Every finding on record at Irving Park Living & Rehab CTR

Based on observation, interview and record review, the facility failed to prevent and protect a resident from staff to resident abuse. This failure affects two (R1, R6) residents out of six residents reviewed for abuse. Findings include: R1's face sheet documents that R1 was admitted to the facility on [DATE], with diagnoses not limited to unspecified dementia, unspecified severity, with agitation; unspecified mood [affective] disorder, insomnia, history of falling; posterior dislocation of lens, left eye; unspecified visual loss; and age-related nuclear cataract, right eye.On 07/18/2026 at 9:45AM, R1 observed being redirected by a nurse to the second-floor nurses' station where he is placed in a chair across from the nurses' station. R1 is noted with confusion and is not interview able. R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status of 5/15, indicating that R1 is cognitively impaired.On 07/18/2026 at 10:27AM, R6 states no one has ever hit her, and she has not seen staff hit other residents. R6's MDS/Minimum Data Set, dated [DATE], documents that R6 has a BIMS/Brief Interview for Mental Status of 10/15, indicating that R6 is cognitively impaired.On 07/18/2026 at 10:45AM, R2 states she did witness a staff member (identified as V4/CNA) slap R1 on the face. R2 states this incident occurred on 07/16/2026. R2 states she saw R1 standing outside of her room urinating in the corner outside her room door. R2 states that R1 is visually impaired and has a history of wandering in the facility. R2 states after R1 urinated in the corner, V4 (CNA) came down the hall. V4 grabbed R1 and slapped him on his face inside of R2's room. R2 states V4 slapped R1 so hard that R1's face turned red. R2 states V4 had no right to slap R1. R2 states she was very upset that this occurred and asked V4 why did V4 slapped R1. R2 states that V4 told R2 that V4 slapped R1 because R1 had urinated on the floor. R2 states after this occurred, she reported it. V1 (Administrator), V2 (Director of Nursing/DON) and social services came to her room to ask her about the incident. R2 states she told them that V4 slapped R1 on his face. R2 states social services then asked her to sign a witness statement about what occurred. R2 states the police then came to the facility to speak with her about the incident occurring between R1 and V4. R2 states a male officer and a female officer came to take her statement and also took a picture of her identification card/ID. R2 states she was informed that V4 was called to the office and she has not seen V4 since the incident occurred.R2's MDS/Minimum Data Set, dated [DATE], documents that R2 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R2 is cognitively intact.On 07/18/2026 at 11:39AM, V1 (Administrator) states she is the abuse coordinator, and she reviewed camera footage from one of the cameras on the second floor of the facility. V1 was not able to see V4 (CNA) slap R1. V1 states once R1 and V4 were inside of R2's room, V1 was unable to see any further events that occurred between R1 and V4. V1 states she can access the camera footage from her cellular phone.On 07/18/2026 at 11:46AM, V1 located inside of the basement conference room with surveyor observing the camera footage (identified as the second-floor elevator hall camera) from V1's cellular phone of the incident that occurred between R1 and V4 on 07/16/2026. Surveyor observes camera footage dated 07/16/2026 at 3:43PM, of R1 wandering/walking with a gown and socks on and at 3:45PM. R1 is now located at the doorway outside of R2's room. At 3:45PM, R1 walks out of the camera's view towards R2's room. At 3:46PM, surveyor observes V4 walking down the hall towards R1 and V4 also walks out of the camera's view towards R2's room. At 3:48PM, surveyor observes V4 exiting R2's room with R1 walking in front of V4. V4 is seen walking behind R1 with her right hand holding R1's right upper arm and V4's left hand placed on R1's back. V4 is observed pushing R1 forward down the hall at a rushed speed and R1 is unable to keep up with the pace of V4 pushing R1 forward. R1 is observed almost tripping over his own feet several times due to V4 pushing him forward.On 07/18/2026 at 11:58AM, surveyor inquires to V1 about another camera's view of the incident that occurred. V1 states there are a total of two cameras (identified as the second-floor elevator hall camera and the second-floor nurses' station camera) that could have captured the incident that occurred. V1 states she did not review camera footage from the second-floor nurses' station camera.On 07/18/2026 at 12:01PM, V1 and surveyor observes the camera footage (identified as the second-floor nurses' station camera) from V1's cellular phone of the incident that occurred between R1 and V4 on 07/16/2026. Surveyor observes camera footage dated 07/16/2026 at 3:40PM of R1 sitting in a chair next to the nurses' station and is then seen getting up from the chair and ambulating down the hallway via walking. At 3:45PM, surveyor observes that R1 is now located at the end of the hall outside of R2's room. R1 then appears to lift his gown up while facing the wall and at this time. R1 appears to be urinating outside of R2's room. At 3:46PM, V4 is observed walking down the hall towards R1 and V4 is seen pushing R1 inside of R2's room, where they are both now out of the camera's view. At 3:48PM, surveyor observes V4 exiting R2's room with R1 walking in front of V4. V4 is seen walking behind R1 with her right hand holding R1's right upper arm and V4's left hand placed on R1's back. V4 is observed pushing R1 forward down the hall at a rushed speed and R1 is unable to keep up with the pace of V4 pushing R1 forward. R1 is observed almost tripping over his own feet several times due to V4 pushing him forward. V4 then places R1 back in the chair located next to the nurses' station.On 07/18/2026 at 12:05PM, V1 states R1 is visually impaired and has dementia. V1 states R1 has a history of wandering in the facility but R1 is allowed to walk around by himself as long as R1 is being monitored by staff. V1 states that based on the video footage that she reviewed with surveyor, V1 observed multiple staff members pass R1 in the hallway and none of the staff members were monitoring R1. V1 states she is not sure why V4 would push R1 into R2's room if that is not R1's assigned room. V1 states during her investigation, V4 informed V1 that R1 was already inside of R2's room when V4 arrived. V1 states that V4 informed her that V4 went inside of R2's room to get R1 out of R2's room and redirect him. V1 states based on the camera footage that she just reviewed with surveyor, V4 did not tell V1 the truth during the investigation. V1 states that based on her interview with V4, V1 thought that R1 had entered R2's room on his own and then urinated inside of R2's room. V1 states V4 should not have pushed R1 and that V4 should have just redirected R1 away from R2's room, especially since R1 is visually impaired. V1 states there is no reason for staff to become aggressive with residents in the facility, even if the resident is aggressive towards the staff. V1 states R1's allegation of abuse was reported to her by V7 (Social Services Director). V1 states V7 informed her that R2 reported to V7 that V4 slapped R1 on the face. V1 states she and V2 (DON) immediately went to speak with R2 and R2 informed V1 that V4 slapped R1 on the face. V1 states R2 stated to her that V4 slapped R1 because V4 was trying to redirect R1 and R1 became aggressive with V4. V1 states R2 is alert and oriented and will report to staff if R2 sees anything. V1 states she submitted an initial report to the state agency on 07/16/2026 and is still in the process of conducting her investigation. V1 states V4 is currently suspended from working in the facility until after a thorough investigation is completed. V1 states she will be submitting a final report to the state agency by Wednesday 07/22/2026. On 07/18/2026 at 12:29PM, V4 (Certified Nursing Assistant/CNA) states she has been working at the facility for three years and was the CNA assigned to care for R1 on 07/16/2026 during the 3:00PM-11:00PM shift. V4 states on 07/16/2026, she was inside of another resident's room putting them in bed. V4 states she then heard a call light sound and went to see that the call light sound was coming from R2's room. V4 states she then saw R1 was urinating in front of R2's room. V4 states R1 is confused and has a history of wandering into other residents' rooms. V4 states she rushed down to where R1 was located and saw that R1 was already inside of R2's room so V4 followed R1 inside of R2's room. V4 states she was trying to redirect R1 out of R2's room but R1 became aggressive with her and tried to punch her. V4 states she restrained herself when R1 tried to hit her. V4 states she only put her hands up in front of her face and tried to protect and cover her face. V4 states she never slapped R1 on his face and only tried to calm R1 down. V4 states once she redirected R1 out of R2's room, V4 placed R1 back inside of his room and went to clean up R1's urine with a mop and towel. V4 states there is nothing that you can do to successfully redirect R1 unless R1 is sleeping. V4 states once R1 is awake, he goes around entering other resident's rooms all the time and R1 hits residents sometimes too. V4 states to surveyor to check the facility's cameras to see and prove that by the time V4 made it down the hallway to R1, R1 was already inside of R2's room. V4 states R1 was already inside of R2's room standing next to the bed once V4 arrived and that she never slapped R1. V4 states she did not finish her shift on 07/16/2026 and was called to V1's office, told V1 what happened, and provided a written statement to V1. V4 states she was asked to punch out and go home. V4 states she is currently not allowed to return to work and was informed that the facility would contact her after they completed an investigation.Facility's CNA assignment sheet dated 07/16/2026 documents that V4 was assigned to care for R1 on 07/16/2026 during the 3:00PM-11:00PM shift.Record review of V4's (CNA) employee file documents that on 10/15/2025, V4 acknowledged receiving information on the facility's abuse program. V4's employee file documents that on 06/03/2025, V4 was accused of threatening to hit another staff member with a mechanical lift in the facility.On 07/19/2026 at 9:14AM, V6 (CNA) states on 07/16/2026 during the 3:00PM-11:00PM shift, R2 saw V6 and screamed V6's name several times telling V6 to come inside of R2's room. V6 states she saw R2 crying and asked what was wrong. V6 states R2 informed her that R2 had just witnessed V4 (CNA) slapping R1 on the face inside of R2's room. V6 states R2 said that R1 was trying to run and get away from V4 to keep V4 from slapping R1. V6 states R2 then asked her to inform V7 (Social Services Director) that R2 wanted to speak with V7. V6 states R2 also later asked V6 to inform V2 (Director of Nursing/DON) that R2 wanted to speak with V2. V6 states she has been working at the facility for 14-15 years. V6 states that R2 informed V6 that she reported R1's allegation of abuse to V6 because R2 knew that V6 would help. V6 states on one occasion in the facility, she and V4 were assisting to transfer a resident (identified as R6) in the facility. V6 states on this occasion, she witnessed V4 take R6's lips and pinch them closed several times because R6 continued to talk while being transferred. V6 states she is not sure how long ago this incident occurred involving V4 and R6, but it occurred sometime during this year and did not occur last year. V6 states V4 kept telling R6 to shut up and to stop talking. V6 states she tried to distract R6 by telling R6 to only talk to her and to not talk to V4. V6 states she never talked with V4 regarding the incident that occurred between V4 and R6. V6 states she is not good with conflict and stays to herself because V4 can be mean and evil. V6 states V4 pinching R6's lips together to keep R6 from talking and telling R6 to shut up is considered a form of abuse. V6 states she believes that those acts performed by V4 towards R6 are considered physical and verbal abuse. V6 states she has been trained on abuse in the facility and verbalizes to surveyor examples of different types of abuse. V6 states she is aware that the administrator is the abuse coordinator, and she should report incidents of abuse to the administrator. V6 states she did not report R6's incident of abuse to anyone. V6 then states You know what, I have no idea why I didn't report it, probably because I was trying to hurry up and work. V6 states she is unaware of V4's current employment status in the facility because V6 tries not to gossip or get in other people's business. V6 states I'm grown, and I stay in my lane.On 07/19/2026 at 9:32AM V7 (Social Services Director/SSD) states he has been working as the SSD for 3-4 months in the facility. V7 states on 07/16/2026, V6 (CNA) came to his office and informed him that R2 wanted to speak with him. V7 states he went to speak with R2 and saw that R2 was crying, and he asked R2 what was wrong. V7 states R2 kept saying That's wrong and R2 informed him that R2 saw V4 slap R1 on the face. V7 states R2 told him that witnessing this incident made her mad and frustrated. V7 states he then apologized to R2 for having to witness the incident between R1 and V4. V7 states R1 has a history of wandering in the facility due to R1 having dementia. V7 states regardless of a resident's behavior, none of the staff should be abusing the residents in the facility. V7 states he then went and informed V1, who is also the abuse coordinator. V7 states he and V1 went to R2's room and began an investigation. V7 states he interviewed all the residents assigned in R2's room, which included R2, R3, R4, and R5. V7 states R3 informed him that she always keeps her privacy curtain closed and did not hear or witness R1 being abused. V7 states R4 told him that R4 only focuses on her own care in the facility and does not get involved with any of the other residents. V7 states he was skeptical about R4's statement and did not know if R4 was withholding information or not. V7 states R5 has memory problems and did not have any recollection of the incident involving R1 and V4. V7 states he is aware that V4 was later called to V1's (Administrator) office and V7 is unaware of V4's current employment status in the facility. V7 states he is trained on abuse, is able to verbalize different types of abuse, has never covered up abuse, and is aware that he must report abuse to V1. V7 states he has never worked with V4 but has heard in passing via other CNAs, that V4 can be mean and cruel.R1's Facility Reported Incident/FRI documents that the facility reported R1's abuse allegation incident to the state agency on 07/16/2026 at 5:57PM.R1's police report dated 07/16/2026 at 4:52PM documents a police report number #JK336094 of simple battery was made for R1.R1's care plan documents in part, R1 is an adult living with chronic health conditions, challenges, co-morbidities and symptomatologic factors that require monitoring. R1 may be at risk due to his aggressive behavior towards others. Goals: R1 will be treated with respect and dignity and will reside in the facility free from mistreatment. Staff will use warm, non-judgmental approach in order to allow the R1 to feel comfortable expressing concerns. Staff will reassess R1 for risk of abuse/neglect. Staff will reassess R1 for risk of abuse/neglect quarterly, annually, and per reported event. R1 is at risk for impaired decision making related to dementia and is prescribe with cognitive enhancing medication.R1's abuse risk screening assessment dated [DATE] documents that R1 scored a '1' on the abuse assessment, indicating that R1 is at low risk for abuse.There is no documentation to show that R1 was reassessed for risk of abuse after R1's reported incident on 07/16/2026.R1's progress note dated 07/16/2026 at 6:52PM, documents in part, It was reported to nurse to assess R1 following an allegation reported by a co-resident, nurse responded immediately to assess R1. R1 observed sitting calmly in the day room chair at time, assisted to his room, a head-to-Toe assessment completed, no injuries, redness, swelling, or bruising noted to the face or body. Resident A/O 1 with baseline confusion. No signs or symptoms of pain or discomfort noted. Respiration even and unlabored. Vital signs all within normal limits. All due medications are administered as ordered. Residents ate dinner well with good hydration. Dr. notified of incident and assessment findings. New order received to administer Ativan 1mg 3 times a day for 10 days as needed, order carried out. R1 guardian/guarantor, V3 notified via phone. Guardian informed of incident, assessment findings, and new medication order; guardian verbalized understanding and verbal consent obtained. R1 will be monitored closely for behavioral changes, delayed injury, or distress. Staff will continue to monitor redirect as needed.Facility policy dated 01/2026 titled Abuse Retaliation Policy Prevention Program documents in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.Abuse means any physical or mental injury.Abuse if the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.Facility policy dated 01/2026 titled Resident's Rights Policy documents in part, No resident should be deprived of any rights. nor shall a resident forfeit any of the following rights.14. The right to be free of abuse or neglect or financial exploitation or to refuse to perform labor;

