Every finding on record at Iroquois Resident Home, The

Based on observation, interview, and record review, the facility failed to maintain the dishwashing machine in a manner to sanitize the meal service dish and service wares. This failure effects all 32 residents residing in the facility. Findings include:On 8/11/26 at 9:23 AM, V11 Dietary Manager, stated the facility dishwashing machine utilized the chemical sanitizer chlorine.On 8/11/26 at 9:23 AM, V11 and V12, Dietary Aide, tested the chlorine level inside the dishwashing machine with a facility test strip. The test strip turned a faint gray color, and as compared to the scale on the test strip container, indicated a chlorine level of approximately 10 parts per million (PPM) of chlorine. V11 and V12 conducted a second and third test of the chlorine level inside the dishwashing machine and both of these tests resulted in a zero level of chlorine.On 8/11/26 at 9:28 AM, there was a one gallon jug of sodium hypochlorite (liquid chlorine) on the stainless steel table directly in front of the dishwashing machine entrance. From this jug, a white opaque tubing connected through a rotary pump into the dishwashing machine. The tubing was disconnected from the outlet of the pump so no chlorine could reach the machine and no chlorine was being drawn into the pump from the jug. Neither V11 nor V12 could state how long the tubing had been disconnected from the pump outlet.On 8/11/26 at 9:40 AM, V11 confirmed the dishwashing machine utilized chlorine to sanitize dishes and the chlorine level needed to be at least 50 ppm to effectively sanitize. V11 stated the dishwashing machine water would not get hot enough to sanitize dishes by high temperature, which would need to reach 160 degrees Fahrenheit.On 8/11/26 at 10:04 AM, V11 and V12 conducted a temperature check of the dishwashing machine which resulted in a 144 degrees Fahrenheit reading on the facility digital thermometer.The NSF (National Science Foundation) data plate label on the front of the dishwashing machine documented the chlorine level must be a minimum of 50 PPM to effect dish sanitizing. The dishwashing machine operations manual included a paper copy of the NSF data plate dated 6/15/1999 documenting the minimum sanitizer required is 50 PPM of free chlorine.The facility's Food Services Policy and Procedures (undated) documents the chemical sanitizer concentrations required to sanitize dish wares and has the chlorine level underlined with the level listed as 50 to 100 PPM for 10 seconds.On 8/11/26 at 10:07 AM, V11 stated the lack of sanitizer in the dishwashing machine has the potential to result in food borne illnesses for all of the residents in the facility.The facility's form 802 Matrix and Resident roster, both dated 8/11/26 document 32 residents reside in the facility, all of whom consume food served on dish wares washed by the facility dishwashing machine.

Based on observation, interview, and record review, the facility failed to administer medications as ordered for two of four residents (R16, R29) reviewed for medication administration in the sample list of 29. This failure resulted in three medication errors out of 30 opportunities, resulting in a 10% (percent) medication error rate.Findings include: 1. Omission of scheduled Florastor Oral Capsule for R16.R16 has a physician order for Florastor (probiotic) Oral Capsule 250 mg (milligrams) 1 capsule by mouth twice a day. No administration of this medication was observed during the medication pass with V8, LPN (Licensed Practical Nurse) on 8/12/26 at 7:53 AM. Upon medication pass reconciliation, the dose was confirmed as omitted.2. Omission of scheduled medications of Amlodipine Besylate (calcium channel blocker) and Lisinopril (ACE/angiotensin-converting enzyme inhibitor) for R29.R29 has a physician order for Amlodipine Besylate 10 mg 1 tablet every day and Lisinopril 10 mg 1 tablet every day. No administration of these medications was observed during the medication pass with V14, LPN on 8/12/26 at 8:19 AM. Upon medication pass reconciliation, the dose was confirmed as omitted. V14 stated at 2:30 PM Yes, you are right I did not give the medication.The facility's policy titled Administration of Medications revision date August 2022 documents under POLICY Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies.Section titled RESPONSIBILITY documents It is the responsibility of the Charge Nurse to ensure that all medications are passed within a timely manner.V2, DON (Director of Nurses) stated on 8/12/26 at 3:15 PM Looks like I need to do another in-service on administration of medication with all of my nurses.

Based on observation, interview and record review the facility failed to ensure medication labels were present and failed to date opened insulin injection pens for four of four residents (R5, R6, R28, R40) reviewed for medication storage in the sample list of 29. Findings include:On [DATE] at 11:21 AM V20, LPN (Licensed Practical Nurse) opened the medication carts top drawers. There were four Insulin Injection Pens not labeled with the date of being opened and one un-identified insulin pen with no name or date of opening on the pen.R5's Novolog Insulin Pen did not have an opening date on the pen.R6's Lispro Insulin Pen did not have an opening date on the pen.R28's Lantus Insulin Pen did not have an opening date on the penR40's Lantus SoloStar Insulin Pen did not have an opening date.One unknown Glargine Insulin Pen did not have a name or opening date on the pen.V20 stated on [DATE] at 11:45 AM Yes we are supposed to date the insulin pens the day we open the pen to use for the resident.The facility policy titled Handling of Expired Medication with the review date of [DATE] documents under the section titled Responsibility states 1. It is the responsibility of the nurse on duty to date insulin, 20 mg/ml (milligram per milliliter) liquid Morphine, eye drops, or ear drops upon opening.V2, DON (Director of Nurses) stated on [DATE] at 2:30 PM Yes the nurses are to date the insulin pens with the date they open them.

Based on observation, interview, and record review, the facility failed to ensure privacy during personal care for two of two (R2, R21) residents reviewed for privacy in the sample list of 29. Findings include:On 8/11/26 at 9:30 AM, during a facility tour, R2 and R21's entrance door was knocked on and opened. Upon entering the room, none of the privacy curtains were pulled to provide visual privacy for R21, who was receiving personal care and was exposed to R2. R21 was lying on R21's left side facing the wall while V17 and V18, Certified Nursing Assistants (CNAs), were cleaning R21's buttocks area. R2 was in R2's bed and had a clear view of the personal care being provided to R21.On 8/11/26 at 9:33 AM, V18 stated, We are providing personal care for R21 to get (R21) up for the day.V17 stated, There is no privacy curtain available to pull when you enter the room.On 8/11/26 at 9:36 AM, there were other privacy curtains present in the room; however, none were pulled to block visibility of R21 while receiving personal care.On 8/13/26 at 11:15 AM, R2 stated, I have seen R21's butt all the time. It doesn't bother me anymore because it happens every day. At this same time, R2 declined to respond.On 8/13/26 at 2:40 PM, V1, Administrator, stated, I understand we need to put up a privacy curtain in the room; this issue has been addressed before.

