 2/22/21 at 11:00am, V12 (Registered Dietician) said she has concerns with R4's weight. V12 said R4 used to wander a lot. V12 stated she can't say if R4 not getting the supplements she recommended has contributed to her weight loss, and added with R4's diagnosis, she thinks R4 is at a point that whatever you give her isn't going to help. V12 also said R4 is on medication to help increase her appetite and isn't going to get the full effect from any medications.

Based on observation, interview, and record review the facility failed to a) implement preventative treatment and services for individuals at risk for Pressure Ulcer, b) timely identify and treat an area of compromised skin and/or pressure ulcer, c) follow the facility policy for preventative skin care and the facility Decubitus Care/Pressure Area Policy for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 3. This failure resulted in R1 developing three unstageable pressure ulcers with (MRSA) [MEDICAL CONDITION] infection that have not shown consistent improvement. Findings Include: 1)R1's Minimum Data Sets ((MDS) dated [DATE] documents R1 was admitted to the facility from the hospital on [DATE] and has a BIMS (Brief Interview for Mental Status) score of 01 (Severe Impairment). R1's [DIAGNOSES REDACTED]. R1's MDS dated [DATE] continues to document R1 requires extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. This assessment also documents R1 is at risk for developing pressure ulcers with no current pressure ulcers documented. R1's assessment documents, a pressure reducing device should be in place for R1's chair and bed and a turn/reposition program. R1's quarterly MDS dated [DATE] documents R1 has a cognitive skill score for daily decision making of 3 (severely impaired); requires extensive assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, and personal hygiene; and R1 remains at risk for pressure ulcers. R1's baseline care plan dated 01/22/18 documents R1 requires assist of 2+ staff for bed mobility, transfer, and toileting, and assist of 1 staff for locomotion, grooming/hygiene, and bathing. R1's baseline care plan continues to document turn and reposition as a skin break intervention. The care plan does not document a turn and reposition schedule or instructions for staff on how or when to turn and reposition R1. R1's current care plan (not dated) does not document a focus problem, goals, or interventions related to prevention of skin breakdown. R1's care plan has a focus problem with an initiation date of 5/22/18 that documents R1 is on isolation R/T (related to):ESBL (extended spectrum beta-lactamases) in urine [MEDICAL CONDITION] in wound. R1's Braden Scale for predicting Pressure Sore Risk dated 1/29/18, 5/2/18, and 7/7/18 document R1 as being at high risk for developing pressure sores. R1's hospital admission history and physical dated 2/26/18 includes diabetes mellitus as a [DIAGNOSES REDACTED]. R1's laboratory results document high blood sugar results of 133 on 3/1/18, 177 on 3/5/18, 128 on 4/5/18, 166 on 4/6/18, 126 on 5/3/18, and a normal blood glucose reading of 88 on 7/9/18. On 7/10/18 at 12:20 PM, R1 was observed in an isolation room on a bed without an air mattress. V3 (Licensed Practical Nurse-LPN), V6 (Certified Nurse's Assistant-CNA), and V7 (Regional Director of Nurses) were present. V3 performed wound treatments as ordered by the physician for three unstageable wounds to R1's left back, right back, and coccyx. R1's left back wound had black eschar and a thick yellow center with pink and red surrounding tissue. R1's coccyx wound was deep with a red and yellow center and clear drainage noted. R1's right back wound had a black and red center. R1's right heel was black in color and V3 treated the area with [MEDICATION NAME] as ordered by the physician. R1 only had one heel protector in R1's room at this time. V6 stated, V6 had to go find R1's other heel protector and that R1's air mattress had stopped working sometime over the weekend and the facility had moved R1 to a bed with a regular mattress until R1's air mattress could be fixed or replaced. V3 verified R1 was on isolation for an infection in R1's wounds. R1's nurses notes document on 4/29/18 orders received from primary care physician to send R1 to the emergency room for evaluation of urinary symptoms. R1's nurses notes continued on 4/29/18 to document R1 was admitted to the local hospital with a [DIAGNOSES REDACTED]. On 5/1/18 R1's nurses notes document R1's return to the facility and R1 has open areas on bilateral feet, reddened coccyx, red area on R (right) hip and (R) back. There is no further documentation related to R1's reddened and/or opened areas until 5/3/18. R1's hospital stay with an admission date of [DATE] and a discharge date of [DATE] includes a wound assessment dated [DATE] that documents a red area that does not blanch located on R1's upper right back, and a red area that does not blanch on R1's coccyx. The wound assessment continues to document an [MEDICATION NAME] foam sacral pad was applied. R1's hospital record continues to document a discharge summary dated 5/1/18 that includes under Physical Exam: .Patient (R1) was awake this morning wound care was in the room assisting with skin examination .They were marking room (sic) and taking pictures patient has several superficial and deep tissue areas of concern. On 5/3/18 R1's nurses note document the primary care physician saw R1 and ordered [MEDICATION NAME] sol (solution) 10% to (R) heel and (L) lateral foot once daily, heel protector's bilat (bilateral) feet. Consult (V4). R1's nurses notes do not document information related to R1's wounds until 5/10/18 when they document, the wound specialist (V4) saw R1 and new treatment orders were given for R1's right heel and left medial foot and an attempt was made to reach R1's guardian (V8). R1's nurses notes document the wound specialist (V4) visit on 5/17/18 with new orders for a wound on R1's left knee. R1's nurse's notes then document V4's visit on 5/24/18 and new treatment orders for R1's coccyx and right upper back. On 5/31/18 the next nurses note related to R1's wounds document V4's visit and that R1 had a culture of R1's right back wound done. R1's nurses notes do not document when new wounds are acquired and/or an assessment of R1's wounds when they are identified between the wound specialist visits. The facility weekly pressure ulcer reports for accurate