Based on interviews and record reviews, the facility failed to provide adequate supervision for one cognitive impaired resident (R2) who is a high fall risk with a history of falls with injury out of a sample of four [R1, R3, R4] residents reviewed for falls. This failure resulted in R2 falling, transferred to the emergency department, and sustained a left eye orbital fracture.Findings Include, R2 ‘s clinical record indicates the following in part: R2 was admitted with hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, essential hypertension, vitamin D deficiency, restlessness, history of falling, type II diabetes, anxiety disorder, depression, and fracture of upper end of left humerus. R2's minimum data set [MDS] Section [C] Brief Interview Mental Status score [11]. Indicates R2 is mildly cognitively impaired. MDS Section [GG] indicates R2 requires maximal assistance with toileting, personal hygiene, and transfers.R2's Facility IDPH Reportable in part:6/3/26 at 7:05 AM, Upon staff rounds observed R2 on the floor at bedside. R2 noted with left eye and forehead discoloration. Neuro checks initiated. Physician gave order to send R2 to the emergency department. R2 was admitted to the hospital for a left orbital wall fracture.R2's Care Plan in part:12/15/25R2 is a high fall risk.R2 is incontinent of bowel and bladder, requires incontinent care.12/27/25R2 primarily speaks mandarin, understand basic English. R2 is forgetful at times.12/29/25R2 has dementia with impaired decision making.R2 requires the support, care, and services of a long-term care facility. R2 demonstrates symptoms of cognitive impairment.R2 living with chronic psychiatric illness. R2 has ineffective coping modalities, disorganized thought process and mood patterns, delusions, hallucinations, difficulty meeting basic self-care needs. Having reduced insight and judgment related to schizoaffective disorder.R2's Fall Incidents in part:[R2 was admitted on [DATE]]12/16/24, R2 was observed on the floor mat in her bedroom. Intervention: Bed will remain in lowest position, floor mats in place, make sure all needs are met.1/12/25, R2 was observed on the floor in her bedroom lying on the stomach near wheelchair. The wheelchair footrest was on top of R2's calf. R2 was sent to the emergency room and sustained a left arm fracture. Interventions: Monitor for ortho hypertension.1/18/25, R2 was observed on the floor in her room near the closet. R2 said the closet door hit her head. R2 was sent to the emergency room, no injury noted. Intervention: There was no intervention in care plan.2/25/25, R2 was observed siting on the floor in her bedroom, no injury. Intervention: Continue therapy, staff to anticipate needs related to ADL care.Anti-anxiety medications [Power of Attorney refused medications]6/3/25, R2 was observed on the floor in her bedroom. R2 was sent to the emergency room and sustained a left eye orbital fracture. Interventions: [None] R2 did not return back facility.Interviews:On 7/17/25 at 10:20 AM, V13 [Certified Nurse Assistant] stated, On 6/3/25, I was R2's first shift certified nurse assistant. It was around 7:00 AM, I was at the nursing station getting myself together, when I heard a loud noise and heard R2 yell out. I went into her room and looked like she fell out the bed on to the floor. I ran and told the 11PM - 7AM nurse that R2 was on the floor. The nurses assessed R2 and we put her into the wheelchair. Typically, I make rounds when I get to the nursing unit, but I was getting my assignment. R2 has fallen in the past. R2 needs close monitoring all the time. R2 fell during shift change when everyone was at the nursing station, third shift and first shift staff.On 7/17/25 at 10:50 AM, V16 [Certified Nurse Assistant] stated, I was the night shift aide, worked on 6/3/25, when R2 fell. I provided care to R2 around 6:00 AM. Around 7:10 AM, all the first-floor staff was at the nursing station when we heard a noise. I ran into R2's room and she on the floor. R2 left side of her face was discolored dark. R2 needs close monitoring. R2 needs to go to the bathroom frequently and it takes a long time to take her. R2 knows how to place on her call light sometimes, but she does not wait for assistance, she will try to take herself and will fall. Some of R2's fall interventions are, close monitoring, floor mats, low bed and keep the call light in reach. R2 constantly tries to transfer herself all the time.On 7/17/25 at 12:30 PM, V14 [Licensed Practical Nurse] stated, I was R2's third shift nurse. Around 7:05 AM the nursing staff was all at the nursing station. I was giving report to the first shift nurse when we heard a noise came from R2's room. The certified nurse assistance went to her room first to check on the resident. I was called to R2's room I saw R2 on the floor lying on her left side. R2 said she was okay, and after assessing her she was placed into her wheelchair noted with her left side of face was discolored dark. R2 requires constant supervision. Through the night shift the Certified Nurse Assistant sits in a chair outside R2's room to provide one to one monitoring. R2 pulled the call light, but before someone was able to answer her call light, she tried to transfer herself. This happens all the time. I saw her last around 6:00 AM, she was resting in bed. The first shift nurse took over and notified the physician, family, and administration. On 7/17/25 at 2:00PM, V15 [Registered Nurse] stated, I was R2's nurse on 6/3/25, working first shift. I was at the nursing station waiting to get nurse report. Certified Nurse Assistant came and said R2 was on the floor. Everyone ran into R2's room. R2 was lying on the floor with a bruise to her left side of her face. R2 said she was okay. R2 vital signs were with in normal range, and I started neuro checks. R2's physician gave an order to send R2, to the emergency department. Later, the hospital called and said R2 had a left eye orbital fracture. I notified the administration. R2 needs frequent supervision and monitoring. When R2 places on the call light, you have to answer call light immediately or R2 will try to take herself to the bathroom and fall.On 7/16/25 at 11:00 AM, V2 [Director of Nursing/ Fall Coordinator] stated, I been working here since 1/16/25 as the Director of Nursing and Fall Coordinator. On 6/3/25, during shift change, staff heard a noise, went to R2's room and observed her laying on the floor and noted with left side facial discoloration. R2 was sent to the emergency department and R2 was diagnosis with a left orbital eye fracture. R2 had a total of five falls with two falls resulted in an arm fracture and then a left orbital eye fracture. R2 needs supervision, close monitoring, practically one to one supervision. The facility is not able to provide R2 with a one-to-one sitter all the time. R2's fall interventions should be patient centered for each fall to assisted in preventing another fall.On 7/18/25 at 11:00AM, V18 [Physician] stated, R2 is very confused with left sided weakness and need close supervision. R2 has anxiety and needed antianxiety medication. R2's power of attorney refused for R2 to take antianxiety medication. During the examination of R2, it takes two staff members to assist me, because R2 is always trying to get up. R2 had an arm fracture from a fall, and recently a left eye orbital fracture. The falls were avoidable, if R2's power of attorney would have allowed R2 to take antianxiety medication to help her.Policy documents in part:Falls and Fall Prevention:To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment.Resident will be reassessed quarterly and after each fall.Immediate change in intervention that were successful.Documentation as indicated.Resident fall risk intervention will be identified on the care plan.The frequency of safety monitoring will be determined by the resident's risk factors and care plan.Resident care plan intervention will be as indicated.IDT [Team] to discuss post incident/accident and or fall incident to ensure prevention from reoccurring.