Based on observation, interview and record review, the facility failed to contact a physician for orders to treat a resident's signs and symptoms of an infection for one of 11 residents (R12) reviewed for infection control on the sample list of 29.Findings include:According to R12's medical record, R12's current diagnoses includes the following: Apnea Not Elsewhere Classified, Fatigue, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non- Dominant Side, Dissection Of Thoracic Aorta, Unspecified, Presence Of Prosthetic Heart Valve, Presence of Other Vascular Implants and Grafts, Neurologic Neglect Syndrome, and Dysphagia, Oropharyngeal Phase.On 8/11/2026 at 10:35 am R12 was lying in bed. R12 was actively coughing during the interview. R12 stated R12 has had 'a sore throat and a cough for four days.' R12 stated the nurses (unidentified) told R12 that they have called the doctor each day and told R12 that they are trying to get ahold of the doctor (later identified as V7, Physician), for orders. R12 stated the facility nurses cannot get orders for treatment because the doctor has never called back to give them. R12 stated (R12) would like a throat culture because (R12) is sure (R12) has strep (bacterial infection), and (R12) wants a chest X-ray because (R12) believes (R12) has pneumonia.R12's Progress Note dated 8/09/26 at 1:11 pm documents the following: Called (V7, Physician) and left message on voicemail regarding (R12) has sore throat and POA (Power of Attorney, unidentified) is also concerned about strep throat. Awaiting a call back.R12's Nurse's Progress Notes dated 8/11/26 at 11:39 AM documents R12's POA came to the facility and took R12 to Urgent Care for cold like symptoms.R12's Emergency Department Provider Assessment dated 8/11/26 documents the following: History of Present Illness:(R12's age) (R12's gender) with PMH (Past Medical History), CVA (Cerebral Vascular Accident), AAA (Abdominal Aortic Aneurysm) requiring cadaver aortic valve who presents with a sore throat associated with a cough productive of clear mucus and congestion x 4 days (for four days). Sore throat is described as scratchy.R12's same Emergency Department Provider Assessment dated 8/11/26 documents the following: Medical Decision Making:Medications given in ED: Levaquin (Broad Spectrum Fluoroquinolone Antibiotic), diagnoses Acute Sinusitis.'On 8/11/26 at 12:15 pm V8. Licensed Practical Nurse stated Over the weekend (8/08/26 and 8/09/26), I heard that staff (unidentified) were trying to get ahold of (V7, Physician). He is out of town until Wednesday (8/12/26). I don't work on that hall, so I am not sure which resident it was about. Since (V7, Physician) is not available we can call (V6, Medical Director/Physician).On 8/11/26 at 12:20 pm V9, Licensed Practical Nurse (LPN) stated I am agency (staff). I did hear in report that (V7, Physician) needed to be contacted about (R12). (R12) is mine (V9, LPN is caring for R12) today, but I don't know what they needed from (V7, Physician), for (R12). I just figured that the facility nurses would take care of whatever it was.On 8/11/26 at 12:55 pm V2, Director of Nursing (DON) stated V2, DON was just informed by the floor nurses that (V7, Physician) was out of town until Wednesday, and the staff nurses were trying to reach (V7) over the weekend (August 8, 2026, and August 9, 2026), regarding (R12) and (R12's) sore throat. (V2) read the note from August 09, 2026. V2 also stated Our Medical Director (V6, Physician/Medical Director) should have been called in (V7's) absence. Usually, the doctors let us know if they are going to be gone. (V7) did not do that, this time. (V6, MD) should have been called. (V6) would have been covering (for V7). V2 also said Given all the information I have now with (R12's) cough and sore throat, this would be considered a delay in treatment.

Based on observations, interview and record review the facility failed to provide adaptive eating utensils for one of one resident (R40) reviewed for dining services in the sample list of 29.Findings include:R40's admission Diagnoses Sheet dated 7/29/26 documents the following: Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Dominant Side, Dysphagia Following Cerebral Infarctions, Muscle Weakness, Other Malaise, Carpal Tunnel Syndrome, and Chronic Pain Syndrome.R40's Minimum Data Set (MDS) dated [DATE] documents R40's Brief Interview for Mental status score of 14 out of a possible 15, indicating R40 has no cognitive impairment.R40's current Care Plan documents the following: PT/OT (Physical Therapy/Occupational/Therapy) evaluation and treatment as per MD (Medical Doctor) orders. Date Initiated: 08/05/2026. Nursing Rehab/Restorative: Eating- Provide residents labeled built-up silverware during meals to promote independence with self-feeding. Encourage residents to utilize adaptive silverware during meals and provide assistance as needed. Monitor effectiveness of adaptive utensils and communicate concerns to therapy and the interdisciplinary team. Ensure resident's labeled built-up silverware remains with the resident and is not sent to the kitchen; hand wash after use and return to the designated storage location.R40's Occupational Therapy Treatment Encounter Note dated 8/10/26 documents the following: Trialed built up silverware with simulated fork and spoon use. (R40's) notes ease of use of utensils using built ups. (R40) will attempt utilizing built up utensils for further meals.On 08/11/2026 from 11:40 am -to 12:05 pm during the dining room observation task, all residents (unidentified), were eating lunch out of disposable foam containers and using plastic utensils, due to dishwasher issues in the main kitchen.On 8/12/26 between 10:00 am and 11:05 during Resident Council Group Meeting, R40 stated R40 had to eat R40's lunch on 8/11/26 from a disposable foam plate and use plastic utensils. R40 also stated (R40) has built up (foam like modified handles), real silverware (metal) for a reason. (R40) can't use plastic and feed myself. It makes me feel awful trying to use it. It makes me sick. I don't like it.On 8/13/26 at 11:10 am V2, Director of Nursing (DON) stated R40 is to have built-up silverware provided at every meal. The silverware allows R40 to eat on R40's own. V2 stated R40's built up silverware is to be hand washed and returned to the kitchenette here on the unit. It should be available for every meal.On 8/13/26 at 11:55 am R40 was seated in the dining room eating a piece of meatloaf, corn and scalloped potatoes. R40 said R40 did not get built up silverware again today.On 8/13/26 12:00 pm V2, DON confirmed by observation that R40 does not have R40's built up silverware again today. V2 stated They (specialty built up silverware) should be served every meal to ensure they are available if (R40) needs them.On 8/13/26 at 12:25 pm R40 said R40 would appreciate the special built-up silverware be served with R40's meals because several food items are difficult for R40 to manage without them.

Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe ambient temperature for six (R1, R2,R3 R4, R7 and R8) of eight residents reviewed for physical environment.Findings include:According to the weather forecast for Watseka, Illinois, on July 3, 2026, the forecasted high temperature was 91 degrees Fahrenheit, with a low of 76 degrees Fahrenheit. The heat index was forecast to reach 99 degrees Fahrenheit, with relative humidity as high as 94 percent. An Extreme Heat Warning was in effect.On 7/3/2026 at 8:20 a.m., V3, Facilities Maintenance Director stated the facility's central air conditioning system had been inoperable for approximately one week due to a failed compressor. V3 stated the replacement compressor had arrived and installation was pending. V3 stated that although each resident room had an individual heating and cooling unit, the units were unable to adequately cool resident rooms because the hallways and common areas were not air conditioned while the central system was inoperable.On 7/3/2026 at 8:56 a.m., R1 was observed lying in bed with two fans directed toward her. The temperature in R1's room measured 84.5 degrees Fahrenheit (F). R1 stated that the room was too warm and that she had been lying in bed because she was uncomfortable.R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has an active diagnosis of Hypertension, Anxiety, and Dementia.On 7/3/26 at 9:02 a.m., V4, Registered Nurse (RN), stated that both staff and residents had been complaining about elevated indoor temperatures over the past week and that recent outdoor heat had worsened the facility's ongoing temperature regulation issueOn 7/3/26 at 9:11 a.m., R2 was observed in bed wearing supplemental oxygen via nasal cannula, with a fan directed toward R2. The thermostat in R2's room read 79 degrees F and was verified using a handheld thermometer. R2 stated that her room was among the cooler rooms in the facility. R2 also stated that, due to humidity and a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), she required supplemental oxygen the previous day due to shortness of breath.R2's MDS dated [DATE] documents R2 has an active diagnosis of COPD, Obstructive Sleep Apnea, Atrial Fibrillation, Essential Hypertension, and Congestive Heart Failure (CHF).On 7/3/26 at 9:39 a.m., V5, Certified Nurse Assistant (CNA), stated the building was hot and that one of the resident rooms measured 84 degrees F the previous day. V5 stated R2 had shortness of breath due to humidity after attending bingo at approximately 1:00 p.m. the previous day and required daytime supplemental oxygen in addition to routine nighttime use. V5 stated R4 was newly admitted and expressed discomfort due to heat and that management responded by providing fans.On 7/3/26 at 9:46 a.m., R4 was observed in bed with the head of the bed elevated, wearing a hospital gown. The thermostat in R4's room measured 82 degrees F. R4 stated, It's darn hot. R4 stated the heat made it difficult to get comfortable and affected her appetite. R4 stated R4 offered to purchase R4's own air conditioner.On 7/3/26 at 9:50 a.m., R7 was observed seated in R7's wheelchair in the hallway wearing a T-shirt and shorts. R7's face appeared flushed with sweat noted on the forehead, and R7 appeared uncomfortable. R7 stated that the heat worsened symptoms related to right-sided weakness.On 7/3/2026 at 10:04 a.m., R3 stated that without the fan, R3's room would reach 90 degrees F. The temperature in R3's room measured 80.4 degrees F. R3 stated R3 has increased difficulty breathing due to the heat, requiring more frequent use of oxygen for R3's COPD over the past month, and stated R3 went to the dining area the previous evening to sit near a large fan and drink water because of the heat.R3's MDS dated [DATE] documents that R3 has an active diagnosis of COPD, Essential Hypertension, and Anxiety.On 7/3/26 at 10:10 a.m., V8, Housekeeper/CNA Trainee, stated the facility had been warm for several days and that staff were providing fans, fresh water, and other comfort measures to help residents cope with the increased indoor temperatures.On 7/3/26 at 10:27 a.m., V9, Social Services Director stated the facility had been warm throughout the week. V9 stated maintenance was investigating the issue, fans were being provided to residents as needed, and several residents had complained their rooms were warm.On 7/3/26 at 10:33 a.m., V3, the Facilities Maintenance Director, stated that the hospital was aware of the air conditioning failure. V3 stated that, despite maintenance staff's efforts to address the issue, there did not appear to be a sense of urgency within the hospital management to complete the necessary repairs.On 7/3/26 at 10:36 a.m., V9, Physical Therapy Assistant (PTA) stated the building had been hot, while the hospital side remained cooler due to a separate air conditioning system. V9 stated V9 has been encouraging hydration, using fans during therapy, and conducting some therapy sessions on the hospital side. V9 also stated that one resident with chronic breathing difficulties received therapy on the hospital side because of the cooler environment.On 7/3/26 at 11:18 a.m., V1, Administrator stated compressor repairs were delayed due to replacement parts and contractor installation. V1 acknowledged the facility had been warm and stated that portable air conditioning units were rented to address resident comfort during the ongoing system outage.On 7/3/26 at 11:19 a.m., V11, CNA stated the building was hot and that residents were gathering in the dining room near a large fan to remain comfortable.On 7/3/26 at 12:31 p.m., R8 was observed seated on the side of the bed with a fan directed toward R8. R8 stated the facility was kind of warm and reported poor sleep due to difficulty getting comfortable from elevated temperatures. R8 stated management had not provided clear communication regarding the cause of the excessive heat. The thermostat in R8's room read 81 degrees and confirmed with a handheld thermometer.A Grievance Report dated 6/24/26 documents a complaint indicating that a resident's air conditioning was not functioning properly, resulting in the room becoming uncomfortably hot.A Grievance Report dated 7/2/26 documents that multiple residents voiced concerns regarding the temperature within the facility, reporting that the building was too warm.V3 provided documentation of temperature logs covering the period from 6/21/26 through 7/2/26. The records reflected indoor temperatures ranging from 73 degrees F to 86 degrees F. On 7/3/26, ambient temperatures were recorded throughout the facility as follows:Employee Lounge at 8:00 a.m.: 83.3 degrees F; and at 9:35 a.m.: 84.4 degrees F.Hall 3 at 9:50 a.m.: 82.0 degrees F; 81.3 degrees F in the middle of the hall; 84.0 degrees F at the end of the hall.Therapy Department at 9:58 a.m.: 83.1 degrees F.Hall 2 at 10:00 a.m.: 81.1 degrees F near the end of the hall; 79.8 degrees F in the middle; 79.1 degrees F near the front.Nurses' Station at 10:10 a.m.: 79.1 degrees F.The facility's Hot Weather-Related Emergencies Policy, dated August 2022 and reviewed March 2024, states that its purpose is to provide facility staff with guidelines for an appropriate response during periods of extreme summer weather.The policy outlines the following procedures for extreme weather events:Identify residents who are at high risk for heat stroke or heat exhaustion, including:Residents with circulatory or respiratory disorders.Frail elderly residents.Residents receiving certain medications, including diuretics, antihypertensives, sedatives, hypnotics, and anticholinergic medications (such as antihistamines).Closely monitor high-risk residents during periods of extreme temperatures.Immediately notify the physician upon identifying any adverse health effects.Monitor for signs and symptoms of heat stroke and heat exhaustion.Increase resident comfort by implementing the following measures:Monitor indoor air temperatures and compare them with temperature and humidity reports provided by local weather forecasts.Measure indoor temperatures every two hours between 8:00 a.m. and 10:00 p.m. whenever the outdoor temperature is 90 degrees Fahrenheit or higher.Relocate ambulatory or semi-ambulatory residents to the coolest area of the building when appropriate. The resident's physical condition should be evaluated to ensure that relocation would not be more harmful than providing supportive care in the resident's room.Increase fluid intake and ensure that water and other fluids are readily accessible to residents who are confined to bed.Dress residents in, or encourage them to wear, loose-fitting, lightweight clothing.Monitor resident activities and reduce or eliminate strenuous scheduled activities.Increase ventilation by using fans and opening windows. Close blinds and shades on windows exposed to direct sunlight. Turn off unnecessary heat-producing equipment. If outside air increases the indoor temperature, windows should be closed.Do not allow residents to sit or lie in direct sunlight.If the facility is unable to effectively cool the building, a hot weather-related emergency will be declared. The Administrator will notify the Illinois Department of Public Health, and the facility's Emergency Evacuation Plan will be implemented.Refer to Section 300, Table D, of the Illinois Administrative Code regarding relative humidity and temperature requirements. Resident rooms are to be maintained at or below 85 degrees Fahrenheit.

Based on observation, interview and record review the facility failed to employ an Infection Preventionist. This failure has the potential to affect all 27 residents residing in facility. Findings include: The facility Daily Midnight Census dated 6/24/24 documents 27 residents residing in the facility. Observations were made during Annual Licensure and Certification survey from 6/24/24/-6/26/26 with no Infection Preventionist onsite. On 6/25/24 at 12:45 PM V2 Director of Nurses (DON) stated the facility does not currently have an Infection Preventionist (IP). V2 DON stated the previous IP left the facility a month ago. V2 stated V2 is planning on signing up for the IP class but has not yet. On 6/26/24 at 9:05 AM V1 Administrator confirmed the facility does not currently have an Infection Preventionist. V1 Administrator stated I know we (facility) are small but having an IP would be a great benefit. We (facility) do have residents who are prescribed antibiotics, who are on contact isolation and staff who need education and monitoring for proper Personal Protective Equipment (PPE). The 'Facility Assessment' revised January 2024 documents the facility will include an Infection Preventionist (IP) as a staff member to provide support and care for residents.