MDS 3.0 coding documents the following for R1; 5/3/2018- no wounds documented for R1 5/10/18- site #1 right heel unstageable DTI (Deep Tissue Injury) 7 x 7 x nmcm (non-measurable centimeter) > (greater than) 20 days, site # 2 left medial foot unstageable DTI 1.5 x 2 x nmcm >2 days. 5/17/18- site #1 measures at 5 x 5 x nmcm and site #2 measures at 1.5 x 2 x nmcm. 5/24/18- site #1 measures at 5 x 5 x nmcm and site #2 measures at 3 x 1 x nmcm. Site # 4 upper right back unstageable DTI 2 x 2 x 0.2 cm >2 days and site # 5 coccyx unstageable DTI 5 x 5 x 0.1 cm > 5 days. 6/07/18- site #1 measures at 5 x 5 x nmcm, site #2 measures at 2 x 2 x nmcm, site #4 measures at 3 x 2 x 0.2, site #5 measures at 5 x 5 x 0.1 cm, and site #6 upper left back unstageable DTI > 11days measures at 5 x 5 x nmcm. 6/14/18- site #1 measures at 5 x 5 x nmcm, site #2 measures at 1.5 x 1 x nmcm, site #4 measures at 3 x 2 x 0.2 cm, site #5 measures at 5 x 4 x 0.1 cm, and site #6 measures at 7 x 5 x nmcm. 6/21/18- site #1 measures at 5 x 5 x nmcm, site #2 measures at 1.5 x 1 x nmcm, site #4 measures at 3 x 2 x 0.2 cm, site #5 measures at 5 x 4 x 0.1 cm, and site #6 measures at 5 x 5 x 0.2 cm. 6/28/18- site #1 measures at 5 x 5 x nmcm, site #2 measures at 1.5 x 1 x nmcm, site #4 measures at 3 x 3 x 0.2 cm, site #5 measures at 5 x 3 x 0.1 cm, and site #6 measures at 7 x 4 x 0.8 cm. 7/5/18- site #1 measures at 5 x 5 x nmcm, site #2 measures at 1.5 x 1 x nmcm, site #4 measures at 3 x 2 x 0.2 cm, site #5 measures at 5 x 3 x 0.1 cm, and site #6 measures at 7 x 4 x 0.8 cm. R1's treatment records dated 2/2018, 3/2018, 5/2018, 6/2018, and 7/2018 do not document weekly skin assessment notes. The facility was unable to provide reproducible evidence of R1's (MONTH) (YEAR) treatment records. R1's resident data collection records document R1's coccyx was red on R1's return from the hospital on [DATE]. On 5/7/18 R1's resident data collection records document a 7 cm (centimeter) black area on right heel, 10 ½ cm x 4 cm red area right hip, 1 x 2 cm open area R (right) back, 5 cm black (area not designated), 2 x 1 cm open area (area not designated), inner aspect L (left foot) 4 cm red area, 2 x 1 cm black area little toe outer aspect of left foot, 9 cm red (area not designated), 8 x 7 cm discolored area L lower leg. R1's resident data collection notes, daily skilled notes and nursing notes do not document assessments of R1's skin prior to 5/1/18. R1's notes do not document the facility notifying the primary care physician or the wound specialist of new wounds acquired between the wound specialist visits. R1's current care plan includes a focus problem of actual impairment to skin integrity with an initiation date of 5/10/18. The focus problem of actual impairment to skin documents under Interventions; 6/14/18 Prostat 30 ml in per [DEVICE] (feeding tube), avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. MD (physician) treatments as ordered. Monitor for side effects of the antibiotics and over the counter pain medications: [REDACTED]. Obtain blood work such as CBC with diff, Blood cultures and C&S (culture and sensitivity) of any open wounds as ordered by Physician. Skin checks as scheduled. The resident needs pressure relieving/reducing mattress to protect the skin while in bed. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R1's structured turning and repositioning program documentation dated 6/12/18 through 7/11/18 documents R1 was not turned and repositioned every two hours for 11 of the 29 days. On 7/17/18 at 2:08 PM V7 (Regional Director of Nurses) stated if a new area of skin breakdown was identified or if there were any concerns regarding the skin when the weekly skin assessment was completed the nurse should document that on the back of the Treatment Records or in the nurses notes. On 7/11/18 at 10:44 AM, V9 (Licensed Practical Nurse) stated when residents return from a hospital visit, nurses should do skin assessments and document type, stage, and measurement of any wounds. On 7/12/18 at 9:40 AM, V6 (Certified Nursing Assistant) stated there was not a specific turn and reposition schedule in place for R1. V6 stated staff just knew if R1 was on R1's left side then R1 would need to go to R1's right side or back. When asked if R1 had any preventative measures in place prior to R1's skin break down V6 stated, No, we report skin issues and nurses get stuff in place then. R1 was observed at this time sitting in R1's wheelchair in R1's room. R1's wheelchair had a cushion in the seat but no padding/support was observed for R1's back. When asked if R1 had any type of pad/cushion in place for R1's back wounds V6 stated, No. On 7/12/18 at 11:58 AM V4, (Wound Specialist) stated the facility had not notified V4 between visits of each new wound R1 developed. V4 stated V4 would expect the facility to follow the recommendations V4 made for R1's pressure ulcers and R1 should have been turned and repositioned at least every two hours. V4 stated the facility had not communicated to V4, R1 had a [DIAGNOSES REDACTED]. On 7/12/18 at 1:01 PM, V2 (Director of Nurses) stated V2 would expect the nursing staff to notify the physician of any new wounds that occurred between the physician's visits. When asked where the notifications were documented in R1's record V2 stated, I am not seeing it documented. V2 confirmed V2 was not aware R1 had a [DIAGNOSES REDACTED]. On 7/12/18 at 1:01 PM, V2 (Director of Nurses) stated R1 did not have a care plan in place or preventative measures in place after being assessed as high risk for pressure ulcer upon admission. When asked if the facility implemented new interventions after R1's initial skin integrity care plan dated 5/10/18 and his continued skin breakdown V2 stated, I don't believe so. V2 confirmed the facility did not have reproducible evidence of R1 having a turn and reposition schedule in place with specific directions for the staff to follow. V2 also confirmed the facility did not have reproducible evidence R1 had been turned and repositioned every two hours. On 7/13/18 at 2:40 PM V4 stated V4 did not think R1's wounds could have been prevented if V4 had known of R1's [DIAGNOSES REDACTED]. sugars were controlled. When asked if R1's wounds were avoidable if the facility had put interventions in place to prevent pressure ulcers, made changes to R1's interventions when R1 began to develop additional wounds, and followed V4's recommendations, V4 