Based on observations, interviews and records review, the facility failed to safely transfer one (R1) of three residents reviewed for mechanical lift transfer. The failure cause R1 to sustain injury to his right fifth toe requiring three sutures. Findings include: R1 is [AGE] year-old individual whose current face sheet documents R1 medical diagnosis to include but not limited to: Unspecified Sequelae of Cerebral Infarction, Pressure Ulcer of Sacral Region, unspecified stage, Neuroleptic Induced Parkinsonism, Schizophrenia, unspecified. MDS (Minimum Data Set) section C-Cognitive abilities dated 3/17/2025, documents R1's BIMS (Brief Interview for Mental Status) as 7/15 indicating R1 has severe cognitive impairment. MDS section GG-Functional abilities documents R1 has impairment on both upper and lower extremities and requires Substantial/maximal assistance. Eating, Oral hygiene, Toileting hygiene Shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear, Personal hygiene, R1 is dependent on staff. Facility Reported Incident Report (final) dated 3/24/2025, documents: -Based on facility investigations, Resident (R1) with diagnosis of Neuroleptic Parkinsonism which causes rhythmical movements bumped his right foot on the foot board of the bed during transfer which resulted in resident (R1) sustaining laceration to right 5th digit. On 3/18/2025, R1 returned to the facility from the hospital with three sutures on the right 5th digit with discharge instructions to remove sutures in one week. On 04/12/2025, at 11:01 AM, R1 was observed laying in bed awake and stated two staff use the mechanical lift to transfer him. R1 stated he does not remember what happened when he was being transferred but his toe was hit during the transfer. He had stitches but they were removed. 04/12/2025, at 11:03 AM, V5 (Licensed Practical Nurse -LPN) and surveyor observed R1's right fifth toe. The back side of the toe was observed with three marks where the sutures were removed. R1 stated he was not in pain when V5 touched his fifth small toe. V5 stated two staff operate the mechanical lift when transferring residents and monitor the resident to prevent resident injury. V5 further stated staff have to be careful and watchful when using the mechanical lift to transfer residents because residents can be scared during transfer and move around which could cause resident injury. On 04/12/2025, at 11:11 AM, V6 (Certified Nursing Assistant-CNA) V6 stated when moving a resident with a mechanical lift, staff must concentrate and watch what they are doing to prevent resident injury. On 04/12/2025, at 1:00 PM, V9 (Licensed Practical Nurse -LPN) via phone stated she was the nurse for R1 on 3/17/2025, when R1 sustained an injury on the right small toe during transfer. V9 stated she was in the hallway when V10 and V11(CNAs) were transferring R1 from the specialized chair to the bed using a mechanical lift. V10 called her to R1's room because R1 was bleeding from the right small toe. V9 stated V10 and V11 told her that R1 became impulsive during transfer, was moving around and hit his foot on the bed frame. V9 stated she assessed R1 and gave R1 a pain medication. V9 notified V3 (Director of Nursing) then notified V12 (Physician) who gave V9 orders to send R1 to the local hospital for further evaluation. V9 stated she called the hospital later that evening and was informed R1 had received sutures on the right small toe. V9 stated a mechanical lift is used to transfer residents so that residents can be safe and not sustain injuries. On 04/12/2025, at 1:40 PM, V10 (Certified Nursing Assistant-CNA) via phone stated on 3/17/2025, he was guiding the mechanical lift while transferring R1 with V11(CNA) and V11 was operating the lift. V10 stated he and V11 were transferring R1 from the specialized chair to the bed when R1 started getting agitated, anxious, and was moving around. V10 stated R1's right toe got caught at the end of the foot board. R1's toe was bleeding. V10 stated V9 was notified and came to assess R1. V10 stated dependent residents who need maximal assist for transfer are transferred using a mechanical lift to prevent injuries and falls. On 04/12/2025, at 1:57 PM, V11 (Certified Nursing Assistant-CNA) via phone stated there were two CNAs. V10 and V11 were assisting R1 to transfer R1 from the specialized chair to the bed using a mechanical lift. V11 was operating the mechanical lift and V10 was guiding the lift. V11 stated R1 was getting agitated, scared, and V11 was behind the mechanical lift. V11 does not know what happened or what hit R1 on the foot. V11 stated V10 was the one guiding the mechanical lift sling to the bed when R1's right leg hit the bed. R1 started bleeding on the small toe, and V11 and V10 called V9 to come assess R1. V11 stated there are two CNAs operating the mechanical lift for the safety of the resident to prevent injuries during transfer. R1 is a two person assist. On 04/21/2025, at 2:34 PM, V13 (Nurse Practitioner) via phone stated physical therapy assesses residents for mobility. R1 is a two person assist for mobility safety. V13 stated V12 (Physician) is the one who was notified when R1 had injury to the foot, therefore he (V13) does not have details of the injuries but knows V12 gave orders for R1's sutures to be removed by wound care at the facility. On 04/12/2025, at 3:38 PM, V3 (Director of Nursing -DON) stated mechanical lifts are supposed to be used to be operated by two or more staff for the safety of the resident and staff. V3 stated R1 was new to the facility and was admitted on [DATE]. On 3/17/2025, during the afternoon shift, (V10 and V11(CNAs) were going to move R1 from the specialized chair to the bed using a mechanical lift. V3 stated one staff was operating the mechanical lift and the other was maneuvering R1 while on the lift for safety. R1 has Parkinson's disease and tends to flip over or shake because of Parkinson's disease. V3 stated the goal of using a mechanical lift with two staff is to make sure the resident is safely transferred. V3 stated as V10 and V11 were lowering R1 to the bed, his (R1's) foot hit the foot of the bed and R1 sustained injury to the right fifth posterior digit. V3 stated R1 was lowered to the bed, and assessed by V9 (LPN). V13 (Physician) was notified and R1 sent to hospital for further evaluation. V3 stated R1 come back on 3/18/2025, at 2:15 AM, with three sutures to the right fifth posterior digit with orders to monitor and remove sutures in the facility in seven days by wound care. V3 stated V10 and V11 should have stopped transferring R1 when they noticed he was agitated/fidgety or anxious and should have notified V9 to assess duty to assess R1 so that R1 could have been transferred safely. On 04/12/2025, at 4:00 PM, V14 (Therapy Director) via phone stated R1 was never assessed by therapy at the facility because he come to the facility as a mechanic lift transfer resident when he transferred to this facility from a sister facility. V14 stated if a resident is dependent and requires two staff to transfer, a mechanic lift is used for safety reasons to avoid injuries during transfer. V14 stated the staff are supposed to monitor the resident so that the resident does not sustain injuries during transfers. The resident is not able to help at all during transfers and the helper does 100% of the work. V14 stated that is why R1 is transferred with a mechanical lift for the safety of R1. V14 further stated she does not expect a resident who is being transferred with a mechanical lift to be injured during transfer because staff are the ones operating the machine and should be monitoring the resident as they transfer to prevent injuries. Policy titled: Hydraulic Lift (Hoyer Lift) no date, documents: PURPOSE -To enable two staff to lift and move a resident safely, with as little effort as possible Nursing progress notes dated 03/17/2025, 5:21 PM document: Around 4:00 PM, two Certified Nursing Assistants (V10, V11) were transferring R1 from the specialized chair to bed using a mechanical lift. R1 bumped his right foot by the foot board during transfer. Upon assessment (by V9-LPN) noted a small laceration to the posterior right 5th digit. First aid was rendered. MD (Medical Doctor-V13) notified, and orders were given to transfer R1 to a nearby hospital for medical evaluation. Nursing progress notes dated 03/18/2025, 2:52 AM, document: R1 returned to the facility from the hospital with DX (Diagnosis) of Foot Laceration. Right foot 5th digit noted with 3 sutures with discharge instruction to remove sutures in one week. Hospital records dated 3/17/2025, documents: -R1 was seen at the emergency department for a concern of a laceration to right little toe and received three sutures to help bring the skin together. Sutures to be removed in one week. R1's care plan dated 3/17/2025, documents: Pressure Ulcer/Injury-Laceration Right Toe Incident -Staff Education/Inservice on Resident safety transfer was given to all nursing staff. R1's care plan dated 3/18/2025, documents: -Resident will be transferred with mechanical lift and sling daily. Verbal cues and two persons assist from staff for resident safety and proper use of device.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) discard expired food based on use by guidelines and date, c.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 75 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:45 AM, during initial kitchen tour observed V11 (Cook) washing cooking equipment in the three-compartment sink. Observed V12 dipping the cooking equipment into the third sink containing sanitizing solution for less than 10 seconds and then putting the items on the side to air dry. On [DATE] at 9:48 AM, surveyor asked V12 to watch V11 washing various cooking equipment pieces and observed V11 dipping the cooking equipment quickly into the sanitizing solution and pulling them out to air dry. None of the items were submerged in the sanitizing liquid for more than 10 seconds. On [DATE] at 9:50 AM, V12 stated the cooking equipment must sit in the sanitizing solution for a full 60 seconds to sanitize the item. V12 stated the problem with the items not being fully sanitized is that all the bacteria on the item is not cleaned off which could potentially cause a food borne illness. On [DATE] at 9:45 AM, V12 (Dietary Manager) stated all food items should be labeled and dated with a prepared and use by date. V12 stated It is important to have both dates on each food item so the staff knows when to throw out the food and so they do not serve an expired item. V12 stated prepared/opened items use by date range between three to seven days depending on what the food item is. On [DATE] at 9:51 AM, observed the following items in the reach in coolers: 1.) Opened 2.5-pound package of deli ham wrapped in plastic wrap with no open or use by date. V12 stated the deli ham should be dated with an opened and use by date and the ham should be used within seven days of the package being opened. 2.) Opened package of sliced deli turkey wrapped in plastic wrap stored inside a box of labeled as bacon. The opened package of sliced deli turkey was not labeled with an open or use by date. V12 stated all items should be labeled and dated and if there is no date there is no way to know how long that item has been sitting there. 3.) Opened 5-pound package of sliced Swiss Cheese wrapped in plastic wrap with no open or use by date on it. 4.) Unopened 5-pound bag labeled as Grated Parmesan Cheese dated with a use by date of [DATE] with visible spots of green circles inside the bag of cheese. V12 stated, that's mold! 5.) Opened box of cucumbers dated with a delivery date of [DATE]. Six out of 14 cucumbers inside the box had visible signs of deterioration including very soft spots, large circle spots of white/light green fuzzy material, and wrinkled areas. V12 stated, those look like they went bad and need to go into the garbage and those cucumber should not be moldy, soft, and bad like that. 6.) Metal container labeled butterscotch pudding labeled with prepared date [DATE] and use by date [DATE]. V12 stated this item was labeled incorrectly and should have been labeled with a use by date of [DATE]. 7.) Opened half full 46-ounce container of Lemon-Flavored Water Nectar Consistency labeled with an opened date [DATE] and use by date [DATE]. V12 stated once opened this item must be used within seven days. V12 stated V12 would not give this product to a resident because it is passed the seven days and therefore expired and needs to be thrown out. On [DATE] at 10:46 AM, V16 (Regional Culinary Specialist) stated the facility uses a quat (quaternary) sanitizer for their three-compartment sink to sanitize cooking equipment. V16 stated the items being washed need to be submerged in the solution for at least one minute to sanitize the item(s). V16 stated all items in the refrigerators should be labeled and dated with a prepared or opened date and a use by date to make sure the products are still in food condition for service and that expired items are not served to residents to prevent food borne illnesses. On [DATE], facility provided list of diet orders for all residents in the facility. The diet order list indicates there are three residents receiving nothing by mouth (NPO). Facility provided policy titled OnTray Dietary Policies and Procedures undated documents in part sanitize items in the 3rd sink and submerge items for at least 60 seconds and purpose is to ensure food safety. Facility provided policy titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020 documents in part, all food items will be labeled, and the label must include the name of the food, the date by which it should be consumed, or discarded and discard food that has passed the expiration date. Facility provided policy titled OnTray Use By Guidelines undated which documents in part, pudding should be use by 3 days.

Based on observation, interview, and record review, the facility failed to ensure the dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 78 residents. Findings include: On 01/15/25 at 8:02 AM, during observation of the outside dumpster with V12 (Cook), one smaller dumpster close to the back door was overfilled with garbage bags with the lid opened. Observed a second larger dumpster in the corner of the parking lot propped open with empty cardboard boxes and the resident's personal refrigerator with some garbage bags inside towards the back of the dumpster. V12 stated that the smaller dumpster close to the back of the door was too full, and that was why the lid was not closed. V12 stated the larger dumpster is mostly empty, with room to put more garbage, but the lid is being kept open because someone did not push the old refrigerator and boxes all the way inside to allow the lid to close. V12 stated the lids should be closed because rats could get up in there. On 01/15/25 at 8:18 AM, V6 (Maintenance Director) observed the dumpsters outside with opened lids and stated the lids should not be open because rodents can get inside because they are attracted to the garbage inside. V6 stated the pest control company the facility uses has rat houses set up outside around the building. On 01/16/25 at 8:03 AM, observed small dumpster close to the back of the door with more garbage bags in it than seen on 01/15/25 and the lid of the dumpster was open. Facility policy titled, Dumpster/Waste Pick-Up Containment dated July 1, 2024 documents in part, the facility will ensure timely pick-up of garbage and proper containment of garbage to prevent pests and the maintenance director/designee must ensure the dumpster is covered at all times.

Based on observation, interview, and record review, the facility failed to ensure (a) hand hygiene was performed between each resident contact during medication administration; (b) proper PPE (Personal Protective Equipment) was worn during a High-Contact Resident Care Activity (gastric tube flush) for a resident on Enhanced Barrier Precautions; (c) proper handling and storing of linens; (d) ensure IPCP (Infection Prevention and Control Program) standard policies and procedures are reviewed at least annually. These failures could affect all 78 residents residing in the facility as of census dated 1/14/25. The findings included: On 01/14/25, at 2:40 p.m., the Surveyor observed 7 uncovered bins with clean linens, washcloths, towels, gowns, bed sheets, fitted sheets, and pillowcases by the basement hallway exposed to the air. On 01/14/25, at 2:52 pm, V6 (Maintenance Director) stated that he has been working in the facility for 9 years and is also responsible for laundry services. V6 said the linens in the bins by the basement hallway were all clean and should be covered when not in use to avoid exposure to contaminants. He said clean linens are used for all residents in the facility, and if clean linens are not stored properly, there could be potential contamination. On 1/15/25, at 8:40 a.m., the Surveyor and survey team observed bins with clean linens uncovered by the basement hallway, exposed to contaminants. On 1/15/25 at 2:09 pm, the Surveyor interviewed V23 (Infection Preventionist / IP Nurse). She said she has been working in the facility for [AGE] years. She said clean linens should be stored or contained properly to prevent exposure to contaminants or potential contamination. On 1/16/25, at 9:45 a.m., the Surveyor toured the laundry room with V6 and observed loose, soiled linens (towels and sheets) not properly bagged inside the chute container. The surveyor also observed a soiled towel not bagged inside the laundry room bin. V6 said staff should properly bag soiled linens/towels for infection control and to prevent contamination. On 1/16/25 at 11:05 a.m., V3 (IP Nurse) said that the policy and procedures provided to the Surveyor, including IPCP standards, are all current / updated. On 1/16/25, at 12:56 pm, the Surveyor interviewed V18 (DON / Director of Nursing). She said clean linens need to be covered to prevent potential contamination or exposure to contaminants. She said clean linens are used by all residents in the facility. V18 said soiled linens and residents' personal clothing should be bagged properly before being sent to the laundry chute for infection control to prevent contamination. The facility's census report dated 1/14/25 showed 78 active residents. The facility's laundry/linen policy and procedure dated 12/23 documented in part: All linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment for patients, healthcare workers, and visitors. The nursing department assumes the direct and immediate responsibility for safely securing all clean and soiled linens. Linens soiled with body fluids shall be placed in a plastic bag before being sent to the laundry for processing. All soiled linens must be bagged in/near the room in which the procedure is being performed. Bags must be securely sealed before being removed from the room. Clean linen must be stored in the linen rooms on each unit. If the facility utilizes a linen chute, no loose items can be thrown down the linen chute and must be bagged per this policy. Facility's infection prevention and control program policy dated 11/2/23: The infection control program meets the guidelines of the US department of health and human services' centers for disease control and prevention, The occupational health and safety administration, local, state and federal rules. 39779 Findings include: On 01/14/25 at 09:25 AM V4 (Registered Nurse) prepared and administered medication standing at the medication cart to R38 in a medication cup and supplied R38 with a cup of water. R38 took her medication then handed the medication and water cup to V4. V4 retrieved the medication and water cup and placed it in the medication cart garbage then began preparing R130's medication without performing hand hygiene. R130 has diagnosis not limited to Orthopedic Aftercare, Effusion Right Knee, Primary Generalized Osteoarthritis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Pyogenic Arthritis, [NAME] Syndrome, Spinal Stenosis, Hyperlipidemia, Hypothyroidism, Polycythemia, Bipolar Disorder, Depression, Retention of Urine, Iron Deficiency Anemia and Muscle Spasm. R130's Physician's Orders document in part: Focus: Enhanced Barrier Precautions: Device IV (Intravenous access site. R130's Care Plan document in part: Focus: Enhanced Barrier Precautions: Resident has a device-Right arm PICC line, wound -right knee surgical site, small opening to great toe, Foley Catheter needing Enhanced Barrier Precautions as prevention. Goals: Staff will prevent the spread of infection. Interventions: Maintain Enhanced Barrier Precautions for High-Risk Contact. Maintain infection control practices through proper handwashing. 01/14/25 at 09:32 AM V4 (Registered Nurse) entered R130 room with Signage posted on the entry door indicating Enhance Barrier Precautions and administered R130 medications. At 09:38 AM V4 returned to the medication cart without performing hand hygiene. R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: Enhance Barrier Precautions: Klebsiella Pneumoniae. R25's Care Plan document in part: Focus: Enhanced Barrier Precautions. Goals: Staff will prevent the spread of infection. Interventions: Maintain Enhanced Barrier Precautions. Maintain infection control practices through proper handwashing. On 01/14/25 09:40 V4 (Registered Nurse) put on a pair of gloves then entered R25's room with Signage posted on the entry door indicating Enhance Barrier Precautions and administered R25's medications. V4 Administered the Basaglar insulin 15 units to R25's left lower abdomen. On 01/14/25 at 10:04 AM V4 (Registered Nurse) returned to the medication cart removed the gloves then put on another pair of gloves without performing hand hygiene. V4 reentered R25 room and proceeded to R25's roommate R7 bed, obtain the gastric tube syringe and water container, went to the bathroom to get water, returned to the bedside then flushed R7 gastric tube with 60 ml (milliliters) of water without putting on a gown. On 01/14/25 at 10:07 AM V4 (Registered Nurse) returned to the medication cart and removed the gloves. V4 was made aware that she (V4) was not observed performing hand hygiene between residents. V4 stated There is a potential for the spread of infection. When flushing R7's gastric tube I should have worn a gown. On 01/16/25 at 09:48 AM V18 (Director of Nursing) stated when passing medication at the start the nurse should wash their hands with soap and water. When going between residents use hand sanitizer so you won't spread infection from one resident to the other. Complete hand washing should have been done, the nurse should have put on a gown and gloves before going to do the gastric tube flush to prevent the spread of infections. Document Titled Enhanced Barrier Precautions document in part: Every Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Policy: Titled Enhanced Barrier Precautions dated 03/01/23 document in part: Enhance Barrier Precautions are indicated (when contact precautions does not otherwise apply). 3. Gloves and gowns must be worn for the following High-Contact Care Activities. Device care or use: central line, urinary catheter, feeding tube and tracheostomy. 4. Enhanced Barrier Precautions are indicated for all residents with any of the following: Wounds and/or indwelling medical devices (e.g., Central line, urinary catheter, feeding tube). 5. During High-Contact of these resident's care. Enhanced Barrier Precautions will be implemented. Titled Hand Hygiene Policy and Procedure undated document in part: Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. All members of the healthcare team will comply with current Centers of Disease Control and Prevention (CDC) hand hygiene guidelines. Indications for handwashing and Hand rubbing: A. Indications for Handwashing: 3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. B. Indications for Hand rubbing: If hands are not visibly soiled, an alcohol-based hand rub may be used routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with a patient's intact skin. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves.