Based on observation, interview, and record review the facility failed to assess, treat, and notify the physician of newly acquired pressure ulcers and apply a physician ordered treatment for one of one (R23) resident reviewed for pressure ulcers on the sample list of 18. Findings include: On 6/24/24 at 1:25 PM, R23 was sitting in a recliner in his room. R23 stated he was having terrible pain to his bottom. R23 stated, It's sore! On 6/26/24 at 10:00 AM, V8 Certified Nurse's Assistant stated that she worked on Sunday (6/23/24) and noticed that R23 had open areas to his buttocks and coccyx. V8 stated she notified V10 Licensed Practical Nurse about the open areas. V8 stated she worked Sunday (6/23/24), yesterday (6/25/24), and today (6/26/24) and has not seen a treatment on R23's buttocks or coccyx. On 6/26/24 at 10:10 AM, a dime sized pressure ulcer was present to the left of R23's coccyx, an eraser head sized pressure ulcer was present to the right of R23's coccyx, and a thick, red, raised area of skin containing scattered open areas was present on R23's left buttock along the entire length of the intergluteal cleft. At this time, a treatment was not in place to the coccyx or buttocks. V2 (Director of Nursing) then walked in and assessed the areas and confirmed that R23's buttocks had multiple stage two pressure areas with maceration to the left buttock. R23's medical record did not contain an assessment with measurements or a description of the wounds to R23's buttocks, or that the physician was notified. There is no documentation that a treatment was ordered for the pressure areas that were present to the right and left of the coccyx. R23's Treatment Administration Record form documents an order dated 6/6/24 for an absorbent wound dressing to the left buttock and to change it every three days for Moisture Associated Skin Damage (MASD). This sheet does not document an order or that a treatment was applied to the pressure areas to the right and left of R23's coccyx. On 6/26/24 at 11:20 AM, V2 stated an assessment of R23's wounds should have been documented in R23's medical record. V2 stated on 6/23/24, V10 should have assessed the areas to R23's coccyx and notified the physician after V8 told her about the areas. V2 stated there is a treatment order for the MASD but not for the pressure ulcer to the left and right of R23's coccyx. V2 stated an absorbent wound dressing should have been present to the MASD on R23's buttocks.

Based on interview and record review the facility failed to implement fall prevention interventions, complete thorough fall investigations to determine root causes and failed to complete Neurological Assessments post falls for two (R2, R25) residents out of two residents reviewed for accidents in a sample list of 18 residents. Findings include: 1.) R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. R2's Care Plan intervention dated 3/22/24 instructs staff to anticipate and meet the needs of the resident. This same care plan documents R2 should be offered toileting every two hours and as needed. R2's Fall investigation dated 5/31/24 at 6:10 AM documents R2 had an unwitnessed fall from his wheelchair while sitting in his room. This same report documents R2 was observed laying on his Right side with his wheelchair sitting next to him. This same report documents sensor alarms were to be initiated for R2's recliner and wheelchair. This same report does not include the last time staff observed R2. R2's Electronic Medical Record (EMR) documents the last time R2 was toileted or assisted with bed mobility was 5:59 AM 5/30/24. R2's Fall Investigation dated 5/31/24 at 6:40 AM documents R2 was sitting at the nurses station when he leaned forward causing himself to fall out of his wheelchair. This same report documents R2 hit his head due to falling out of wheelchair. This same fall report documents R2's sensor alarm in his wheelchair was not in place. R2's Fall Investigations dated 5/31/24 at 6:10 AM and 5/31/24 at 6:40 AM do not include a root cause of falls. R2's Electronic Medical Record (EMR) documents Neurological Assessments were initiated but not completed for R2's 5/31/24 fall at 6:31 AM nor R2's fall on 5/31/24 at 6:59 AM. R2's Nurse Progress Note dated: -5/31/2024 at 6:31 AM documents (R2) observed on the floor on his Right side and wheelchair nearby (R2). -5/31/2024 at 6:59 AM documents (R2) went forward out of wheelchair. (R2) landed on Left side, hit head. (R2) was sent to emergency room (ER). -5/31/24 at 12:11 PM documents (R2) returned from emergency room . No fractures. (R2) has skin tear on top of Right hand from fall. Area is 2 1/2 inches long by 3 1/2 inches wide. Area cleansed and steri stripped. Band aid covering. On 6/26/24 at 11:20 AM V1 Administrator stated R2's two falls on 5/31/24 could have been prevented with closer supervision and implementing fall care plan interventions. V1 Administrator stated We (facility) have a lot of work to do with our fall program. We are going to start with inservicing. On 6/26/24 at 1:15 PM V2 Director of Nurses (DON) stated anytime a resident has an unwitnessed fall the staff should assume there is a possibility of the resident hitting their head and complete Neurological Assessments for three days. V2 DON stated I don't think that is in our fall policy but that is what the standard of care is and that is what our nurses should do. I obviously have some fall training to do with our staff. 2.) R25's undated Face Sheet documents R25's medical diagnoses of history of Right Radius fracture, Cerebral Infarction, Cardiomyopathy and Dementia R25's Minimum Data Set (MDS) dated [DATE] documents R25 as severely cognitively impaired. This same MDS documents R25 is dependent on staff for bathing, dressing, personal hygiene, bed mobility and transfers. R25's Care Plan intervention dated 5/22/24 documents R25 is to use a scoop mattress. This same care plan documents a fall intervention dated 4/16/24 instructing staff to anticipate R25's needs. R25's Fall Risk assessment dated [DATE] documents R25 as a high risk for falling. R25's Fall Investigations dated 6/21/24 at 5:40 AM and 6/21/24 at 11:10 PM do not include a root cause of falls. R2's Nurse Progress Note dated: -6/21/24 at 5:40 AM documents (R25) found on floor. Assisted (R25) with lift (total body mechanical lift) back in bed. Ensure bed in low position and call light in reach. -6/21/2024 at 11:10 PM documents (R25) was found on the floor face down on Left side of bed. Slight scrape on Right knee slightly pink in color. Left knee also pink. Lower Left Rib area pink. (R25) apparently flipped self out of bed. R25's Fall Investigation dated 6/21/24 at 5:40 AM documents R25 had an unwitnessed fall while trying to get out of bed. This same report documents R25 did not have any injuries due to unwitnessed fall. This same fall investigation does not document R25 was laying on a scoop mattress. R25's Fall Investigation dated 6/21/24 at 11:10 PM documents R25 had an unwitnessed fall in his room trying to get out of bed. This same investigation does not document the last time R25 was observed/assisted. R25's Electronic Medical Record (EMR) does not document any Neurological Assessments completed for R25's 6/21/24 at 5:40 AM fall. This same EMR documents incomplete Neurological Assessments for R25's 6/21/24 11:10 PM fall. This same EMR documents the last time R25 had been observed prior to his 6/21/24 at 5:40 AM fall was 10:00 PM on 6/20/24 and the last time R25 had been observed prior to his 6/21/24 at 11:10 PM fall was 8:03 PM. On 6/26/24 at 11:20 AM V1, Administrator stated R25 fell in his room twice the same day on 6/21/24. V1 stated That is on us. We (facility) should have seen that one coming since (R25) is cognitively impaired and he did not have his fall interventions in place. V1 stated the facility does not really know what happened because the fall investigation was not thorough and there are no root causes determined. V1 Administrator stated when a resident falls and hits their head that resident should be assessed Neurologically for three days total. V1 stated if a resident falls while on Neurological Assessments, then the Neuro's start all over again. V1 Administrator stated We (facility) have a lot of work to do with our fall program. We are going to start with inservicing. On 6/26/24 at 1:15 PM V2 Director of Nurses (DON) stated anytime a resident has an unwitnessed fall the staff should assume there is a possibility of the resident hitting their head and complete Neurological Assessments for three days. V2 DON stated I don't think that is in our fall policy but that is what the standard of care is and that is what our nurses should do. I obviously have some fall training to do with our staff. The facility policy titled 'Fall Prevention Program' reviewed March 2024 documents the facility will identify and implement related care link interventions. The facility will review and discuss potential root cause of fall. The facility policy titled 'Head Injury' reviewed March 2024 documents the facility will complete Neurological Assessments on all residents who have suffered from a head injury.