stated, I don't really know .the only one that may have been avoidable would have been the wound on the coccyx. R1's wound care specialist (V4) evaluation notes document the following; 5/10/18 Patient has a wound on their heel . (R1) presents with an unstageable DTI (deep tissue injury) of the right heel (site 1) of at least 20 days duration .There is no indication of pain associated with this condition .etiology: pressure .wound size 7 x 7 x not measurable cm (centimeter) wound of the left medial foot (site 2) .wound size 1.5 x 2 x not measurable cm . Recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 5/17/18 .Unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm, wound progress: improved; wound of left medial foot(site 2) .wound size 1.5 x 2 x not measurable cm, wound progress: no change; .shear wound of the left knee (site 3) .duration >3 days .wound size 1 x 0.7 x not measurable cm . recommendations elevate leg(s) float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 5/24/18 .Unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm .wound progress: no change . wound of left medial foot (site 2) . wound size 3 x 1 x not measurable cm .wound progress: no change .shear wound of the left knee (site 3) .wound progress: resolved .unstageable (due to necrosis) of the right upper back (site 4) .etiology: pressure .duration > 2 days .wound size: 2 x 2 x 0.2 cm . Unstageable (due to necrosis) coccyx (site 5) .etiology: pressure .duration > 5 days . wound size 5 x 5 x 0.1 cm .recommendations: elevate legs, float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 5/31/18 .unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size 3 x 1 x not measurable cm .wound progress: no change .unstageable of the right upper back (site 4) .wound size 2 x 2 x 0.2 cm .wound progress: no change .unstageable coccyx (site 5) . wound size 4 x 4 x 0.1 cm .wound progress: improved . unstageable (due to necrosis) of the left upper back (site 6) .etiology: pressure .duration > 5 days .wound size: 5 x 4 x 0.1 cm .arterial wound of the left foot (site 7) .etiology: arterial .duration: > 3 days .wound size: 2 x 2 x not measurable cm .investigations deep swab (culture) technique performed on unstageable (due to necrosis) of the right upper back on 5/31/2018 .recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 6/7/18 .unstageable DTI of the right heel (site 1) .wound size: 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size 2 x 1 x not measurable cm .wound progress: improved .unstageable (due to necrosis) of the right upper back (site 4) .wound size: 3 x 2 x 0.2 cm .wound progress: no change .unstageable (due to necrosis) coccyx (site 5) wound size: 5 x 5 x 0.1 cm wound progress: no change unstageable (due to necrosis) of the left upper back (site 6) .wound size 5 x 5 x not measurable .wound progress: improved .arterial wound of the left foot (site 7) .wound size 2 x 2 x not measurable cm .wound progress: no change .arterial wound of the left fourth toe (site 8) .etiology: arterial .wound size: 0.5 x 0.5 x not measurable cm .investigations deep swab technique of unstageable (due to necrosis) of the right upper back demonstrates morganella morgana,[MEDICAL CONDITION] ([MEDICAL CONDITION] on 6/7/18 .recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol .antibiotic choice, [MEDICATION NAME] 100 mg (milligrams) BID (twice daily) x 10 days 6/14/18 .unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size 1.5 x 1. Not measurable cm .wound progress: improved .unstageable (due to necrosis) of the right upper back (site 4) .wound size 3 x 2 x 0.2 cm .wound progress: no change unstageable (due to necrosis) coccyx (site 5) .wound size: 5 x 4 x 1 cm .wound progress: improved .unstageable (due to necrosis) of the left upper back (site 6) .wound size 7 x 5 x not measurable cm .wound progress: no change .arterial wound of the left foot (site 7) .wound size 2 x 2 x not measurable cm .wound progress .no change .arterial wound of the left fourth toe (site 8) .wound size: 0.5 x 0.5 x not measurable cm .wound progress: no change .recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 6/21/18 .Unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size 1.5 x 1 x not measurable cm .wound progress: no change .unstageable (due to necrosis) of the right upper back (site 4) .wound size: 3 x 2 x 0.2 cm .wound progress: improved .unstageable (due to necrosis) coccyx (site 5) .wound size 5 x 4 x 1 cm .wound progress: improved .unstageable (due to necrosis) of the left upper back (site 6) .wound size 5 x 5 x 0.2 cm .wound progress: improved arterial wound of the left foot (site 7) .wound size 1 x 1 x not measurable cm .wound progress: improved .arterial wound of the left fourth toe (site 8) .wound size 0.5 x 0.5 x not measurable cm .wound progress: no change 6/28/18 .unstageable DTI of the right heel (site 1) .wound size: 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size: 1.5 x 1 x not measurable cm .wound progress: no change .unstageable (due to necrosis) of the right upper back (site 4) .wound size: 3 x 3 x 0.2 cm .wound progress: no change .unstageable (due to necrosis) coccyx (site 5) .wound size 5 x 3 x 1 cm .wound progress: improved .unstageable (due to necrosis) of the left upper back (site 6) .wound size 7 x 4 x 0.8 cm .wound progress: no change .arterial wound of the left foot (site 7) .wound size: 1 x 1 x not measurable cm .wound progress: no change .arterial wound of the left fourth toe (site 8) .wound size 0.5 x 0.5 x not measurable cm .wound progress: no change recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . 7/5/18 .Unstageable DTI of the right heel (site 1) .wound size 5 x 5 x not measurable cm .wound progress: no change .wound of the left medial foot (site 2) .wound size 1.5 x 1 x not measurable cm .wound progress: no change .unstageable (due to necrosis) of the right upper back (site 4) .wound size: 3 x 2 x 0.2 cm .wound progress: improved unstageable (due to necrosis) coccyx (site 5) .wound size: 5 x 3 x 1 cm .wound progress: no change .unstageable (due to necrosis) of the left upper back (site 6) .wound size: 7 x 4 x 0.8 cm .wound progress: no change .arterial wound of the left foot (site 7) .wound size 1 x 1 x not measurable cm .wound progress: no change .arterial wound of the left fourth toe (site 8) resolved 7/5/18 .recommendations: elevate leg(s), float heels in bed, limit sitting to 60 minutes, obtain consent for debridement, off-load wound, reposition per facility protocol . R1's MD Wound Care notification forms dated 5/17, 5/24, 5/31, 6/7, 6/14, and 6/21/18 document notification made to R1's primary care physician which include each wound the size of the wound and the current treatment. R1's wound care notification forms do not document the wound specialists (V4) recommendations or a request for the primary care physician to write orders for V4's recommendations to be followed. On 7/11/18 at 11:19 AM V2 confirmed R1 had not been seen by the wound specialist (V4) prior to 5/10/18. On 7/12/18 at 1:01 PM when asked if V2(Director of Nurses) would expect the wound specialist recommendations to be followed, V2 stated, that would depend on what the primary physician wanted. When asked to explain V2 stated when the wound specialist makes recommendations and gives orders for treatments the facility then fills out a MD notification form and sends it to the primary care physician for him to write orders on the recommendations he wants the facility to follow. When asked to review the MD notification form and show the surveyor where on the form the wound specialist's recommendations are documented, V2 confirmed the facility had not notified the primary care physician of the wound specialist's recommendations for R1. When asked what the facility was doing to heal R1's current wounds and prevent further wounds V2 stated, We should be following our policy. The facility Preventative Skin Care Policy dated (January 2014) documents, To provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Under procedures the facility preventative skin care policy continues to document, 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4 then will be reassessed at least quarterly and/or as needed. 2. Staff on every shift and as necessary will provide skin care. After thorough cleansing of the skin, lotion may be applied and observation of any reddened areas will be reported to the Charge Nurse. 4. A thin layer of body lotion and/or barrier cream may be applied as a protective barrier to area(s) exposed to incontinence. 5. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every (2) hours. 6. Special mattresses and/or chair cushions will be used on any resident identified as being at high risk for potential skin breakdown. 7. Pillows and/or bath blankets may be used between two (2) skin surfaces or to slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. 8. If resident is able to understand, teach the resident about good skin care. Inform them of the cause of pressure ulcers and encourage them to actively participate in the prevention of pressure ulcers. 9. Ensure proper fit of wheelchairs, splints, braces, prosthesis, etc. 10. Provide good nutrition and adequate hydration. A. Nursing assistants are to report decreased food or fluid intake to the Charge Nurse who will evaluate and contact the physician if indicated b. Keep fluids within reach of the resident and/or offer frequently. C. Monitor weight at least monthly, more frequently if indicated. 11. Practice care in moving and lifting residents .12. Maintain wrinkle free, clean, dry bed linen. 13. Encourage resident activity, when feasible. Use repositioning techniques and Range of Motion exercises when indicated. 14. Keep incontinent residents clean and dry. 15. Keep resident's fingernails and toenails short and smooth to prevent them from accidentally scratching themselves. The facility Decubitus Care/Pressure Area Policy dated (January 2014) documents, To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Procedure: Upon identification of skin breakdown the following will be completed; 1) the pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following NPUAP (National Pressure Ulcer Advisory Panel) guidelines i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician) ii. Document the stages of the pressure ulcer as follows: (a) Suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood -filled blister due to damage of underlying soft tissue from pressure and/or shear. (b) Stage I: redness, which does not resolve 30 minutes after pressure is relieved, no broken skin. (c) Stage II: broken skin, an abrasion, blister or shallow crater (d) Stage III: broken skin, affects full thickness and presents as a deep crater (e) Stage IV: broken skin, muscle and/or bone exposed iii) Document the color according to the following: (a) Red: pale pink to beefy red with or without healthy granulation tissue (b) Yellow: whitish yellow, creamy-yellow, yellow-green, or beige (c) Black: black, stringy gray or gray scab 3. Notify the physician for treatment orders. The physician's orders [REDACTED]. The order must have specific frequencies. vi) Initiate physician order [REDACTED]. The assessment may include: i) Characteristics (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment. 5) Reevaluate the treatment for [REDACTED]. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 6. Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician. 7) Initiate problem on care plan. 8) When the pressure area is healed, a preventative regimen is instituted. 2. A document titled Action Summary for (MONTH) (YEAR), indicates that on 7/3/2018 at 3:00 PM, R2 left on a leave of absence for a home visit and was subsequently discharged from the facility on 7/9/2018. Documentation dated 4/30/2018 states that a superficial wound was noted to R2's buttocks, treatment order obtained, Doctor and Power of Attorney notified, V4, Wound Doctor, to see R2 on next visit. V4's initial evaluation of the wound on 5/10/18 documents the etiology of the wound is a shear, measuring 1 cm (centimeter) x 0.5 cm x (depth not measurable), surface area 0.5 cm squared. Orders for daily treatment and application of dressing were included. According to V4's notes, R2 was seen by V4 at the facility weekly on the following dates, and documentation included the following information; 5/17/18, Wound debrided, wound progress is improved as evidenced by a decreased surface area. 5/24/2018, Wound debrided, wound progress has deteriorated due to patient non- compliant with wound care. 5/31/2018, Wound progress is improved. Wound debrided. 6/7/2018, Wound progress improved. Wound debrided. 6/14/2018, wound size, 2 x 0.5 x 0.6 cm, surface area 1.00 cm squared. Wound progress deteriorated due to patient non-compliance with wound care, debridement. On this same document an order was written to add [MEDICATION NAME] ointment to the daily treatment of [REDACTED]. 