Based on interviews and record reviews, the facility failed to provide a $60 monthly allowance to eligible residents receiving SSA (Social Security Administration) since the increase from $30 to $60 in January 2024. This failure affected 16 eligible residents receiving SSA allowance per resident fund management service (RFMS) dated 1/3/25 in a sample of 48 residents. The findings include: R33's face sheet documented admitted on 7/25/19 with diagnoses not limited to Congestive heart failure, Ischemic cardiomyopathy, Essential (primary) hypertension, Presence of cardiac pacemaker, Venous insufficiency, Benign prostatic hyperplasia, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease. On 1/15/25 at 10 a.m., the Surveyor conducted a resident council meeting, and R33 was one of the attendees. He is alert and oriented x 3 and verbally responsive. R33 said he has been receiving a $30$ monthly allowance given by the facility, the last of which he received a week or so ago. He said there was never an increase in his monthly allowance. On 1/15/25 at 11:04 a.m., the Surveyor interviewed V23 (HR/Human Resource and BOM/Business Office Manager), who has been working in the facility for over a year. Stated she is assisting corporate staff who is distributing resident's trust funds or monthly allowance and is coming to the facility at least once a month. V23 said a resident gave and signed a receipt that a trust fund / monthly allowance was provided. V23 said residents are receiving $ 30 per month, and she is aware that there has been an increase from $ 30 to $ 60 since last year (January 2024) for residents receiving SSA. She said the facility has not implemented it yet. On 1/15/25 at 12:01 p.m., the Surveyor interviewed V1 (the Administrator). She said the facility has been providing a $30$ monthly allowance to residents who are qualified to receive it. She stated she would verify with corporate regarding the monthly allowance and was aware of the increase for certain qualified residents. On 1/15/25 at 12:20 p.m., V1 (Administrator) verified a monthly allowance of R33 and stated he should be receiving a 60$ monthly allowance because he is under SSA. V1 said she spoke with corporate and will provide R33 with back pay as the increase in monthly allowance started last year (January 2024). V1 said it is a resident's rights who are qualified for $60 monthly allowance to receive the correct amount. On 1/16/25 at 10 a.m. V23 (HR / BOM) confirmed with corporate that 16 residents, including R33, reside in the facility under SSA and will be given back payment since there was an increase in monthly allowance from $30 to $60. She said there was only 1 corporate person giving trust funds for 7 facilities and was running behind, so an increase from 30$ to 60$ was not implemented yet. The company has already hired 2 more staff to help distribute trust funds / monthly allowance, and all residents eligible to get $60 will be given a back payment as it is their right to receive the correct amount. MDS (Minimum Data Set) dated 10/9/24 showed R33's cognition was intact. R33's RFMS (resident fund management service) statement dated 1/15/25 showed in part: Allowance = $60.00. Resident advance cash of $30.00 was given every month from January 2024 to January 2025. The facility's RFMS transaction report dated 1/16/25 showed 16 residents under SSA. Provider notice issued 1/25/24 documented in part: This notice informs nursing Facilities (NF) that effective January 1, 2024, provides for the increase in the personal needs allowance (PNA) from $30 per month to $60 per month for nursing home residents who reside in a nursing facility licensed under the Nursing Home Care Act and who are determined to be eligible for Medical Assistance. The facility's Trust Fund Policy, dated 1/2024, documents in part that residents have a right to manage their own funds or to have the facility manage their funds. The patient allowance for residents who receive Social Security benefits or other pension benefits will be $60.00 per month. Facility's resident's rights policy (undated) documented in part: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the state of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this community. Illinois Long-Term care Ombudsman Program Residents' Rights for people in long term care facilities dated 11/18 documented in part: Your rights regarding your money.

Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment [A] failed to maintain hot water temperatures for six [R24, R25, R52, R57, R58, R73] resident's rooms and the third-floor shower room, [B] failed to maintain a safe smoking patio environment related to not removing snow and ice for six [R25, R38, R52, R53, R73, R74] residents outside smoking reviewed in a sample of 18 residents. Findings include, On 1/14/25 at 9:40 AM R24 stated, In my bedroom the water does not get warm enough for two weeks. I'am tired of going to the first floor to take a shower. When I just want to give my self a bed bath, the nurse assistant warms up my water in the microwave. Sometime the water is too hot, and the nurse assistant would have to go bath and forth to get the basin water temperature right. Its not just my room, I been hearing other residents say they don't have warm water either. On 1/14/25 at 10:00 AM, V14 [Certified Nurse Assistant] stated, The water in a few rooms has not been warm for about a week or more. I reported the cool water to V6 [Maintenance Director] and Administration. To have warm water for the residents, I warm up the water basin in the microwave. I test the water temperature by touching the water. The residents are taken down to the first floor for showers, but some residents refuse to go down to the first floor. On 1/14/25 at 12:10 PM, V17 [Certified Nurse Assistant] stated, The water has not been hot for a couple of weeks, but when I need warm water for the residents, I warm up the water in the microwave. I don't know what temperature the water should be at, but I put my finger in the water to see if the water is too hot before washing up the residents. The administration people are made aware the water is not warm. On 1/15/25 at 8:20 AM, R73 stated, The bathroom water is cold, its s been over a week. On 1/15/25 at 2:30 PM, V6 [Maintenance Director] and surveyor obtain water temperatures in the following areas: Residents' bathroom water temperature measured: R24 [ 66 degrees Fahrenheit] [F]. R52 and R58 [63 degrees F]. R25 [72 degrees F]. R57 [72 degrees F]. R73 [65 degrees F]. Third floor shower room temperature measured 64 degrees F. On 1/16/25 at 1:00 PM, V6 [Maintenance Director] stated, The resident's areas such as their bathrooms and shower rooms the water temperature should be 110 degrees Fahrenheit. The whole facility is not affected. The first-floor shower rooms are 110 degrees F. The kitchen is 140 degrees F and laundry is 140 degrees F. The facility has two hot water tanks. One tank was rusted and went out on 1/7/25. The administrator and corporate was made aware the water tank need to be replaced. On 1/10/25 the water tank was ordered and will take up to two weeks for delivery. Once the tank is delivered, it will be installed with in 24-hours. For the rooms with cool water, the nursing staff can go to other areas for warm water. On 1/16/25 at 2:40 PM V1 [Administrator] stated, I was made aware the hot water tank was not working. Corporate was contacted and a new tank was ordered on 1/10/25, should be delivered with in two weeks. There is hot water in other parts of the facility and first floor. I was not aware the nursing staff was warming up basins of water in the microwave. I will provide an in-service and thermometers to all nursing staff to make sure the water is not too hot. Using microwave water could potentially cause burn injury to the resident. Also, all nursing staff will be in-serviced that the first-floor shower room is available for resident showers. On 1/14/25 at 1:35 PM, V1 [Administrator], V10 [Social Service Director], and surveyor observed six residents [R25, R38, R52, R53, R73, R74] and V23 [Assistant Director of Social Service] on the outside smoking. The smoking patio ground was covered with snow and ice. V23 was monitoring residents outside smoking. On 1/14/25 at 1:35 PM, V10 [Social Service Director] stated, I can see the smoking patio from the office window. The snow and ice need removing. I will call V6 [Maintenance Director] to come clear the smoking patio now. On 1/16/25 at 11:38 AM, V23 [Assistant Director of Social Service] stated, I was outside on the smoke patio monitoring the 1:30PM smoke break on 1/14/25. Earlier that morning it was snowing, but the snow had stopped. Typically, V6 [Maintenance Director] would have been contacted to remove the snow and ice to prevent an accident. I allowed the residents to go outside on the smoking patio because the snow and ice was not so bad. On 1/16/25 at 12 PM, V6 stated, On 1/14/25 it did snow in the morning. However, our annual survey started, and I was busy. I forgot to shovel the smoking patio. The social service department was able to shovel the smoking patio as well or they should not have allowed the residents outside on the smoking patio. On 1/16/24 at 12:15 PM, V1 [Administrator] stated, Protocol for snow and ice removal is the Maintenance Director [V6] wound monitor the snow and inclement weather reports and outside premises. V6 is responsible to remove the snow and salt the ground for any ice. The residents should not have been outside on the snow and ice. It snowed this morning [1/14/25], but by the 1:30PM smoke break, my expectation was the snow and ice should have been removed before the residents were allowed outside on the smoking patio. The snow and ice could have potentially caused a fall.' Policies documented in part: Water Temperature Policy date 4/2007. The hot water temperatures are maintained by regulating valves. Resident services 110 degrees Fahrenheit [F] Smoking Safety Policy dated 4/2010 Provide a safe and healthy living environment with respect for the health and well-being needs of each resident. The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. Fall Prevention policy dated 11/28/2012. To assure the safety of all residents in the facility. Identify risk factors, use and implement of professional standards of practice, and communication with staff members. Safety interventions will be implemented for each resident. Maintenance Policy Inspections verify that all equipment and furnishings are clan and free from safety hazards internal and external the building. Building inspections include Water temperatures. 39779 On 01/15/25 at 09:44 AM R25 stated I have complained of the water being warm for at least the pass 2 weeks. I don't know if there is something wrong with the boiler. I have not taken a shower because the water is too cold. I can't do anything for myself and have not had a bed bath. On 01/15/25 at 09:51 AM V4 (Registered Nurse) stated sometimes the residents make the complaint about the water being cold and we try to run the water long enough so that it will warm up. If they want it warmer, we use the microwave so it will be to the residents liking. We have a temperature thing in this room. V4 left the nurse station searching for the device that the water temperature is checked with then returned to the nurse station and stated we normally feel the water and ask the resident is it okay. They will confirm yah or [NAME]. I have not heard any further complaints outside of running or microwaving the water. On 01/14/25 at 01:05 PM R57 stated there have been no hot water for about 3 weeks. Half of the time it is cold, and they will warm the water up. I take a shower at least once a week, twice if possible. I have received 3 showers in the last 3 weeks. Having to bathe in cold water, that makes me feel terrible. I get a bed bath twice a week. 47304 The findings included: R58's face sheet documented admitted on 6/23/23 with diagnoses not limited to Essential (primary) hypertension; Folate deficiency anemia; Rash and other nonspecific skin eruption. On 1/15/25 at 10:00 am Surveyor conducted resident council meeting attended by residents including R58 who is alert and oriented x 3, verbally responsive. R58 said about a week ago, facility have an ice-cold water that he needed to go to his daughter's house to take a shower. R58 said water in 3rd floor shower room is warm and not comfortable for shower. MDS (Minimum Data Set) dated 12/5/24 showed R58's cognition was intact.