Based on observation, interview, and record review the facility failed to position urinary drainage bags in a manner that prevented potential cross contamination for two of two residents (R23, R230) reviewed for catheters on the sample list of 18. Findings include: The facility's Catheter Care Handling policy with a revision date of August of 2022 documents to ensure catheter tubing and drainage bags are kept up off of the floor. 1. On 6/24/24 at 1:25 PM, R23's urinary drainage bag was clipped to the side of a trash can. This drainage bag was not covered and the bottom of the bag was sitting directly on the floor. On 6/26/24 at 11:16 AM, V2 Director of Nursing (DON) stated all urinary drainage bags should be covered and not touching the floor. 2. On 6/24/24 at 2:02 PM, R230 was sitting in a recliner. R230's urinary drainage bag was hooked to the side of the recliner. The urinary drainage bag was not covered and the bottom of the bag was touching the floor. On 6/26/24 at 11:16 AM, V2 DON stated that urinary drainage bags should be below the bladder but not touching the floor.

Based on observation, interview and record review the facility failed to assess one (R2) resident for the use of side rails out of one resident reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Electronic Medical Record (EMR) does not document a side rail assessment for R2. On 6/25/24 at 2:00 PM R2 was laying in his bed with both siderails in the up position. On 6/26/24 at 10:35 AM V5 Minimum Data Set (MDS) Coordinator stated R2 has never been assessed for siderails. V5 stated (R2) should not have those side rails on his bed. We (facility) are taking them off. The facility policy titled 'Side Rails' revised March 2024 documents all residents who utilize side rails will have a side rail rationale screening completed.

Based on interview and record review the facility failed to obtain psychotropic medication consents, assess the need for psychotropic medications, determine symptoms or behaviors warranting use, utilize nonpharmacological interventions, monitor for adverse reactions, establish a psychotropic care plan, and establish parameters for the use of an as needed antianxiety medication for three (R230, 231, 232) of three residents reviewed for psychotropic medications on the sample list of 18. Findings include: The facility's Psychotropic Medication Protocol policy dated 8/31/2022 documents psychotropic/psychoactive medications will not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representatives, and will be provided with and have signed an Informed Consent for Psychotropic Medications. Information will also be provided with given information regarding the need for, the desired effects and the potential side effects of the medication. Residents will not be given unnecessary medications and shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician order. The care plan will include alternatives interventions. 1.) R231's physician order summary (POS) dated 6/26/24 documents that R231 was admitted to facility on 6/17/24 from the hospital on hospice care. This POS includes an order for Lorazepam (antianxiety medication) two milligrams per milliliter (ml), give 0.25 ml sublingual every two hours as needed for anxiety. This POS also includes an order for Chlorpromazine Hydrochloride (antipsychotic medication) 0.25 ml by mouth every one hour as needed for restlessness. This POS does not document parameters for the use of the as needed Lorazepam. On 6/26/24 at 9:50 AM, R231 stated she takes a lot of medications but doesn't know what they are and what they are for because no one has talked to her about her medications. R231 stated she was unaware that there are medications available to her if she has pain, feels anxious, and/or is short of breath. R231 stated she doesn't really have any pain but she does feel anxious sometimes and also short of breath which increases her anxiety. On 6/26/24 at 10:15 AM, V2 Director of Nursing stated R231 is alert and oriented and can make needs known. V2 stated that she is aware that R231 is on psychotropic medications but that either hospice or V5 Care Plan Coordinator does the psychotropic assessments and consents. On 6/26/24 at 10:20 AM, V5 stated that she does not complete the psychotropic assessments and that nursing and social services touch on that and that any assessments and consents would be uploaded into the miscellaneous files on R231's chart. On 6/26/24 at 10:50 AM, V6 Social Service Coordinator stated the only assessments she completes with the residents is the new admission packet which does not include any consents for psychotropic medications. R231's medical record did not contain an assessment for the use of the Lorazepam or the Chlorpromazine Hydrochloride. The medical record did not identify what symptoms R231 was experiencing for the use of the Lorazepam or Chlorpromazine. This medical record did not contain what nonpharmacological interventions should be attempted. R231's Care Plan Record dated 6/26/24 does not include a care plan for psychotropic medications. 35046 2.) R230's medical record documents R230 was admitted on [DATE]. R230's physician order dated 6/21/24 documents an order for Citalopram Hydrobromide Tablet 40 milligrams once a day and Trazodone hydrochloride 50 milligrams at bedtime for depression. R230's medical record does not contain a consent for the Citalopram Hydrobromide or the Trazodone. R230's medical record does not contain what symptoms of Depression R230 has or nonpharmacological interventions for R230's symptoms of Depression. R230's medical record does not document that potential side effects of the Citalopram Hydrobromide or Trazodone Hydrochloride are monitored. On 6/26/24 at 11:01 AM, V2 Director of Nursing stated that R230's medical record does not contain consent for his antidepressant medications. V2 stated antidepressants should not be given without a consent. V2 stated there is no documentation that potential side effects of the medication was monitored. V2 stated there is not an assessment documented for the use of R230's antidepressant medications. V2 stated there is no documentation of behaviors/symptom monitoring or the nonpharmacological interventions that could be used for R230. 3.) R232's physician order dated 6/21/24 documents an order for Xanax Oral Tablet 0.5 milligrams as needed every night for anxiety. R232's medical record does not contain an assessment for the use of the Xanax. R232's medical record does not document the symptoms of R232's anxiety or which nonpharmacological interventions should be attempted for R232's anxiety. On 6/26/24 at 11:23 AM, V2 Director of Nursing stated Xanax was ordered on 6/21/24 for R232's anxiety. V2 stated an assessment was not completed for the use of the Xanax. V2 stated R232's medical record does not document the symptoms of R232's anxiety or the nonpharmacological interventions that should be used for R232's symptoms of anxiety. V2 stated there is no monitoring for potential side effects in R232's medical record.