6/21/2018, Wound progress - no change, wound debrided. 6/28/2018, Wound size, 2 x 1 x 1 cm, surface area 2.00 cm squared, wound progress- no change, wound debrided. On 7/12/2018 at 11:58 PM, V4 stated that on 5/24/2018 and 6/14/2018 V4 documented that R2 was non-compliant with wound care because R2 had told V4 that on one of these dates that (R2) had stayed up in chair most of the day to attend an activity and on the other date stated something like, staff wouldn't help (R2) to bed, I can't recall the specifics. V4 added that V4 did expect the facility to follow V4's recommendation of 6/14/2018 for R2 to limit sitting to 60 minutes. V4 added V4 continued to describe this wound a shear because that is how it started. V4 then stated, that doesn't mean it can't get worse. V4 added that pressure was certainly a contributing factor to the progression of the wound. V4 stated that there was no tunneling or undermining when V4 last saw the wound on 6/28/2018. On 7/11/2018 at 9:00 am, when asked how V2 would expect the recommendation from V4 on R2's wound to be addressed, V2 stated, I would expect it to be communicated to the staff and added to the Care Plan. R2's Current Care Plan includes a focus area of impaired skin integrity and documents that on 5/10/2018 a Shear Wound to the sacrum was present. This same document includes a prevention intervention of Turn and Reposition every 2 hours and prn (as needed). It does not include V4's recommendation of limiting sitting to 60 minutes. A document titled MD Wound Care Notification for R2 dated 6/14/2018 and signed by V13 (R2's primary care physician) does not include V4's recommendation to limit sitting to 60 minutes. On 7/11/2018 at 2:00 PM, R2 was interviewed in local hospital, stated that V4 wanted (R2) turned all the time. When asked how often R2 was turned, V4 stated, Sometimes not all night. R2's MDS (Minimum Data Set) dated 5/23/2018 indicates that R2 requires extensive of two persons for bed mobility and that R2 scored 14 on a Brief Interview for Mental Status which indicates that R2 is cognitively intact. On 7/12/2018 at 12:30 AM, V14, Certified Nurse's Aide, stated V14 works primarily on 3rd shift. V14 stated that R2 was turned every 2 hours. V14 stated that R2 would sometimes ask for bedpan but was mostly incontinent and would frequently be found wet when checked. V14 stated that turning is documented in R2's Electronic Medical Record. On 7/12/18 at 9:10 AM, V22, Licensed Practical Nurse, stated that V22 was confident that R2 was being turned during the night, because if R2 wasn't V22 is sure R2 would tell V22. V22 added that R2 had told V22 this in the past and V22 had written up staff for this. Documentation from R2's electronic medical record for turning and repositioning shows that on 4/19/2018 R2 was turned 4 times; 4/20/18 -7 times; 4/22/2018 -8 times; 4/23/2018- 3 times; 4/29/2018 8 times. It is documented in R2's medical record that R2 was turned 4 times on 7/4/2018 and 1 time on 7/5/2918 when R2 was on a home visit. On 7/13/2018 at 2:08 PM, V7, Regional Director of Nursing reviewed this documentation and confirmed turning had not occurred every 2 hours. On 7/10/2018 at 8:47 am, V15 (family member) stated that V15 was not given prescribed ointment for R2 's wound care when they left the faciity on [DATE]. V15 s (TRUNCATED)

Based on record review and interview, the facility failed to adequately supervise, assess, document, and implement effective interventions for a resident with Alzheimer's disease to prevent elopement, and failed to document the resident's condition after elopement for 1 of 4 residents (R4) reviewed for elopement in the sample of 5. These failures resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, frustration, and fearfulness. Findings include: The 08/10/17 Admission Record documents R4 has [DIAGNOSES REDACTED]. The record also documents that R4 was R4's own Responsible Party. The 08/10/17 admitting Resident-Data Collection document states R4 is combative, answers inappropriately, wanders mentally, has slow comprehension and is disoriented to time, place and person. The record states R4 has dementia with disorganized thought patterns and rambles. The 08/13/17 to 8/20/17 Nurse's Notes documents R4 wanders into peers rooms and takes their items, has increased agitation and aggression, and is exit seeking. The 08/15/17 4:30 pm Nurse's Notes documents a wander guard was applied to R4's left leg. The 08/17/17 Minimum Data Set (MDS) states R4 is unable to complete the Brief Interview for Mental Status (BIMS), which indicates R4 is severely cognitively impaired. Section E0900-Wandering of the MDS, documents R4 had this behavior daily, and the impact on R4 places R4 at significant risk of getting to a potentially dangerous place. On 11/20/17 at 3:55pm, Z4 (Family) stated one morning recently Z4 went outside Z4's apartment to let the dog out, and saw R4 walking across the lawn. Z4 stated a neighbor that resides in a nearby apartment informed Z4 that R4 walked into her apartment, and they had called the police. Z4 stated when Z3 (Police Officer) arrived, Z4 told Z3 that R4 resided at the local long term care faciltiy, and that Z4 knew R4, as R4 was R6's roommate there. Z4 stated Z4 called the facility, and informed a receptionist that R4 was in Z4's yard, adding the facility was not aware R4 was gone at the time Z4 called. Z4 stated Z4 lives about 4 or 5 blocks from the facilily. On 11/21/17 at 2:15pm, Z3 stated a call came into the police department by Z5 (Reporting Caller) stating a female walked into Z5's apartment. Z3 stated when Z3 arrived at the reporting address, R4 was very confused, and stating R4 wanted to go home. Z3 stated that Z4 told Z3 R4 lived in a long term care facility in the area. The 09/07/17 Police Department Summary states a call came into the department at 10:13am, and at 10:17am Z3 was advised there was a female (R4) that walked into Z5's apartment, and R4 did not know where she lived. The report states Z3 was on scene at 10:25am, and R4 was transported back to the facility at 10:40am by Z3. Z3 stated when Z3 arrived at the facility with R4, a male staff member was standing outside and he asked if R4 belonged there, to which the staff member replied that he wasn't sure but he would get someone that knew. A female staff member then came out of the