Based on observation, interview, and record review the facility failed to a.) to ensure medications were securely stored during medication administration, b,) ensure expired medications were removed from 1 of 2 medication storage rooms and 1 of 3 medications carts and c.) ensure medication was labeled after opening for 1 of 3 medication carts reviewed for medication storage and labeling. Findings Include: On 01/14/25 at 09:25 AM V4 (Registered Nurse) prepared and administered medication standing at the medication cart to R38 in a medication cup and supplied R38 with a cup of water. During R38 medication preparation V4 wasted (Aspirin 325 mg (milligram)) orange pills in the top drawer of the medication cart. V4 put on gloves then placed the pills in a clear drinking cup (half full) and placed the cup on top of the medication cart. On 01/14/25 at 09:32 AM V4 (Registered Nurse) entered R130 and left the clear cup with the Aspirin on top of the medication cup unattended. On 01/14/25 09:40 V4 (Registered Nurse) entered R25's room leaving the clear cup with the Aspirin on top of the medication cart unattended. On 01/14/25 at 10:07 AM V4 (Registered Nurse) returned to the medication cart then placed the clear cup with the Aspirin 325 mg in the drawer of the medication cart. Surveyor asked was the clear cup of orange pills (Aspirin 325 mg) supposed to be left on top of the medication cart unattended. V4 responded I inadvertently left the pills in the cup on top of the medication cart. Someone could have taken the pills. On 01/14/25 at 11:44 AM the 2nd floor medication storage room was reviewed with V7 (Licensed Practical Nurse) One bottle of Liquid Pain Relief Acetaminophen 160 mg/5ml was observed in the cabinet with an expiration date of 12/24. V7 removed the medication from the medication storage room. On 01/14/25 at 11:49 AM the 2nd floor medication cart 1 was reviewed with V7 (Licensed Practical Nurse). One bottle of B complex was observed with an expiration date of 10/24 and One bottle of docusate sodium liquid 50mg/5ml with an expiration date of 10/24. On 01/14/25 at 12:51 PM the second-floor medication cart 2 was reviewed with V8 (Agency Licensed Practical Nurse) R1 Breztri aerosphere dispensed 12/27/24 was observed in the medication drawer with no open date. On 01/16/25 at 09:43 AM V18 (Director of Nursing) stated expired medications should be removed from the medication cart and medication room and properly disposed of. This should be done so you don't give a resident expired medication. When medications are opened it should be dated to know when to dispose of it. On 01/16/23 at 02:33 PM V2 (Interim Director of Nursing) stated medications should not be left on top of the medication carts because anyone can get them. Policy: Titled Medication Storage in the Facility effective date 07/18 document in part: medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations for those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, four staff members lawfully authorized to administer medications. E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart designated area. Expiring Date: B. Drugs dispensed in the manufacturers original container will be labeled with the manufacturer's expiration date. E. When the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best sticker to affix contain both a date opened and expiration' notation line). H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Titled Medication Storage revised 07/02/24 document in part: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. 3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.

Based on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect seven residents (R9, R10, R31, R35, R47, R56) receiving pureed diets prepared in the facility's kitchen based on list of residents receiving pureed diets dated 01/16/25 in a sample of 48. Findings Include: On 01/14/25 at 11:52 PM, during unit dining tours observed residents on regular diet consistencies receive roast turkey, egg noodles, mixed vegetables, fruit cup, and bread with margarine. Observed R9, R31, R35, R47, R56 who were on pureed diets receive pureed turkey, mashed potatoes, pureed vegetable, and pureed dessert. Pureed bread was not served. Pureed buttered noodles were not served. On 01/14/25 at 12:07 PM, observed lunch tray line in the kitchen still in progress with V12 (Cook) serving the food. V12 stated residents on regular diets and mechanical soft diets are receiving egg noodles and the pureed diets are receiving mashed potatoes in place of the egg noodles. On 1/14/25 at 12:08 PM, V11 (Dietary Manager) stated the residents on pureed diets get the same food as the residents on regular diet consistencies except in pureed form. On 01/14/25 at 12:09 PM, V12 stated V12 made mashed potatoes instead of pureeing the egg noodles. V12 stated V12 did not prepare pureed bread so the residents on pureed diets did not get it today. V12 stated, I just didn't do it. I didn't have time. On 01/15/25 at 7:30 AM, observed breakfast tray line in progress with V12 (Cook) serving the food. Observed one large pan of oatmeal. Surveyor observed oatmeal to be thick and lumpy. V12 stated V12 does not puree the oatmeal and that residents on regular and pureed diet receive the same oatmeal because the oatmeal is soft enough to give to the pureed diets. On 01/15/25 at 7:49 AM, V11 (Dietary Manager) stated giving the same oatmeal to the residents on regular and pureed diets is okay because the oatmeal is real soft. V11 stated the oatmeal does not need to be pureed. On 01/16/25 at 9:33 AM, via phone interview V21 (Speech Language Pathologist) stated a resident could require a pureed diet for overt mastication difficulties which means the resident cannot break down the food properly and this could lead to choking and/or aspiration. V21 stated pureed foods should be a smooth consistency with no lumps or bumps. V21 stated oatmeal should be pureed after it is cooked to prevent lumps and bumps; it should have a flow to it and not be too thick or sticky. V21 stated as a preventative measure the oatmeal should be pureed to be safer for a resident on a pureed diet. V21 stated serving oatmeal which is too thick and/or has lumps in it could potentially lead to swallowing difficulties. On 01/16/25 at 11:13 AM, V19 (Consultant Registered Dietitian) stated the kitchen should be following the spreadsheets and serving all the items listed. V19 stated this is important to make sure the meals fall within the parameters of the diet for calories, and protein. V19 stated if items listed on the spreadsheets are not being provided over time there is the potential for weight loss. V19 stated the spreadsheets and recipes should also be followed to make sure the kitchen is providing the correct texture and consistency for the diet order as generated by the physician. V19 stated if the food can be pureed safely, and the pureed item is palatable the pureed diets should be receiving the same foods as the residents on a regular diet consistency except in pureed form. V19 stated pureed diet consistencies should be smooth and free from chunks and hot oatmeal needs to be pureed because of the lumps. V19 stated the pureed diets should have received pureed egg noodles instead of mashed potatoes. V19 stated this is important for an eating enjoyment component in terms of offering greater variety of items to residents on pureed diets and from a dignity standpoint as residents on pureed diets have the right to be served the same meal as the regular diet consistencies. Facility provided copy of R9, R10, R31, R35, R47, R56's physician order sheets which document in part pureed diet texture as part of diet order. Facility provided copy of R9, R10, R31, R35, R47, R56's meal tickets which document in part, pureed diet texture and list pureed buttered noodles and pureed buttered white bread to be served on lunch - day 17 and pureed hot cereal to be served on breakfast - day 18. Facility provided copy of Diet Spreadsheet Tuesday day - 17 which documents in part for pureed to be served at lunch pureed buttered noodles, and pureed buttered white bread. Facility provided copy of recipes titled Pureed Buttered Noodles dated 2024, Pureed Buttered Dinner Roll dated 2025 and Pureed Hot Cereal dated 2024. Facility provided document titled, Pureed dated 2022 which documents in part hot oatmeal should be modified in a blender or food processor for pureed diets and pureed regular bread continue to be pureed as a separate menu item. Facility provided document titled, Cycle Menu dated 2018 which documents in part, the menu spreadsheets will be used in tray service. Facility provided document [NAME] dated 01/05 documents in part, duties, and responsibilities to include prepared food according to written menus and use standardized recipes.

Based on observations, interviews, and record reviews, the facility failed to provide fortified supplement as prescribed by the physician for six (R4, R10, R15, R23, R34, R55) residents reviewed in a total sample of 48. Finding include: On 01/15/25 at 7:30 AM, observed breakfast tray line in progress with V12 (Cook) serving the food. Observed one large pan of oatmeal. V12 stated V12 only prepared one type of hot cereal for the meal which was the oatmeal and that V12 had not prepared super cereal. V12 stated the oatmeal V12 prepared is like super cereal because V12 adds brown sugar, and cinnamon to it. V12 stated the oatmeal is prepared with water. On 01/15/25 at 7:47 AM, V11 (Dietary Manager) stated super cereal is a fortified food and is used for residents who need to gain weight. V11 stated super cereal is recommended by the Registered Dietitian and ordered by the resident's physician. V11 stated super cereal is listed on the resident's meal ticket to be served at breakfast daily. V11 stated super cereal is not the same as regular oatmeal and that there is a specific recipe for super cereal which the cook should be following. V11 stated the cook should have made super cereal today. On 01/16/25 at 11:13 AM, V19 (Consultant Registered Dietitian) stated fortified foods are used to add extra calories and protein to a resident's diet. V19 stated V19 may use super cereal as a nutrition intervention for an additional calorie source if a resident is losing weight. V19 stated if super cereal is ordered by the physician, then it should be made and provided to the resident. V19 stated if the resident had an order for super cereal but was not being provided with the super cereal then the planned and/or desired weight gain may not occur. Facility provided copy of R4, R10, R15, R23, R34, R55's breakfast meal tickets which list Super Cereal to be provided. Facility provided copy of R4, R10, R15, R23, R34, R55's Physician Orders which document in part, super cereal at breakfast. Facility provided recipe titled Super Cereal dated 2025 includes ingredients not limited but including non-fat dried milk, evaporated milk, margarine, brown sugar, granulated sugar. Facility provided recipe titled Choice of Hot or Cold Cereal dated 2024 includes ingredients not limited to water to prepare hot cereal and salt. Facility provided policy titled Fortified Foods dated 2017 which documents in part, fortified foods may be tried for clients who have difficulty meeting their nutritional needs with the regular food provided at mealtimes, fortified foods include items such as super cereal, and information on serving the fortified foods will be on the tray ticket.

Based on interview and record review, the facility failed to (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R10, R11, R18, R25, R35) of eight residents reviewed for pneumococcal vaccinations in a sample of 48 residents. The findings include: 1. R10's face sheet admitted on 12/31/08, age 97, with diagnoses not limited to -Alzheimer's disease and essential (primary) hypertension. R10's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS (Minimum Data Set) dated 1/2/25 showed R10's cognition was severely impaired. MDS showed that the Pneumococcal vaccine was not given and was not offered. R10's has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R10's record. 2. R11's face sheet documented admitted on 1/3/23, age 90 with diagnoses not limited to Alzheimer's disease; Type 2 diabetes mellitus; -Chronic kidney disease, stage 3. R11's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS dated [DATE] showed R11's cognition was severely impaired, and the Pneumococcal vaccine was not given and was not offered. R11 has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R11's record. 3. R18's face sheet documented admitted on 6/4/24, age 79 with diagnoses not limited to Dementia; Essential (primary) hypertension; Encephalopathy, unspecified. MDS dated [DATE] showed R18's cognition was severely impaired, and the Pneumococcal vaccine was not given and was not offered. R18's immunization record showed Pneumovax23 was given on 11/2/16. 4. R25's face sheet showed admitted on 11/9/21, age 61 with diagnoses not limited to Paraplegia; I10-Essential (primary) hypertension; Unspecified atrial fibrillation; Peripheral vascular disease, unspecified; Type 2 diabetes mellitus; chronic kidney disease, stage 3. MDS, dated [DATE], showed R25's cognition was intact. R25 has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R25's record. 5. R35's face sheet documented admitted on 6/5/24, age 84, with diagnoses not limited to Malignant neoplasm of the prostate; Essential (primary) hypertension; -chronic kidney disease, stage 3. R35's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS dated [DATE] showed R35's cognition was severely impaired. R35's has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R35's record. On 1/15/25 at 2:09 PM, the Surveyor interviewed V3 (Infection Preventionist / IP nurse), who stated she has been working in the facility for [AGE] years. She said they are following CDC (Centers for Disease Control) guidelines regarding Pneumococcal immunization. V3 said all eligible residents should receive Prevnar 20. She said assessments are done for pneumococcal vaccination to determine if they are eligible, provide education, and document in resident's health records. She said that those residents who are eligible to receive the Pneumococcal vaccine should be offered at least annually, document education, or refusal. The surveyor reviewed pneumococcal immunizations for the following residents with V3 (IP nurse) and said R25's pneumonia vaccine (pcv23) was given on 10/19/14. V3 said they are waiting for PCV20 vaccine. No education or assessment found in R25's record. V3 said R10, has no Pneumococcal immunization record. No education provided or assessment found in R10's record. V3 said R18 pneumo vaccine (PPSV23) was given on 11/02/16. No education or assessment found in R18's record. V3 said R35 has no record of the pneumonia vaccine. No assessment or education found in R35's record. V3 said R11 PPSV23 was given on 10/1/15. PCV13 was given on 10/31/19. No assessment or education found in R35's record. V3 said Pneumonia vaccine is given to residents for preventative measures to prevent possible severe complications. The pneumonia vaccine is not guaranteed to have 100% protection from pneumonia, but it could possibly or potentially prevent severe symptoms or complications from the disease. On 1/16/25 at 12:56 PM, the Surveyor interviewed V18 (DON / Director of Nursing) and said Pneumonia immunization is offered and encouraged to all residents. Assessment should be done to determine the eligibility for the vaccine; education should be provided and documented in the resident's record. V18 said the Pneumo vaccine is given to boost resident's immune systems related to pneumonia and is not 100% guaranteed protection but could prevent severe complications. She said facility is Following CDC guidelines regarding pneumococcal immunization. The facility's resident pneumococcal vaccination info showed: R25 PPSV23 was given on 8/19/15 with no education. R10 no pneumococcal vaccine record and no education. R18 PCV13 was given on 10/1/19, but no education was provided. R35 no pneumococcal vaccine record and no education. R11 PCV13 was given on 10/31/19, no education provided The facility's influenza and pneumococcal policy dated 4/21/22 was documented in part to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia. The facility shall provide residents or legal representatives with pertinent information about the significant risks and benefits of vaccines. Each resident is offered a pneumococcal immunization per CDC recommendations. The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of immunization and either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. CDC's Pneumococcal Vaccination 2024 showed in part: Age [AGE] years or Older who have not previously received a dose of PCV13, PCV15 or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. Previously received PCV 13: 1 dose PCV20 or 1 dose PPSV23. Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20. Administer PCV15 or PCV20 at least 1 year after the last PPSV23 dose. Age 16-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20.