Based on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents (R23, R25, R230) out of four residents reviewed for Infection Control in a sample list of 18 residents. Findings include: 1. R25's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 4/17/24 for Jevity 1.5 calorie/Fiber liquid. Give 355 milliliters (ml) via Gastrostomy tube (G-Tube) every shift for nutritional supplement. Flush with 50 milliliter (ml) water before and after each feeding. On 6/24/24 at 10:30 AM R25's Electronic Medical Record (EMR) documents R25 has a Gastrostomy tube (G-tube) in use. R25's room was not identified with an Enhanced Barrier Precaution sign. There was no Personal Protective Equipment (PPE) available to enter R25's room. No isolation disposal bins were located in or near R25's room. On 6/25/24 at 2:45 PM V9 Licensed Practical Nurse (LPN) completed R25's Gastrostomy tube (G-tube) dressing change. V9 LPN did not wear Personal Protective Equipment (PPE) gown during R25's G-tube dressing change. 2.) R230's Electronic Medical Record (EMR) documents R230 has a urinary catheter drainage system. On 6/24/24 at 10:40 AM R230's room was not identified with an Enhanced Barrier Precaution (EBP) sign. There was no Personal Protective Equipment (PPE) available to enter R230's room. No isolation disposal bins were located in or near R230's room. 3.) R23's Electronic Medical Record (EMR) documents R23 has a urinary catheter drainage system. On 6/24/24 at 11:00 AM R23's room was not identified with an Enhanced Barrier Precaution (EBP) sign. There were no Personal Protective Equipment (PPE) available to enter R23's room. No isolation disposal bins were located in or near R23's room. On 6/25/24 at 1:00 PM V2 Director of Nurses (DON) stated the facility has not implemented Enhanced Barrier Precautions (EBP). V2 DON stated R23 and R230 have urinary catheter drainage system and R25 has a Gastrostomy tube (G-tube) that would all require EBP. V2 DON stated if EBP were to be implemented for all residents with a history of Multi Drug Resistant Organism (MDRO) 'all of the residents would need to be placed on EBP.' V2 DON stated the facility does not have a policy for EBP.

Based on interview and record review the facility failed to follow their Antibiotic Stewardship Protocol by administering a prophylactic antibiotic for one of four residents (R10) reviewed for Infection Control in a sample list of 18 residents. Findings include: R10's undated Face Sheet documents R10's medical diagnoses as: Alzheimer's Disease, Dementia and a personal history of Urinary Tract Infections (UTI). R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. R10's Physician Order Sheet (POS) dated June 2024 document a physician order starting 12/24/23 for Cephalexin 250 milligrams (mg) daily for recurrent Urinary Tract Infections (UTI). R10's Medication Administration Record (MAR) dated June 2024 documents R10 was administered Cephalexin 250 mg daily for the month of June, 2024. The facility antibiotic tracking log dated January-June 2024 documents R10 was on Cephalexin 250 mg daily prophylactically for a history of UTI's. On 6/25/24 at 1:30 PM V2 Director of Nurses (DON) stated R10 has been on an antibiotic for a history of frequent Urinary Tract Infections (UTI). V2 DON stated Normally the Infection Preventionist (IP) would catch that and make sure the documentation is complete but we (facility) don't have an IP so that got missed. V2's Family insisted that we (facility) put (R10) on the antibiotic long term. I don't think it has helped though because (R10) had a UTI a few months ago when she was already on the prophylactic antibiotic. The facility policy dated November 28, 2017 titled 'Antibiotic Stewardship Program' documents review of laboratory reports for susceptibility and the need to change the current antibiotic will be used. Antibiotic stewardship requires the right antibiotic for the right indication at the right dose and the right duration.

Based on observation, interview and record review the facility failed to ensure bed rails were safely attached to a bed for one of one resident (R2) reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 3/15/24 for bed rails for bed mobility and positioning. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. On 6/24/24 at 9:35 AM R2 was laying in bed with both legs hanging off of mattress from knees to feet. R2's quarter bed rail on the same side of bed was hanging at a 45 degree angle. On 6/24/24 at 9:36 AM V4 Certified Nurse Aide (CNA) and V3 Licensed Practical Nurse (LPN) both confirmed R2's bed rail was not in place. V4 CNA stated This siderail wiggles back and forth and is not safe for (R2). V3 LPN stated That should have been on a maintenance order and been fixed by now. On 6/26/24 at 10:35 AM V5 Minimum Data Set (MDS) Coordinator stated R2's siderails could be a trip hazard for him causing him to fall. On 6/26/24 at 11:10 AM V7 Maintenance Director stated R2's side rails were not safe for R2 and should be removed.

Based on interview and record review, the facility failed to timely report an allegation of sexual abuse to the Administrator for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. On 4/17/24 at 11:09 am, V1 (Administrator) stated on 4/10/24, V8 CNA (Certified Nursing Assistant) came up to V1 and asked V1 if V1 was aware of what happened on 4/9/24 between R1 and R2. V1 explained V1 was unaware of anything happening, then V8 reported that V8 had been told that R2 kissed R1. V1 stated V8 did not know any of the specifics though and told V1 to talk to V4 CNA(Certified Nursing Assistant), who was present when it occurred. V1 then questioned V4 and V4 reported that V4 was taking R1 to the restroom on 4/9/24 before lunch, around 11:15 am, when R2 approached R1 and kissed R1 and stated, I'm here now or I'm back, something to that affect. V1 explained R1 was in a wheelchair at that time and that V4 intervened and told R2 that R2 couldn't do that, that it was inappropriate. V1 stated V1 educated V4 that V4 should have reported it immediately to V1 because it is reportable and I (V1) am on a timeline to get things reported. V1 explained that V4 has worked at the facility for a long time, so (V4) should have already known that this would be considered a sexual abuse allegation and should have been reported. V4 reported to V1 that V4 reported the allegation to V10 RN (Registered Nurse) when it happened but when V1 spoke to V10, V10 said that the allegation was never reported to V10. On 4/17/24 at 12:02 pm, V4 CNA stated V4 was taking R1 to the restroom by the Nurses Station when R2 came up behind us and said I'm going to be here and bent over and kissed R2 on the lips. V4 explained V4 told R2 that R2's actions were inappropriate and that R2 couldn't be doing that {kissing R1}. V4 stated V4 reported the incident to V10 RN (Regitered Nurse), because V4 was busy and assumed that V10 would have reported the incident to V1 but V10 didn't. V4 explained, the following day, V1 asked V4 about the incident after being told about it by another CNA. On 4/17/24 at 7:49 pm, V10 RN (Registered Nurse) stated V4 did not report the incident of R2 kissing R1 to V10 explaining, if V4 would have, V10 would have immediately reported the incident to V1. The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated 1/4/24 documents any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will then report abuse to the state agency per State and Federal requirements. Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. The Investigation only contained witness statements from R1, R2, V4 CNA (Certified Nursing Assistant), V3 Secretary, and V10 RN (Registered Nurse). No other residents were interviewed. On 4/17/24 at 11:09 am, V1 Administrator stated the only residents that were interviewed were R1 and R2, the two residents involved in the allegation. V1 stated no other residents were around but now understands that other residents should have been interviewed to see if they have ever had concerns with R2 or if they had ever witnessed R2 displaying inappropriate behaviors. On 4/17/24 at 12:02 pm, V4 CNA(Certified Nursing Assistant) stated V4 was taking R1 to the restroom by the Nurses Station/Dining Room when R2 came up behind us and said I'm going to be here and bent over and kissed R2 on the lips. V4 stated there were several people; staff and residents, in the general location as the incident occurred right before lunch, around 11:15 am. The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated 1/4/24 documents the facility will have written procedures for investigating abuse, neglect, misappropriation, and exploitation that include: identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations to provide a complete and thorough documentation of the investigation.