building and verified that R4 did reside at the facility. An untitled document dated 09/07/17, and signed by E21 (Previous Receptionist/Payroll) states at about 10:15am E21 received a call from a gentleman, who did not leave his name, who stated R4 was there. The document states the caller told E21 a street name. The document states E21 proceeded to the 300/400 Hall nurse's station and told nursing staff R4 was gone. The document states several staff members exited the building to go get R4. The document further states E21 saw R4 about 9:30am walking toward the 300/400 Hall nurse's station that morning. On 11/21/17 at 1:30 pm, E11 (Licensed Practical Nurse) stated E11 was R4's nurse on 09/07/17, the day R4 left the facility. E11 stated R4 wore a wander guard bracelet and had a history of [REDACTED]. E11 stated E11 gave R4, R4's morning medications around 9:00am and recalls that E11 left the facility E11's self around 10:00am when E11 went on E11's break. E11 stated E11 returned to the facility in about 10-15 minutes and when E11 arrived E11 saw a police car in the parking lot, and R4 being taken back inside the facility. E11 stated E11 did not fill out an incident report because R4 did not have any injuries. E11 stated E11 cannot recall if E11 documented E11's assessment on R4 after R4 returned, but stated E11 did complete a head to toe assessment which included checking skin integrity, mental status, range of motion and vital signs. E11 also stated E11 called Z1 (Physician) and Z6 (Family) to inform them of the elopement. E11 stated E3 (Director of Nurses) was in the building during this time. On 11/21/17 at 1:45pm, E9 (Certified Nurse Aide-CNA) stated E9 was caring for R4 on 09/07/17, the day R4 left the facility. E9 stated E9 recalls seeing R4 at breakfast between 7:00am-8:00am, adding R4 wandered around the facility. E9 stated R4 wore a wander guard bracelet and would try to get out of the building frequently. E9 stated E9 was leaving the building E9's self around 10:00am that day for break when E9 heard E21 talking on the phone and stating R4 was out of the building. E9 stated E9 immediately got in E9's car with a therapy employee (cannot state name) and started looking for R4 based on the street name the caller gave E21. E9 stated 4 or 5 cars went out looking for R4 and E9 estimates E9 and the therapy employee looked for R4 for around 20 minutes and was unsuccessful. E9 stated when they returned to the facility, the police had brought R4 back to the facility. E9 stated R4 did not have any injuries and once back inside I kept R4 with me, for me. E9 stated E9 does not recall 15 minutes checks or a recording log for any monitoring checks once R4 returned. E9 stated the facility staff were not aware that R4 was missing until Z4 called the facility to inform them. R4 was discharged from the facility, according to record review, and not available for interview. However, with the results of the 08/17/17 Minimum Data Set (MDS) stating that R4 is unable to complete the Brief Interview for Mental Status (BIMS), which indicates that R4 is severely cognitively impaired, R4 would not be able to express how R4 felt while wandering around outside lost for a period of time and being picked up and escorted by a police officer back to the facility. A reasonable person would react to such a situation with feelings of anxiety, distress, frustration, and fearfulness. On 11/20/17 at 2:05pm, E1 (Administrator) stated E1 was on vacation on 09/07/17 and was not notified of R4's elopement. E1 stated E1 returned to work on 09/11/17 and in morning meeting E1 was informed R4 was transferred to a different facility, but was not aware of the elopement. E1 stated the staff could have reported the incident to E10 (Regional Director of Operations) in E1's absence, but cannot state if this was done or not. E1 stated E1 cannot say if the facility staff called the police. E1 stated E3 is currently on vacation and cannot be reached. On 11/20/17 at 4:15pm, E4 (Assistant Director of Nurses) stated if a resident has a wander guard, the nurses are to check placement and function every shift and record it on the Medication Administration Record (MAR). On 11/21/17 at 4:30pm, E10 stated staff are to immediately follow the facility policy on elopement if this should occur. E10 stated E10 should have been notified of the elopement, adding E10 was not aware until this investigation. E10 added E10 was not aware the police had brought R4 back to the facility. The 08/10/17 Care Plan states R4 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis(es) of: dementia and problems understanding the immediate environment. Symptoms are manifested by: Attempting to leave the facility without a responsible escort (elopement),. pacing, roaming or wandering in and out of peers' rooms .Discharge planning is being done to move R4 to a more appropriate and safe environment. The Interventions in the 8/10/17 Care Plan include: Wander guard placement and function to be checked every shift, and assign 1:1 staff when elopement behaviors have escalated. The 09/07/17 elopement is not documented on R4's Care Plan. A 09/11/17 typed document titled Incident Involving R4 with a typed signature of E3 details R4's elopement from the facility without an escort, and the facility was made aware of R4's location by a visitor familiar with R4. The report does not state the police returned R4 back to the facility. The report states close supervision was implemented until R4's discharge. The Facility's March 2015 Elopement Policy states: 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and condition of the resident; c. Notify the resident's legal representative (sponsor). R4's August and September, 2017 MAR does not include wander guard placement and check every shift. R4's medical records do not include an incident and accident report of the 09/07/17 elopement. There is no documentation that the facility notified the police when they discovered R4 was missing. The records do not include documentation of an injury assessment or R4's condition upon return to the facility, with proper notification to a physician or family/legal representative. In addition, there is no documentation of any interventions implemented after R4 returned to the facility to prevent the risk of future elopements. Facility staff were unable to provide any of the above requested documentation throughout the duration of the survey.