Based on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerators, c.) ensure resident refrigerators are in proper working order. This has the potential to effect one resident (R53) out of six residents reviewed for personal food storage in a total sample of 48. Findings include: On [DATE] at 12:21 PM, R53 gave surveyor permission to look in R53's personal refrigerator at bedside. The inside of R53's refrigerator was warm, not cold, or cool. All items inside felt warm to the touch. Thermometer located inside R53's refrigerator read 58 degrees Fahrenheit (F). The temperature log on the outside of R53's refrigerator documented in part that on [DATE] the refrigerator temperature was 38 degrees F. Inside R53's refrigerator found the following items: 1.) Two unopened 2-ounce packages labeled Smoked Ham and printed on packaging use by [DATE] by manufacturer. 2.) In freezer compartment of refrigerator found fully defrosted box labeled Beef Pot Pie. Cardboard packaging was completely wet, saturated with water. Not dated. 3.) Two unopened 7-ounce containers labeled as Strawberry Creme Parfait. Not dated. 4.) One unopened 8-ounce container labeled as Rice Pudding with Cinnamon. Not dated. On [DATE] at 12:35 PM, V14 (Certified Nursing Assistant) it is housekeeping's responsible to check the temperatures of the resident's refrigerators every day and the CNAs assist with cleaning out the resident's refrigerators and check the date of the food items before giving an item to the resident to make sure it has not expired. On [DATE] at 12:40 PM, V14 observed items inside R53's refrigerator and stated the deli ham had expired and should be thrown out. V14 stated the Beef Pot Pie should be frozen solid and there is no date on it so there is no way to know how long it has been in there. V14 felt the Strawberry Creme Parfait and Rice Pudding containers and stated they feel like they are at room temperature, and they should be cold. V14 stated, that refrigerator is hot in there and maintenance is needed and that is a serious concern. V14 stated it is important for the temperature of the refrigerator to be cold to keep the food fresh and safe for the residents to eat. On [DATE] at 1:21 PM, V6 (Maintenance Director) stated the housekeeping staff checks the temperatures of the resident's refrigerators daily and let V6 know if the temperatures are higher than 40 degrees F or below 30 degrees F. V6 stated V6 is responsible for making sure the resident's refrigerators are in working order and V6 rounds once a week to check to see if they are in working order. On [DATE] at 1:29 PM, V6 observed R53's refrigerator and stated the temperature is 60 degrees and it's pretty warm in there and none of the items inside are cold at all. V6 stated the risk to the resident if the refrigerator temperature is not at the right temperature being 40 degrees or less is the food could spoil and make them sick if they ate any of the food inside it. On [DATE] at 9:56 AM, V12 (Dietary Manager) stated the refrigerator temperatures should be 40 degrees F or below. On [DATE] at 11:35 AM, V19 (Consultant Registered Dietitian) all food items in resident personal refrigerators should be labeled and dated to prevent food borne illness and expired items should be discarded so they are not consumed by the resident. On [DATE] at 9:20 AM, V2 (Interim Director of Nursing) stated it is the CNAs responsibility to label and date food items in a resident's refrigerator, and to discard any expired items. V2 stated it is important that this is done because the food can spoil and if the resident was to eat any of those expired items they would get sick. R53's Refrigerator Log dated [DATE] documents in part, food refrigerator temperature to range ,d+[DATE] degrees F. Facility provided policy titled, Refrigerators (Resident) Policy for Maintaining and Cleaning undated, documents in part: 1.) The maintenance/housekeeping staff is responsible for ensuring that a resident's refrigerator is in proper working order. 2.) The CNA responsible for overseeing care for a resident with a refrigerator will check all contents for proper date of food items and check for cleanliness of the refrigerator on a weekly basis. 3.) If the CNA finds that the refrigerator has outdated food, the CNA will dispose of all outdated food and notify the resident. Facility provided policy titled, Food from Family, Visitors, Community dated 2020 documents in part, in order to prevent foodborne illness outbreaks, the facility staff will ensure proper handling, serving, and storage of any food items brought into the community and food stored for residents should be labeled and dated appropriately and discarded per safe food storage guidelines.

Based on observation, interview, and record review the facility failed to ensure a resident received the prescribed amount of insulin for 1 (R25) resident reviewed for significant medication error in a sample of 48. Findings Include: R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: Basaglar Kwik Pen U-100 Insulin 100 unit/ml (milliliter) (3 ml) subcutaneous, inject 15 units by subcutaneous route Twice a day. Monitor Blood Sugar AC/HS (before meals/hour of sleep. R25's Care Plan document in part: Focus: Diabetes Mellitus: Resident has elevated blood glucose level secondary to diagnosis of NIDDM (Non-Insulin Dependent Diabetes Mellitus). Interventions: Monitor blood glucose level as ordered by MD (Medical Doctor). On 01/14/25 09:40 V4 (Registered Nurse) prepared R25's medication and placed a needle on the insulin Kwik pen then set the dial to 15 units without priming the needle. On 01/14/25 at 09:56 AM V4 (Registered Nurse) said I am going to check R25's blood glucose. The nurse may have missed the blood sugar. I think he (R25) should be fine because he has already eaten. V4 entered R25's room and administered the Basaglar insulin 15 units to R25's left lower abdomen. On 01/14/25 at 10:07 AM V4 (Registered Nurse) stated I figured since R25 had eaten, the blood glucose would not be accurate, and I felt it was safe to give 15 units of insulin as ordered. I should have primed the Kwik pen after putting on the needle. There is a potential R25 did not get the full dose of the insulin. On 01/16/24 at 09:36 AM V18 (Director of Nursing) stated the procedure when giving insulin is to check if it is for the resident, right dose medication, get the needle out, check to see what I am about to give, clean the top with an alcohol wipe, apply the sterile needle then prime the needle with two units, check dose and go to that dose. The nurse should explain what is being done, clean the site then administer the insulin. The purpose for priming the needle is not to give air and to give the exact dose. If priming the needle is not done the resident won't get the correct dose and air is injected into the residents' skin that is not needed. This would result in not giving the correct dose that the doctor ordered and that would be a medication error. Policy: Titled Medication Administration Policy updated 01/24 document in part: 17. Qualified nursing personnel shall perform monitoring (apical pulse, blood pressure, blood sugar test, etc.) prior to medication administration. Medication may be withheld in conjunction with monitoring results. Titled Insulin Administration Policy revised 07/02/24 document in part: To ensure proper administration of insulin. 1. Perform hand hygiene and apply clean gloves. Title Flex Pen Insulin Administration reviewed 09/24 document in part: Flex Pen is used to administer manmade insulin to control high blood sugars on residents with diagnosis of Diabetes Mellitus. Procedure: 1) Wash Hands. 6) To avoid injecting air and ensure proper dosing, perform air shot before each injection. 7) Turn dose selector to 2 units, hold Flex Pen with needle pointing upwards, tap cartridge gently 2 times with finger a few times. Keep needle pointing upwards and press push button all the way in and see a drop of insulin appears at the end of the needle tip.

Based on interviews and record reviews, the facility failed to follow its policy and procedure to ensure advance directives are included in residents' comprehensive care plans and updated as indicated for three (R32, R47, R63) out of 12 residents reviewed for advance directives in a final sample of 48 residents. Findings include: R47 was admitted to the facility on [DATE], and diagnosis included but was not limited to Parkinson's Disease and Neurocognitive Disorder with Lewy Bodies. R47 MDS dated ,d+[DATE] documents in part, resident is rarely/never understood. R47's Physician Orders dated [DATE] documents in part Do Not Resuscitate (DNR) ordered [DATE]. R47's POLST (Practitioner Order for Life-Sustaining Treatment) Form dated [DATE] documents, in part, no CPR: Do Not Attempt Resuscitation (DNAR). R47's Advance Directives/Code Status care plan dated [DATE] documents in part, I wish for my code status to be FULL CODE. I am my own decision maker and have no POLST form on file at this time. On [DATE] at 8:55 AM, V10 (Social Service Director) reviewed R47's EHR (Electronic Health Record) and stated R47 has a physician order dated [DATE] for DNR and a POLST Form dated [DATE] for DNR. V10 stated that R47's advance directives care plan says full code, and that is a mistake. V10 stated that R47's care plan should have been updated to be DNR. V10 stated that the resident's wishes in the care plan should match the physician's orders and that the resident's care plans should be updated to reflect the resident's wishes. V10 stated it is important for the advance directive care plan to be updated so the nurses and the rest of the team know the code status of the resident and the plan of care in case of an emergency. R63 was admitted to the facility on [DATE], and the diagnosis included but was not limited to Age-Related Osteoporosis, Glaucoma, and Chronic Pain. R63's Physician Orders dated [DATE] documents in part, full code ordered [DATE]. On [DATE] at 02:54 PM, the surveyor reviewed R63's care plans. R63 has no care plan for advance directives in R63's EHR. On [DATE] at 8:59 AM, V10 (Social Service Director) reviewed R63's EHR and stated R63 is full code. V10 stated R63 does not have a care plan for advance directives but R63 should have one. Facility provided policy titled Advance Directives dated [DATE], which documents in part advance directive (s) shall be included in the resident's care plan and will be reviewed quarterly and updated, as needed. The facility provided policy titled Comprehensive Care Plan dated [DATE], which documents in part: 1.) Purpose to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2.) Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment. 3.) The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. 47304 The findings include: R32's face sheet documented admitted on [DATE] with diagnoses not limited to Hemiplegia following cerebral infarct affecting right dominant side; Malignant neoplasm of prostate; Chronic systolic (congestive) heart failure; Essential (primary) hypertension; Type 2 diabetes mellitus without complications. On [DATE] At 8:48 am Surveyor interviewed V10 (SSD / Social Service Director) and said Advance directives include code status of the resident, to see what they would like or their wishes for medical care. She said code status is very important so staff will be able to know how to proceed when there is an emergency. V10 stated there should be a Care plan for advance directives so nurses know how to care for the resident during emergency whether to do CPR (Cardiopulmonary Resuscitation) for Full Code and or DNR (Do Not Resuscitate). She said Code status should have an order either full code or DNR. Surveyor reviewed R32's EHR (Electronic Health Record) with V10, no care plan found for advance directives. On [DATE] at 12:56pm Surveyor interviewed V18 (DON / Director of Nursing) and said resident should have Advance directives / code status and should be care plan so staff can carry out the resident's wishes for medical care whether to proceed with full CPR or DNR during emergency situation. MDS (Minimum Data Set) dated [DATE] showed R32's cognition was intact. R32's physician order dated [DATE] showed order not limited to: Advance Directives - Full code. R32's care plan reviewed and found no care plan for advance directives.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards for a PICC (Peripherally Inserted Central Catheter) line for 1 (R130) of 3 (R17, R132) sampled residents related to the maintenance of intravenous access devices. Findings Include: R130 has diagnosis not limited to Encounter for Other Orthopedic Aftercare; Primary Generalized (Osteo)Arthritis; Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Hyperlipidemia, Hypothyroidism, Polycythemia Vera, Bipolar Disorder, Effusion, Right Knee, Pyogenic Arthritis, [NAME] Syndrome, Spinal Stenosis, Testicular Hypofunction, Depression, Retention of Urine, Morbid (Severe) Obesity, Iron Deficiency Anemia and Muscle Spasm. R130's Care Plan document in part: Focus: Intravenous Therapy: Antibiotic therapy. Resident has a need for IV (Intravenous) antibiotic therapy ceftriaxone 2-gram solution due to osteomyelitis. IV site will remain free of signs and symptoms of infection. R130's Resident Medication Administration Record provided by facility on 01/14/25 document in part: PICC (Peripherally Inserted Central Catheter) line IV catheter-change catheter dressing site dressing, start date: 01/14/25 with blank entry on date of 01/14/25. Resident Medication Administration Record provided by facility on 01/16/25 document in part: PICC line dressing change dated 01/15/25. On 01/14/25 at 09:32 AM R130 was observed lying in bed with a right arm PICC line dressing dated 01/07/25. On 01/15/25 at 09:29 AM R130 was observed lying in bed with a single lumen PICC line to the right arm with dressing dated 01/07/25. R130 stated they said that they will be back in to change the dressing. I receive IV antibiotics every morning. On 01/15/25 at 10:00 AM V4 (Registered Nurse) stated the PICC line dressing is change every 7 days and I would assume it would be in the morning. It would be documented on R130's 11pm-7am TAR (Treatment Administration Record). On 01/16/25 at 09:13 AM V18 (Director of Nursing) stated the PICC line dressing are changed weekly or as needed. When the dressing is changed it is signed and dated. If the PICC line dressing is not changed as ordered there's a potential for infection control and the assessment of the site. The dressing is changed to see if there is any change in the PICC line length and the site to see if there are any signs of infection. If R130's PICC line was dated 01/7/25 it should be changed the 01/14/25. Policy: Titled PICC Line / Midline Dressing Change Policy dated 04/23 document in part: PICC line/Midline catheter dressings will be changed at specific intervals, or when needed, to prevent catheter related infections associated with contaminated, loosened, or soiled catheter-site dressings. Guidelines: 1. Change PICC/Midline catheter dressings 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Documentation: The following information should be recorded in the resident's medical record. a. Date and time dressing as changed.