Based on interview and record review, the facility failed to ensure a resident (R1) was not subjected to verbal abuse by an employee. R1 is one of three residents reviewed for abuse on the sample list of five. Findings include: On 10/7/23 at 11:24am V3 Certified Nursing Assistant (CNA) said, on 9/20/23 at 2:00pm V4 Certified Nursing Assistant (CNA) was preparing R1 for a shower in R1's room. V3 said, V3 heard V4 tell R1 that if R1 doesn't stop yelling, V4 will drown R1 in the shower. V3 said, V4 gave R1 a shower, and brought R1 back to R1's room. V3 said, V3 than heard V4 tell R1 to shut the (expletive) up, because R1 was yelling out. V3 said, V3 immediately went and told V2 Director of Nursing (DON). On 10/7/23 at 1:15pm V1 Administrator said, on 9/20/23 V1 was notified of an allegation of abuse between R1 and V4 Certified Nursing Assistant (CNA). V1 said, V1 interviewed V3 Certified Nursing Assistant (CNA) who informed V1 that on 9/20/23 at 2:00pm V4 Certified Nursing Assistant (CNA) was preparing R1 for a shower, V4 stated V4 was going to drown R1 if R1 didn't stop screaming. V1 said, V3 further informed V1 that upon V4 bringing R1 back to R1's room, V4 told R1 to shut the (expletive) up, because R1 was yelling. V1 said, V1 interviewed V4 who admitted telling R1 to shut the (expletive) up. V1 said, as the result of the investigation, it was determined that V4 committed verbal abuse by admitting using inappropriate tone with R1 and telling R1 to shut the (expletive) up. R1 Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Type 2 Diabetes Mellitus, Hyperlipidemia, Protein-Calorie Malnutrition, Anxiety Disorder, Major Depressive Disorder, Hypothyroidism, HTN, Osteoarthritis, Noninflammatory Disorders of Uterus, Pulmonary Fibrosis, Cholelithiasis, Solitary Pulmonary Nodule, Constipation, Dementia, and Abnormalities of Gait and Mobility. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 0, severe impairment and is total dependence two-person physical assist with all Activities of Daily Living (ADL). The Facility's Final Investigation Report dated 9/25/23, for R1 incident which occurred on 9/20/23 documents V4 Certified Nursing Assistant (CNA) was preparing R1 for a shower, V4 reportedly stated V4 was going to drown R1 if R1 didn't stop screaming. Upon returning R1 from the shower to R1's room, V4 reportedly told R1 to shut the (expletive) up, because R1 was yelling. The Facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property revised 12-1-2022 documents, Preface: It is the policy of the facility to encourage and support all residents, staff, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents medical symptoms. i. Verbal abuse is defined as the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to ensure the facility was sufficiently staffed to meet the needs of the residents. This failure affects five residents (R5, R14, R20, R23, R28) on the sample list of 21. This failure has the potential to affect all 28 residents residing in the facility. Findings include: The facility's Resident Council Meeting Minutes documents the following nursing concerns: 4/19/22 residents would like more Certified Nursing Assistants (CNA's) on evening shift. On 5/19/22 residents would like more CNA's. 6/16/22 one resident stated was not getting their bath today because not enough staff. Residents say we are understaffed for CNA's on early evenings and weekends. 7/14/22 one resident stated sits too long when going to the bathroom around meal times and residents state would like more CNA's. 9/26/22 residents have concerns that there are not enough to help out in case of an emergency and complaints that CNA's like to stand around and visit when they hear call lights go off. 10/13/22 residents stated they need more CNA's. Resident stated they have had to wait on the toilet for 25-30 minutes several times before a CNA could come help. 11/13/22 residents stated they need more help on the weekend due to long call light wait times. 12/5/22 residents stated there are not enough CNA's. 2/6/23 residents raise concerns about the number of CNA's per shift. Residents stated lack of CNA's is affecting their care. 4/4/23 residents raised concerns about number of CNA's per shift. 5/2/23 a resident questioned staffing on weekends. On 5/2/23 at 9:39am, R28 stated R28 receives showers every three to four days. R28 stated, they are under staffed. On 5/2/23 at 2:45pm during the Resident Council Meeting with the State Surveyor, R20 stated the facility is short staffed CNA's on weekends. R20 stated R20 takes a diuretic which causes the need to use the bathroom frequently and R20 needs assistance to use the bathroom. R20 stated call light wait times are longer at night. During this same meeting, R5, R14, and R23 all agreed call light wait times were longer at night and on weekends. R5 stated R5 is not receiving showers twice a week due to not enough staff. R5's Electronic Medical Record (EMR) under Tasks-ADL (Activities of Daily Living) - Bathing Prefers: Bath on Monday and Thursday Day shift documents R5 received a shower and/or bed bath on 4/8/23, 4/12/23, 4/19/23, and 5/3/23. R5's CNA Bathing Observation and Duties Sheet documents R5 received a shower and/or bed bath on 4/2/23 and 4/8/23. R5 did not receive a shower and/or bed bath twice a week during the weeks of 4/9/23, 4/16/23 and 4/23/23. There is no documentation is R5's EMR that R5 refused showers and/or bed baths during the weeks of 4/9/23, 4/16/23, or 4/23/23. R28's EMR under Tasks-ADL-Prefers: Shower Wednesday and Saturday PM shift. This task sheet document R28 not available or not applicable. There is no documentation in R28's EMR or a CNA Bathing Observation and Duties Sheet in EMR noting refusal or R28 not available. On 5/4/23 10:48am, V1 Administrator stated the facility is working on hiring staff. V1 stated V1 and V2 determine staffing hours. On 5/4/23 11:45am, V2 Director of Nursing stated the facility has hired some night shift hires and have new hires going through the process. V2 stated it does not help when they do not show up and call off. V2 confirmed staff work 12 hour shifts. The Resident Census and Conditions of Residents report dated 5/2/23 document 28 residents reside in the facility.