Based on observation, interview and record review, the facility failed to ensure that assessed needs for providing assistance with a transfer were followed and failed to consider new interventions related to falls for 3 of 4 residents (R1, R6, R8) reviewed for falls in the sample of 8. This failure resulted in R8 being hospitalized after a fall that resulted in acute fractures of the left tibia and fibula. The findings include: 1. R8 is a [AGE] year old resident with [DIAGNOSES REDACTED]. This Discharge Summary also included the discharge [DIAGNOSES REDACTED]. R8 stated during an interview on 8/27/2013 at 2:00 pm that she had a broken leg. When asked what happened, R8 replied that a "CNA" (Certified Nurse Aide) had dropped her. R8's quarterly Minimum (MDS) data set [DATE] indicates a Brief Interview for Mental Status is scored as a 15 (Cognitively Intact). R8's Nurses Notes dated 6/14/2013 at 9:35 am documented that a CNA was getting R8 off the commode and when R8 couldn't bear weight the CNA lowered R8 to the floor with R8's left leg getting under R8. It was further documented that R8 stated that "she heard her leg pop" and after being assessed on the floor, was assisted to a wheel chair where it was then noted that a knot was visible below the knee. R8's physician was notified and R8 was transferred to the emergency room . The Incident/Accident Report dated 6/14/2013 documented the same information. The hospital Discharge Summary documented that R8 was admitted after a fall in which R8 sustained a left tibia-fibular fracture and due to severe osteopenia, non operative conservative management was decided. R8 was put in an immobilizer brace and ordered to be non weight bearing and returned to the facility on [DATE]. E7, Licensed Practical Nurse, stated during interview that on 8/28/2013 at 2:10 pm, that on 6/14/2013, E8- CNA (Certified Nurse Aide) came and got E7 and told her that as E8 was getting R8 off the toilet R8's leg just went out and E8 had to lower R8 to the floor. E7 verified that E8 had been transferring R8 by herself. E7 stated that she thought R8 was a 2 person assist for transfers. A Fall Risk assessment dated [DATE] documented that R8 was considered a high risk for falls. The admission RAI (Resident Assessment Instrument) dated 5/11///2013 documents under Functional Status that R8 was assessed as needing "extensive assistance of 2 plus persons physical assist". An Occupational Therapy Evaluation with a "Start of Care Date" of 6/02/2013 documents that R8 required maximum assist with toilet transfer with poor standing balance. 2. On 08-27-2013 at 1:37 PM, R6 was being transferred by one assist, E6 (Certified Nursing Assistant) from her wheelchair onto the commode. The commode had an elevated toilet seat that was too high for R6 to safely sit on because her feet could not touch the floor. E6 was trying to adjust R6's clothing to sit her onto the commode when R6 started sliding off of the elevated toilet seat. R6 was half way on the toilet seat and half way onto the floor. E6 was holding onto R6 and was trying to keep R6 from going onto the floor. R6's sister hurriedly came to the nurses station to inform E7 (Licensed Practical Nurse) that R6 was about to slide into the floor and that E6 needed assistance immediately. On 08-27-2013 at 1:40 PM, R6's sister stated during interview that they usually have two Certified Nursing Assistants to transfer R6, and she didn't know why E6 was transferring R6 without getting help. R6's sister stated that R6 is visually impaired and can't really get onto the commode without help. On 08-27-2013 at 1:43 PM, E6 stated during interview that R6 was slipping off of the commode and she kept her from going into the floor all of the way, but couldn't lift her back onto the commode by herself. E6 stated that she usually has someone else helping her with R6. R6's Minimum (MDS) data set [DATE], Section G, states that R6 is Extensive Assist for transfers and requires a two person physical assist and is only able to stabilize with staff assistance when moving on and off the toilet. R6's Fall Investigation Report dated 08-27-2013 does not thoroughly assess the root cause for R6's fall. The Fall Investigation Report states, "C.N.A. (Certified Nurse Aide) trying to put resident on toilet." There was no new intervention documented on the Fall Investigation Report and no new intervention added to R6's Care Plan. 3. The incident report for R1 dated 08-20-2013 at 6:20 PM, states that R1 was getting up to leave the dining room after eating, attempted to get up unassisted, lost her balance, and fell forward onto the floor hitting the right side of her head and the bridge of her nose on the piano causing a one inch gash above her right eye brow and a half inch cut on the bridge of her nose. The Nurses Note dated 08-20-2013 states that R1's physician was notified and R1 was sent to the local emergency room at 6:50 PM. R1's Power of Attorney was notified at 6:35 PM about the fall and injuries. The Fall Investigation Report states that the resident continues to cognitively decline and. attempts to perform activities that she is physically unable to accomplish. There was no other documentation to determine root cause and there was no new intervention documented on the Fall Investigation Report and no new intervention added to R1's Care Plan. R1's Fall Risk assessment dated [DATE] states that R1 is high risk for falls.