Based on observation, interview, and record review the facility failed to ensure a resident with a tracheostomy had the required emergency equipment at the bedside for 1 (R17) resident reviewed for respiratory care in a sample of 48. Findings Include: R17 has diagnosis not limited to Tracheostomy, Chronic Respiratory Failure, Gastrostomy, Dysphagia, Morbid Obesity, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, Hypertensive heart disease, Epilepsy, Shortness of Breath Type 2 Diabetes Mellitus and Primary (Essential) Hypertension. R17's Physician's Orders document in part: Tracheostomy tube changes every 3 months and prn (as needed). (Tracheostomy tube) 6 as needed. Change Inner Cannula (Tracheostomy tube) 6 once daily and prn. R17's Care Plan document in part: Focus: Tracheostomy: Resident with tracheostomy r/t (related/to) dx (diagnosis) of chronic respiratory failure. On 01/14/25 at 01:12 PM Enhanced Barrier Precaution signage was observed on R17's entrance door. Upon entering R17's room, a suction machine, suction catheters, ambu bag and oxygen concentrator was observed at the bedside. On 01/14/25 at 01:17 PM V4 (Registered Nurse) stated R17 has oxygen but really don't use it because he is pretty stable. Surveyor asked V4 the location of R17's emergency step-down trach (Tracheostomy). V4 stated R17 wears an emergency step down #6 (tracheostomy tube trach). V4 proceeded to look in the medication cart drawer then pulled out an inner cannula that was not compatible with the trach that R17 has in use. On 01/14/25 at 01:26 PM V4 (Registered Nurse) entered R17 room then looked at R17 trach and stated R17 has a (tracheostomy tube) XLT (Extra Length Tracheostomy) #6, and the step down should be a #5. V4 looked in the bedside cabinet, on the counter at the bedside and could not locate the emergency step-down trach. V4 exited R17 room and stated, I will have to look for the emergency step-down (tracheostomy tube) trach. On 01/14/25 at 01:32 PM V4 (Registered Nurse) went to a room then returned to the nurse station with a tracheostomy in a box and stated it was in the supply room. When asked, if R17's tracheostomy had dislodged what would she (V4) do. V4 responded, I would have to get the one on the crash cart. I can put this one in R17's room, it is a #6 (tracheostomy tube) XLT. On 01/16/24 at 09:20 V18 (Director of Nursing) stated the tracheostomy supplies at the bedside should be a tracheostomy cannula step down by the wall, that is priority. Suction equipment should always be at the bedside. We should have the trach in the supply room, trach care kit, ties, and dressing change. In case the tracheostomy gets dislodge there is a potential for the stoma closing. It is not good if the stoma closes because that provides an airway for the resident. If the tracheostomy gets dislodged that is bad and the airway could possibly close. The stoma can close. The emergency tracheostomy should be easily assessable at the head of the bed so you can easily grab it. Policy: Titled Tracheostomy Care revised 11/24 document in part: 2. Gather the necessary equipment; (c) Emergency tracheostomy tube replacement the same size or one size smaller (should be kept at the bedside). (g) Trach care kit.

Based on observation, interview, and record review the facility failed to a.) ensure the accurate shift change reconciliation accountability record for controlled substance and b.) ensure an accurate accountability for 2 controlled substances (Clonazepam/Tramadol) by resolving discrepancies in a timely manner. This deficient practice was identified for 1 of 3 medication carts used to store controlled narcotics. Findings Include: Document titled Shift Change Accountability Record for Controlled Substance document in part: 2nd Month-Year January 2025: nurse Initials were missing for 01/13/25 second shift, third shift and 01/14/25 first shift. R9's Control Drug Receipt/Record/Disposition Form: document Date received 07/19/24, Drug Name/Strength: Tramadol HCL Tab 50 mg (Milligrams), Directions: One tablet by mouth every 6 hours as needed for pain. Quantity Received: 30. Amount Left: 16. R9's Bingo Medication Card contain a total of 15 Tramadol HCL Tabs indicating one missing tablet. R59's Control Drug Receipt/Record/Disposition Form: document Date received 10/31/24, Drug Name/Strength: Clonazepam 0.5 mg Directions: Two tablets (1 mg) per g (gastric) - tube three times daily. Quantity Received: 60. Amount Left: 41. R59's Bingo Medication Card contains a total of 39 Clonazepam 0.5 mg indicating two missing tablets. On 01/14/25 at 12:02 PM the second-floor medication cart one was reviewed with V7 (Licensed Practical Nurse). V7 stated when we come in, we count and sign off on the Narcotic Accountability Sheet at the beginning and end of each shift. The narcotics are signed out once given. If there is a discrepancy, we inform the director of nursing. On 01/16/25 at 09:27 V18 (Director of Nursing) stated the purpose of the Shift Change Accountability Record for Controlled Substance is to ensure the narcotic count is completed at the beginning and the end of each shift. Two people should sign it and if it is not signed the narcotic count was not done. If there is a discrepancy the supervisor or director of nursing should be notified and an investigate is done to check for what's going on, check medication card and reprimand whoever was involved. If there are narcotics missing, there is a potential that someone is stealing medication, or the medication is not being giving. Policy: Titled Narcotic/Controlled Substance Counting Policy revised 09/24 document in part: To ensure controlled medications are counted and verified with (2) license nurses on each shift to verify the accuracy of narcotic log sheets. Procedure: 2. Obtain sign-in/sign-out-controlled log sheet and keys to the controlled storage compartment. 4. Have co-nurse assist in the count, if the co-nurse is not available, call the director of nursing. 9. Verbally state medication count to person with sign-out record. 10. Listen while co-nurse verifies the count. 13. Sign name, time, and date of completed count. Procedure for errors in controlled substance count: 1. If the count is not correct and/or the narcotic log sheet from the previous shift was not signed, inform the director of nursing, or administrative nursing staff.

Based on review of records and interviews the facility failed to protect the rights of every resident to be free from verbal or physical abuse for 1 out of 4 residents (R1) reviewed for resident rights to be free from abuse. These failures do not conform with the abuse policy of the facility. Failures affected 1 resident (R1) that had directed verbal aggression and was poked in the hand by R2. Findings include: R1 an [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/02/2024, scored 13. R1 is alert. R1's diagnosis includes dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2 [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/03/2024, scored 14. R2 is alert. R2's diagnosis includes dementia, psychotic disturbance, major depressive disorder. Per facility's incident report investigation with initial date of 12/02/2024, and final date of 12/06/2024, it documents that abuse was founded. R1 stated on 12/01/2024, her roommate R2 was throwing tissues on the floor, threw a cup of water on the floor and tapped/poked her hand. Per social services notes of V4 (Assistant Director of Social Services) dated 12/01/2024, at 3:42 PM, documents that R2 was exhibiting increase agitation being verbally aggressive towards R1. R2 verbalized that she was upset with R1 because R1 placed her items on her meal tray. R2 became physically aggressive with R1 by tossing the cup on the floor. Per nursing notes of V5 (Licensed Practical Nurse) dated 12/03/2024, at 8:49 AM, documents that R1 informed V5 about her finger. R1 was asked how she injured her finger? R1 stated, Yesterday my roommate poked my hand. Written statement of V6 (Licensed Practical Nurse) dated 12/02/2024, documents that when she asked R1 how she got the skin tear to her finger? R1 verbalized that her roommate (R2) had it her on her left hand yesterday (12/01/2024) causing her some bruising. Per nursing notes of V3 (Licensed Practical Nurse) dated 12/05/2024, 9:25 AM, documents that when R1 was asked how she injured her finger? R1 stated, Yesterday my roommate poked my hand. On 12/24/2024, at 11:55 AM, V3 stated that she cannot determine whether it was left or right of R1 that was tapped or poked. V3 stated that R1 had a skin tear on the left hand. V3 stated that she cannot remember the exact date when the poking incident happened. She (V3) did not work the day before (12/01/2024) when R1 informed her with the skin tear (12/02/2024). The facility submitted the nursing schedule for 12/01/2024 and 12/02/2024. V3 worked on both 12/01/2024 and 12/02/2024. V3 stated that R1 asked to be transferred on 12/02/2024 after she told me (V3) about the incident with R2. V3 stated that tapping or poking another person's hand without permission is considered abuse. Written statement of V3 dated 12/01/2024, documents that she worked for 16 hours when social worker called her into the room and broken crackers, tissue, and paper towels on the resident bed and on the floor. On 12/24/2024, at 12:42 PM, V8 (Wound Care Nurse / Licensed Practical Nurse) verified that on 12/03/2024, she saw R1 with skin tear on her left hand, 2nd to the last finger. On 12/24/2024, at 1:07 PM, V4 (Assistant Director of Social Services) stated that on 12/01/2024, when he came in the room. R2 was upset with her roommate (R1). R2 was verbally aggressive towards her roommate or yelling towards R1. The nurse (V3) told him that R2 was yelling and screaming. V4 stated that he did not ask R2 what she screamed to R1. V4 stated that screaming at another person may constitute verbal abuse. V4 stated that transferring of R1 or R2 into another room may help residents to be safe and prevent another similar incident. On 12/26/2024, at 11:11 AM, V1 (Administrator) stated that she was not informed on 12/01/2024, when social service saw R1 with verbal aggression. V1 was informed the next day which was 12/02/2024. V1 stated that she expects facility staff to inform her when a similar incident happens. V1 stated that staff should have called her on 12/01/2024, when the incident between R1 and R2 happened. V1 stated that there was abuse between R1 and R2 because R2 said that she tapped/poked R1's hand. R2 demonstrated what she did (V1 tapped her left hand). Abuse Prevention Policy dated 10/24/2024, reads: This facility affirms the right of our residents to be free from abuse. This facility prohibits abuse of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secured environment. The purpose of this policy is to assure that facility is doing all that is within its control to prevent occurrences of abuse of residents. This will be done by immediately protecting residents involved in identified reports of possible abuse and making changes to prevent future occurrences. Under internal reporting requirements and identification of allegations, employees are required to report any incident, allegation or suspicion of potential abuse they observe, hear about, or suspect to the administrator immediately.

Based on interviews and review of records, facility failed to follow their policy to ensure family members were notified of resident's change in condition for one (R1) out of three residents reviewed for right to be notified of changes, in a total sample of 3. Findings include: On 11/30/2024, at 9:30 AM, V3 (R1's POA/Complainant) stated that she is R1's POA (Power of Attorney) with her husband. V3 stated that she had requested a report from the facility on what happened to R1 the night he was sent to the hospital. V3 stated that she requested R1's report of the transfer to the hospital on November 5th, 2024, and still has not received an update. On 11/30/2024, at 9:50 AM, V1 (Administrator) stated that V3 requested a report from them on 11/5/2024, regarding what transpired with R1 on 10/31/2024; he was sent to the hospital. V1 stated she notified V2 right away. On 11/30/2024, at 10:00 AM, V2 (Director of Nursing) stated that R1 was a resident on the 3rd floor. V2 stated that on Thursday, sometime in October, R1 was sent out to the hospital because he said he wanted to jump out of the window. V2 stated that she was notified by V1 (Administrator) via email about V3's request on 11/5/2024, regarding R1's incident that took place on 10/31/2024. V2 stated that she called V3 that same day to update her on what happened. When surveyor asked for documentation, V2 presented surveyor with a facility concern form that was hand-written, without any name of the resident on the form or signature of R1 or V3. V2 stated that she did not document on R1's electronic health record progress notes about the update to V3. V2 stated that a facility concern form is not the resident's electronic health record. V2 also stated that if it is not documented in the resident's electronic health record that means the action is not done. V2 stated that from now on she will make sure to document in their progress note any time we notify the family. Reviewed facility's concern/compliment form for notifying V3 on R1's change in condition on 10/31/2024. The form does not have name of the resident, name of the person sharing the concern, date, or signature of R1 or V3. Reviewed R1's progress notes. No documentation of facility notifying R1's family on the details of R1's hospitalization on [DATE], due to suicidal ideation. Reviewed email from V3 (R1's POA) on 11/5/2024, requesting a report from incident on 10/31/2024. Facility's Physician and Family Notification Policy (08/2024) documents in part: Charge nurse will document in the Electronic Health Record progress notes when the physician is notified. The documentation should include who was notified, date, time and physician response. Documentation will also occur related to family such as identifying individual who was notified and if individual was spoken to or message was left for return call.