Based on interview and record review, the facility failed to adequately supervise a cognitively impaired resident and maintain a bed alarm in proper working condition. This failure resulted in R1 sustaining Thoracic-10 and Lumbar-2 (spinal) fractures. The facility also failed to utilize the Physician Ordered full mechanical lift to provide a safe transfer for a R3, resulting in a fall. R1 and R3 are two of three residents reviewed for falls on the sample list of six. Findings include: 1. R1's Physician Order Sheet (POS) dated 4/7/23 documents the following diagnoses: Altered Mental Status, Long Term Current Use of Aspirin, Repeated Falls, Unspecified Dementia Unspecified Severity, Osteoporosis and Anxiety. The same POS documents: Bed sensor pad on bed at HS (Bedtime) d/t (due to) poor sitting balance in bed/awareness, weakness, unsteady gait, inability to transfer self. Check every shift to ensure sensor pad is working. Start date 01/18/2021. R1's Minimum Data Set (MDS) dated [DATE] documents the following: R1 has a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. The same MDS documents R1 requires physical staff assistance with transfers, ambulation and toileting. R1's Nurses Note dated 12/24/2022 at 03:32 am documents the following: Note Text: Roommate (unidentified) alerted staff of resident (R1) fall (,) resident on floor in bathroom (,) on right side (.) residents alarm did not sound (.) no injuries present (,) neuros (neurological assessment) and vitals initiated (,) resident (R1) assisted to bed (,) alarm replaced and working (.) resident reminded to use call light. R1's Health Status Note dated 12/28/2022 at 10:15 am documents the following: Note Text: Resident (R1) ambulated to shower room with staff assist-writer called to shower room per CNA (Certified Nursing Assistant) (unidentified)-noted purple/yellow fading bruising across mid chest to top of breasts-resident denies discomfort. Had last fall 12/24/22 which was unwitnessed. DON (V2/Director of Nursing) notified. R1's Nurses Note dated 12/29/2022 at 11:54 am documents the following: Note Text: Follow up on C-Xray (Chest X-ray). (V20/Physician) notified of new compression fracture of T10 and L2 (thoracic and lumbar region of the spine). (V20) would like the family (V27) POA to give a go-ahead for the treatment. (V20) states fosamax (Fosamax) 70 mg wkly (weekly) will be given for treatment of osteoporosis. (V27/R1's Family Member) notified and he gave a go-ahead for the said treatment. (V20) notified. R1's Post Fall assessment dated [DATE] documents the following: Resident observed on the floor in the bathroom on right side. [NAME] nearby. Roommate (unidentified) saw resident (R1) melt into the floor. She (R1) did not hit her head. The same Post Fall Assessment documents: Bed Alarm did not sound during event. Not working. Got new alarm. On 4/7/23 at 10:15 am V2 (Director of Nursing/DON) stated, (R1's) chest bruise 12/28/22 was determined to be from her fall 12/24/22 and not of an unknown origin. The X-ray done 12/28/22 showed she suffered the fractures (Thoracic-10 and Lumbar-2). The root cause of the fall was ambulating without assistance, and malfunction of the bed alarm. The staff know she (R1) has a history of falls, putting her at high fall risk for subsequent falls and requires frequent visuals. On 4/7/23 at 12:50 pm V2 (DON) provided a copy of the facility Sensory Alarm Checklist. V2 reviewed the list and stated, There is really no way to determine if the bed alarm was confirmed to be in working order before the fall. The 'Sensor Alarm Checklist' only has the staff check off if the resident has an alarm. I will be updating the form to make sure it identifies if the alarm was working or if the batteries were changed. It was determined (R1's) bed alarm had to be replaced. It was not a battery issue. The facility Sensor Alarm Checklist dated 1/4/23 documents the following: Please check to make sure alarms are in place and are functioning properly. If alarm is not functioning, replace batteries and cord to sensor pad. Replace immediately if not working. The same 'Sensor Alarm Checklist' documents check-boxes that are labeled Bed, Recliner, Chair to indicate the presence of the alarm. There is not a designated box to indicate if the alarm is functioning properly or if there was a need to replace the batteries. 32172 2. R3's Physician Order Sheet (POS) dated April 2023 documents R3 is diagnosed with Paraplegia, Muscle Weakness, and Falls. The same POS documents starting 1/4/23, R3 was to be transferred with a full mechanical lift. R3's Morse Fall Scale dated 12/29/22 documents R3 is a high risk for falls related to him fallen before, uses ambulatory aides, and he overestimates or forgets limits. R3's Post Fall assessment dated [DATE] documents R3 was being transferred from the bedside commode to the recliner and when he was unhooked from the sit to stand mechanical lift he slid out of the recliner to the floor. On 4/4/23 at 12:00 PM, R3 stated he fell on to the floor from the recliner when he was unhooked from the sit to stand mechanical lift. R3 stated he was sitting too close to the edge of the chair. On 4/5/23 at 10:32 AM V11 (CNA) stated on 3/10/23 that she and V9 (CNA) transferred R3 using the sit to stand mechanical lift. V11 stated R3 started to get weak and pass out and they lowered him to the recliner. V11 stated as soon as they began to unhook the support strap on the lift, R3 slid to the floor. V11 stated they must have sat R3 down too close to the edge of the chair which caused him to slip off. V11 stated as far as V11 knew, R3 was to be transferred with the sit to stand mechanical lift at the time. On 4/5/23 at 10:51 AM V9 (CNA) stated on 3/10/23 she and V11 (CNA) transferred R3 using the sit to stand mechanical lift. V9 stated R3 started to get weak and pass out and they lowered him to the recliner. V9 stated when they unhooked the support strap on the lift, R3 slid to the floor. V9 confirmed they must have sat R3 down to close to the edge of the chair which caused him to slip off. V9 stated as far as V9 knew, R3 was to be transferred with the sit to stand mechanical lift at the time. On 4/7/23 at 2:10 PM V2 (DON) confirmed R3 had an order to be transferred with a full mechanical lift and on 3/10/23 R3 was transferred with a sit to stand mechanical lift. V2 also confirmed that V9 and V11 should have made sure R3 was sitting back safely in the recliner before unhooking the support strap on the mechanical lift. This might have prevented him sliding onto the floor. The facility's Fall Prevention Program dated 8/29/22 documents staff should provide ongoing risk reducing interventions, initiate physician orders as needed, identify and implement related care link interventions, and provide ongoing evaluation of resident response to interventions.

Based on interview and record review the facility failed to ensure that R6 was not subjected to mental abuse by a caregiver. R6 is 1 of 8 residents sampled for abuse. R6 suffered emotional harm while being subjected to embarrassment and humiliation. Findings include: R6's Face Sheet lists a [DIAGNOSES REDACTED]. R6's Minimum (MDS) data set [DATE] indicates R6 is continent of bowel and bladder. On 9/22/10 at 11:35 AM, R6 stated about two weeks ago he was in a physical therapy session walking with E5, Physical Therapist(PT). R6 told E5 that he needed to use the bathroom. E5 told R6 to "go ahead." R6 stated that E5 refused to stop the session to take R6 to the bathroom and he had a bowel movement and urinated in his pants. R6 stated that E5 then took R6 back to his room and left him sitting on his bed in his soiled clothing. R6 stated that E5 then came back to the room later and stated to R6 "I told you to crap on your own time." R6 stated he was embarrassed because nothing like this had ever happened to him before. R6 stated he did not report this incident but stated "word got out" and a few days after it happened E2, told R6 "we took care of your problem." On 9/20/10 a list of the facility abuse, neglect and theft allegations for the previous 6 months provided by E2 did not indicate any allegations related to R6. On 9/20/10 at 1:50, E4, Licensed Practical Nurse (LPN), stated that E6, Certified Nursing Assistant (CNA), notified E4 that R6 had been left on his bed in his soiled clothing by E5,PT. E4 stated that she notified E1 of the incident soon after she became aware of it because E1 "just happened to be in the hallway." On 9/22/10 at 1:25 PM, E1 stated he did not report or do any investigation related to the incidents involving E5. On 9/22/10 E1 wrote a chronological statement of events. According to E1's statement: On 9/8/10 E4 notified E1 that E5,PT, had told R6 that "He should sh** on his own time." E1 stated that as he was being notified E5 walked by and so they discussed the situation. According to E1's statement, E5's response was "I was making sure he was in a safe position so I could get a CNA to clean him up. You pay me a lot of $ (dollars) and my time is not productive cleaning residents up." E1 stated that he and E5 then went to speak with R6 and "Everything seem to be reconciled." On 9/9/10, E1 met with R6 to "make sure things were ok." R6 indicated they were and he "was just embarrassed...I've never lost control of my bowels." On 9/14/10, E1 met with E7,Physical Therapy Assistant, regarding E5 and "concluded that (E5) needed to be replaced." E1 contacted Director of Physical Therapy and E5 was "removed." On 9/15/10, E1's statement indicated E5 "left at noon." Additional information provided by E2 on 9/23/10 indicates that E5, PT, continued to provide therapy for residents in the facility on 9/8/10, 9/9/10, 9/14/10 and on 9/15/10.