Based on record review and interview the facility failed to provide adequate intervention to prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for skin impairment in the sample of 3. This failure resulted in the development of pressure wounds requiring hospitalization for debridement. Findings include: 1. The face sheet in R1's medical record indicates a [AGE] year old female admitted to the facility on [DATE] and discharged to the hospital on 5-4-12. The undated [DIAGNOSES REDACTED]. E4, (Treatment Nurse, Licensed Practical Nurse, LPN), stated R1 was admitted to the facility with a full leg brace for a fractured right femur. E4 noted the brace did not fit properly for it would slide down and have to be readjusted. E4 stated R1 was previously treated for [REDACTED]. E4 stated the morning of 4-24-12 she was asked to do a full body skin assessment on R1. During this assessment the following was noted and recorded on the Treatment Record: skin turgor fair, ulcers noted to right lateral ankle upper site 1 and lower site 2. Site 1 was 3.5cm x 5.3cm x ?, 80% eschar, 20% slough, site 2 was 1.0cm x 1.2cm x ?, 100% slough. Right upper posterior thigh 3cm x 4cm, with 80% slough, 10% granulation and 10% eschar. The right and left heels slightly red, stage I. Treatment begun to all areas. Skin dry and flaky, less than 1 plus [MEDICAL CONDITION] to feel and ankles. Well healed scar to abdomen. E7, (LPN), stated at 4:05PM on 6-4-12, Z2, (R1's daughter), removed R1's brace to apply a clean one around 9PM on 4-23-12 and found open areas on the right outer ankle. Z2 informed E7 of the areas, an assessment was completed by E7 with doctor notification, and treatment orders were obtained. The nursing note by E7 on 4-24-12 notes four pressure ulcers around the right ankle. The sizes noted by E7 were 2.2cm x .8cm, .6cm x .8cm, 1.2cm x .3cm, and 3cm x 4cm. The facility's care plan dated 3-5-12 indicates problem/need of risk for impaired skin integrity related to limited mobility/activity, incontinence, inadequate intakes, obesity and a problem with friction/shearing. The goal states will show healing to current pressure ulcers and have no further skin breakdown through next review. One approach noted was assess/record/report to MD as needed, skin condition, presence of any new areas. Document appearance, measurement, drainage, and stage of any areas. Notify MD and family of development of any new areas. An approach dated 4-24-12 states treatment to right upper posterior thigh as ordered and treatment to right lateral ankle. Heel protectors/float heels. Z#3 stated at 3:30 P.M.on 6/5/12 that he felt that there was a communication breakdown at the facility regarding removing the brace and periodically checking of the skin underneath. He felt if that had been done properly the developement of the pressure areas could have been avoidable. The failure of the facility to implement or coordinate an established frequency (other than weekly) for nursing to observe/assess the leg/foot for break down put R1 at risk developing pressure sores without facility awareness. No padding was applied inside the brace to relieve pressure points. A plan to float heels was not implemented until after the wounds were found on 4-24-12. This was confirmed with E1, (Administrator), at 4PM on 6-5-12.

Based on record review, interview and observation, the facility failed to recognize, identify, evaluate and manage pain for 4 residents (R3, R9, R12, R17) of 9 identified with pain issues from the sample of 23. The failure to provide ordered pain medication for R12 and R17 resulted in significant, untreated pain for an extended period of time. The findings are as follows: 1. Review of the treatment record for March 2011, indicated that R3 had developed an open area on her left lateral ankle which required treatment. An observation was made of the treatment on 5/11/2011 at 1:00 PM. E4, Licensed Practical Nurse, was observed providing the treatment to R3. Before E4 started the treatment, R3 stated "It will hurt, you are going to have to give me some pain medication. E4 proceeded to do the treatment with E3 stating "Ouch, that hurts" and "I have to put my whole hand in my mouth when she cleans it". R3 stated during a resident interview after the treatment observation that it hurts anytime that the treatment is done and other times during care if it gets bumped etc. R3's physician order [REDACTED]. 2. E5, certified nurse aide, was observed to provide passive range of motion for R9 on 5/12/2011 at 11:00 AM. R9 was observed to grimace frequently, as if in pain, during the procedure. E5 stated during the procedure that she can tell that R9 is in pain just from facial expressions. E5 did not stop the range of motion exercises and notify the nurse of residents' expressions of pain. Review of R9's MEDICATION ORDERS FOR [REDACTED]. 3. R12's admission record showed that R12 was admitted on [DATE], with a [DIAGNOSES REDACTED]. On 5-10-11 at 11:10 AM, R12 and R12's spouse-Z1, stated that there was a problem upon admission with R12 receiving her pain medications. R12 went 18 hours without pain medication, when finally Z1 realized that he had some of R12's pain medication at home. Z1 went home, retrieved the pain medication, and gave it to staff. Z1 stated that R12's roommate had the same problem with pain medication when she came in. On 5-12-11 at 9:50 AM, R12 stated that her pain level during the 18 hour wait was at a level 12. R12 did realize that the pain scale was 1-10. R12 stated that she was ready to give up on getting therapy and just go home. Z1 stated that the nurse just kept telling them that the pharmacy vehicle failed to bring R12's pain medication. R12's nurse notes identified that R12 was admitted on [DATE] at 2:20 PM. At 10:45 PM, nursing charted that pharmacy still did not send R12's medications. At 1:00 AM, 2:00 AM, and 3:30 AM, staff again chart that pharmacy had not delivered R12's medications. Staff failed to identify R12's level of pain, failed to identify nursing measure being done to help elevate pain until on 5-4-11 an unidentified time entry regarding giving R12 [MEDICATION NAME] until [MEDICATION NAME] was received per telephone order with no pain level identified. The previous note was at 5:45 AM, but unsigned, and the following note was at 2:30 PM. There was a blank space in the documentation, but no clinical monitoring of R12's pain, wound area, circulation, or vital signs between these two periods of time. 4. R17's admission record showed that R17 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 5-12-11 at 9:45 AM, R17 stated that she did have a problem with getting her pain medications when she first came in. The nurses kept telling R17 that they had just changed drug stores and they could not get it in. R17 was asked, What level of pain were you in during the first 24 hours with out medications? R17 responded, "A 10". R17 nurses notes showed that R17 was admitted on [DATE] at 9:00 AM. The nurses note identified that R17 was alert and oriented times 3, and had the [DIAGNOSES REDACTED]. The next note is has no time documented and dated 5-4-11, that identified staff gave [MEDICATION NAME] 5/325mg's for pain. The level of pain or location of pain was not identified. The next entry is 5-5-11, but again no time is given, and the entry only identified the giving of [MEDICATION NAME], and discontinuation of the [MEDICATION NAME] 5/325. The next entry in the nurses notes is not until 5-8-11. The record failed to identify R17's level of pain, or any other clinical condition being monitored by staff. Interview with Director of Nurses-E2 on 5-12-11 at 11:00 A.M. showed that she would expect staff to document newly admitted residents clinical condition every shift for the first 48 hours. E2 stated, that she does expect staff to chart residents level of pain. E2 reviewed the chart and was unable to determine when R12 first received pain medication. After interviewing E8, E2 stated that R17 received pain medication at 8:45 AM, and 12:45 PM on 5-4-11. E2 stated there was a glitch with the new pharmacy and that is why there was a problem with getting the needed medications. .