Based on interview and record review, the facility failed to ensure that a resident was free from sexual abuse. This failure affected 1 resident (R1) in the sample of 8. This failure resulted in R1 experiencing psychosocial harm by feeling violated and victimized by R2 due to R2's unwanted touching. Findings include: On 5/29/24 at 2:00 pm, R1 stated that R1 was a resident in the facility for about 2 years. R1 stated, I (R1) did not get out of bed because the electric wheelchair didn't work. I would stay in my bed. R1 stated, (R2) was staring at me (R1). I couldn't sleep. (R2) would try to go under my blanket. Tried to get under my covers. Tried to touch my body. (R2) tried to go and put hands near my privates. I would yell at (R2) to stop. When asked if R2 touched R1's p****, R1 stated, (R2) tried to. (R2) put (R2's) hand under my blanket. I wasn't sleeping. I always had an eye open knowing that I was watched. I left there because I didn't feel safe. R1 stated that R1 recorded a video on R1's cellular phone of R2 touching R1 on 5/6/24 around 6:30 pm. When asked if R1 showed this video (from 5/6/24 around 6:30 pm) to anyone in the facility, R1 stated, Yes, I showed (V4, Social Services Director, SSD) and V1 (Administrator). R1 stated I also showed the cops. R1 stated while in the hospital, I showed them (hospital staff). When asked to describe the video contents, R1 stated that R2 was coming to R1's bed, walking to R1's bed and R1 pushing call light. R2 was then over R1's bedside before they (staff) come in my room. R2 was touching my (R1) body, going under my covers. When asked if this happened the one-time R1 recorded it, R1 stated that it occurred different time periods. When asked if facility staff members knew that R2 was coming over unwanted to R1, V1 stated, Staff members and (V1) knew. I have problems with (V4, SSD). I (R1) said that I am being attacked over here. Nothing got done. Now it involved me (R1) taking pictures. No one is protecting me. Yep, I am protecting myself with the video. R1 stated that it's the same video that R1 showed V1 and V4 where R2 went under R1's covers to try to touch R1's private area. R1 stated, (R4) saw everything. When asked if R2 has come over to R1's bedside and tried to touch R1 before R1 making the video, R1 stated, Most definitely. (R2's) done it before. Trying to touch me. Stealing stuff from my table. I would be calling out. I was agitated. (R2) keeps doing the same thing to me. I wasn't alone. (R2) did that to (R4). I saw him do that to (R4). When asked how it made R1 feel when R2 was touching R1's body on 5/6/24, R1 stated, Very uneasy. I (R1) just don't like to be a victim. I'm watching (R2) all night watch (R1). (R2) pulls my (privacy) curtain and keeps coming in. I say, 'Why are you in my space?' It's a violation of my space. Violation of my body. No matter how many times I brought it up (to staff), it keeps happening. R1's Face Sheet documents, in part, diagnoses of hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side; contracture of muscle, multiple sites; unspecified convulsions; chronic kidney disease, stage 3 unspecified; adult failure to thrive; traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela; personal history of traumatic brain injury; essential (primary) hypertension; anxiety disorder, unspecified; hyperlipidemia, unspecified; epilepsy, unspecified, intractable, without status epilepticus; major depressive disorder, recurrent, unspecified; neuromuscular dysfunction of bladder, unspecified; schizoaffective disorder, unspecified; old myocardial infarction; other chronic pain; and muscle weakness (generalized). R1's Minimum Data Sheet (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is 13 which indicates that R1 is cognitively intact. R1's Functional Abilities and Goals for functional limitation in range of motion documents, in part, impairment on one side of upper extremities and impairment on both sides of lower extremities. R1's mobility for bed to chair transfer is coded as Dependent - Helper does all the effort. Resident does none of the effort to complete the activity, and walk 10 feet is coded as Not attempted due to medical or safety concerns. On 5/28/24 at 1:28 pm, R4 stated that R4 remembers R1 as a former roommate, but that R1 is not in the facility anymore. R4 stated that R4 knows R2 and that R2 is still in the facility. R4 stated, (R2) walked towards my bed and (R2) was going under my covers (while pointing towards R4's left lower leg) and I kicked my foot at (R2). I told (R2) no and (R2) stopped. When asked if R4 had reported this incident with R2 to any facility staff, R4 stated, I (R4) told a number of CNAs and told one of the nurses, but R4 didn't remember their names. When asked if R4 had witnessed R2 going over towards R1's bed touching R1 inappropriately on R1's body, R4 stated, I (R4) did see that. R4 stated that R4 couldn't remember the date but that R2 went to R1's bedside, more than one time. R4 stated that R1 told R2, Stop doing that when R2 touched R1 under the covers, and on that same day, R2 tried to touch R4 under R4's cover. R4 said that R2 kept doing it to R1. R4's Face Sheet documents, in part, diagnoses of Parkinson's disease with dyskinesia, without mention of fluctuations; dyskinesia of esophagus; unspecified severe protein-calorie malnutrition; multiple subsegmental pulmonary emboli without acute cor pulmonale; Dysarthria and anarthria; personal history of other venous thrombosis and embolism; cerebral infarction, unspecified; major depressive disorder, recurrent, mild; posttraumatic stress disorder, chronic; polyneuropathy, unspecified; essential (primary) hypertension; venous insufficiency; spinal stenosis, cervical region; hyperlipidemia, unspecified; pain, unspecified; other lack of coordination; cognitive communication deficit; unspecified voice and resonance disorder; muscle weakness (generalized); and need for assistance with personal care. R4's MDS, dated [DATE], documents, in part, that R4's BIMS score is 15 which indicates that R4 is cognitively intact. On 5/7/24 at 3:15 pm, V16 (Hospital Registered Nurse, Sexual Assault Nurse Examiner) documents, in part, in R1's hospital emergency records, (R1) states 'I have been being touched by (R2) and I have told staff, and no one believes me. (R2) has been coming to my bed and touching my leg and chest and is trying to move my gown. I have told (R2) to leave me alone. I told (R2) I don't want to be touched' . (R1) stated (R1) had video on (R1's) phone of (R2) touching (R1) and showed the video to (V16). (V16) observed (R2) wearing a hospital gown walking towards the victim (R1) and touching (R1) on the leg and (R1) telling (R2) to stop touching (R1). The video also shows (R2) also touching (R1) on the abdomen and trying to move (R1's) gown. (R1) states 'I have informed staff, and no one believed me until I told them I had video of (R2) touching me.' R1's Police Report, dated 5/7/24 at 12:00 midnight, documents, in part, the incident of battery; with R1 as the victim; and violent crimes and special victims' units are managing R1's case. On 5/29/24 at 10:11 am, V4 (SSD) stated that on 5/7/24, V4 was doing rounds on the floor and spoke with R1. V4 stated that R1 is alert, oriented, stays in bed and does not ambulate. V4 stated that R1 told V4 that R2 approached R1's bed, tried touching R1's stuff and tried to grab R1's covers. V4 stated that R1 informed V4 that staff members were aware with R1 saying 'I (R1) told everybody.' V4 stated that the only names that V4 can remember from R1 are V10 (Certified Nursing Assistant, CNA) and V14 (CNA). When this surveyor showed a witness statement to V4, dated 5/7/24 with R1's name and statement written on it, V4 stated that V4 authored the document from R1's interview on 5/7/24. After reading aloud this authored witness statement from R1, V4 stated that R1 said that R2 touched R1 above R1's stomach and on the knee. V4 stated that this was the first expressed to me that R2 had been walking over to R1's bedside. V4 confirmed that on 5/7/24, R1 showed V4 the video on R1's cellular phone of R2 coming over to R1's bedside. When asked if R2 is clearly identifiable in R1's video, V4 stated, Yes. It was clear that it was (R2). Facility document titled Witness Statement, dated 5/7/24 with R1's printed name, and signed by R1, documents, in part, (R1) reported that incident occurred on May 6, 2024, around change of 2nd shift. (R1) stated, 'Last night, (R2) standing in window and (R2) walks to my way and tries to touch me. I (R1) see (R2) try to put (R2's) hand here and here but I put my leg up so (R2) can get (R2) away from me.' . (R1) pointed to kneecap and gown. R1's ADT (Admissions, Discharges, Transfers) History document indicates that R1 was admitted to the facility on [DATE] and discharged to another long-term care facility on 5/17/24. R1's room remained the same in the facility from admission to discharge. Facility document titled Census Detail Report, dated 5/6/24, documents, in part, that R1, R2 and R4 were roommates. In R1's Social Services-Screening to Determine Abuse, dated 5/7/24, V4 (SSD) documents, in part, an abuse screening indicator score is 5 which indicates that R1's risk measure for likelihood for a history of previous/recent mistreatment and/or potential future problems/symptoms related to mistreatment is high. In review of R1's complete care plan, printed on 5/28/24, no focus, goal or interventions are documented for R1's allegation of sexual assault from R2 or R1's risk of abuse. On 5/28/24 at 1:25 pm, R2 stated that R2 does not remember R2's former roommate, R1, and that on May 6, 2024, R2 did not touch R1's body. R2 stated that R2 walks around with a walker (observed next to R2's bed). When asked if R2 has recently been hospitalized after incident in facility with R1, R2 stated, No. No. R2's Face Sheet documents, in part, diagnoses of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; hypothyroidism, unspecified; atherosclerosis of aorta; dysphagia, unspecified; cognitive communication deficit; difficulty in walking, not elsewhere classified; adult failure to thrive; muscle weakness (generalized); need for assistance with personal care personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; pain, unspecified; dehydration; and pneumonia, unspecified organism. R2 resides in a room by himself. R2's MDS, dated [DATE], documents, in part, a BIMS score of 6 which indicates that R2 has severe cognitive impairment. R2's ADT History document indicates that R2 was a roommate of R1's since 1/2/24 and was hospitalized from 5/7/24 to 5/20/24. On 5/29/24 at 10:11 am, V4 (SSD) stated that R2 does not converse a lot, is not all the way there and is in (R2's) bubble. V4 stated that R2 has not many issues at all, but when asked about R2 being placed in different rooms several times in May 2024 and R1 and R4's statements of R2 coming to their bedsides uninvited, V4 stated that R2 has poor personal boundary issue. In R2's Progress Notes, dated 5/7/24 at 7:21 pm, V4 (SSD) documents, in part, Resident (R2) was involved in alleged sexually inappropriate behaviors. This resident (R2) has multiple medical diagnoses. Resident (R2) presents with no unusual behaviors . Resident (R2) was interviewed by the appropriate staff. Resident presents with poor insight to (be) interviewed and denies any behaviors. On 5/29/24 at 10:28 am, V3 (RN) stated that V3 was R1 and R2's primary nurse routinely on the day shift. V3 stated that on 5/7/24, V11 (Agency CNA) informed V3 that R1 had taken a video of R2 on R1's phone. V3 stated that on 5/7/24, R1 had not voiced R1's allegation of R2 touching R1, and V3 educated R1 on not taking pictures of fell ow residents. V3 stated that V3 did not view R1's cellular phone video of R2. V3 stated that later 5/7/24 at 11:00 am to noon, V4 (SSD) was talking to R1, and then V3 removed R2 from R1's room. This surveyor read V3's progress note from 5/7/24 about R2 being sexually inappropriate towards a care giver, and V3 stated that V11 (Agency CNA) informed V3 on 5/7/24 that R2 has touched V11's body while V11 was rendering R2's care. When asked what part of V11's body did V11 say that R2 touched, V3 stated, (V11) said it was on (V11's) side (pointing to hip) close to buttock area. V3 stated that V3 sent R1 to the hospital for evaluation and that R1 returned to the facility on [DATE]. V3 also stated that a couple weeks prior, R2 was taking R1's food from R1's bedside and that V3 told R2 to stay on R2's side of room and don't touch other residents' items. In R2's Progress Notes, dated 4/21/24 at 5:52 pm, V3 (RN) documents, Observe resident (R2) taking personal belongings (food items) from roommate's bedside table, educated resident (R2) to keep to (R2's) side of room and not to interfere with roommate's belongings, stated I (R2) know, I know, will continue to monitor and educate. In R2's Progress Notes, dated 5/7/24 at 4:23 pm, V3 (RN) documents, 9;(:)30 am - Resident (R2) sexually inappropriate toward caregiver (V11, Agency CNA), counseled and educated on appropriate behavior, verbalized understanding, will continue to monitor. On 5/29/24 at 12:45 pm V11 (Agency CNA) stated that V11 works in the facility 3 to 4 times a week primarily on R1, R2, and R4's floor. V11 stated that R1 is alert, oriented, normal, always is in bed and needs help with personal care needs. V11 stated that R2 is more confused and walks with an unsteady gait, and that V11 has observed R2 walking unassisted in R1, R2 and R4's room. When asked about V11 reporting to V3 on 5/7/24 that R2 was sexually touching V11, V11 stated that R2 is confused, but then R2 says, I like it. V11 stated that V11 told R2 that it's inappropriate to touch someone like that. V11 stated that R2 touched V11 on the lower back while V11 was rendering activities of daily living care with R2 behind the privacy curtain on the morning of 5/7/24. V11 stated that when V11 told R2 to stop touching V11 inappropriately, V11 heard R1 say from behind the privacy curtain, (R2) do that to me too and (R2) comes to my bed. V11 stated that R1 then showed V11 a video of R2 next to R1's bed. V11 stated that when asked about R2's behavior of touching staff inappropriately, V11 stated that all the CNAs complain about it. V11 stated that V11 provided a statement to V1 for the abuse investigation for R1 and R2 on 5/7/24 and that R1 said that R2 is always trying to be friends with R1. V11 stated that R1 said, I (R1) don't want to be friends with (R2). Those were (R1's) words. On 5/29/24 at 2:54 pm, V15 (Agency RN) stated that V15 was working on 5/6/24 from 3:00 pm to 11:00 pm and remembers R1 and R2. V15 stated that during V15's shift on 5/6/24, V15 heard R1 yelling out, and V15 immediately went to R1's room. V15 stated that V15 observed R2 standing next to R2's bed, and R1 laying in the bed saying that R2 was coming over to R1. When asked what was R1 yelling out to get V15's attention, V15 said that V15 can't recall if R1 said help but what R1 was saying was in a louder tone. V15 stated that when V15 went in R1 and R2's room, Someone (R2) was by (R1) that doesn't belong there. On 5/29/24 at 2:37 pm, V14 (CNA) stated that V14 was working on 5/6/24 from 3:00 pm to 11:00 pm and is familiar with R1 and R2. V14 stated that R2 is a wanderer, confused with R2's mind be all over the place and that R2 just like to get into things a lot of the time. V14 stated that on 5/6/24 during the evening shift, V14 answered R1's call light to observe that R2 was by R1's bed. V14 stated, (R1) would be screaming or on a call light for someone to remove (R2). On 5/29/24 at 3:20 pm, V6 (CNA) stated that V6 was working on 5/6/24 from 3:00 pm to 11:00 pm and that V6 answered the call light two times, for R1, with R2 observed at the end of R1's bed. V6 stated, They (R1 and R4) would pull the light when they see (R2) coming towards in their direction. Both of them (R1 and R4). On 5/29/24 at 2:43 pm, V7 (CNA) stated that V7 was working on 5/6/24 from 3:00 pm to 11:00 pm and that V7 answered R1's call light to observe R2 standing in the middle of their room trying to come over to R1's side of room. V7 stated that V7 takes R2 back to R2's bed saying that R2 can't go over to R1's bedside. On 5/29/24 at 11:05 am, V9 (CNA) stated that V9 was working on 5/6/24 from 3:00 pm to 11:00 pm and that R1 doesn't get out of bed and is a mechanical lift transfer. V9 stated that R2 is confused and walks independent in R2's room. V9 stated that on 5/6/24, V9 stated, I (V9) only heard (R1) shouting, then then nurse (V15) went into R1's room. V9 stated that later on 5/6/24 shift, around bedtime, V9 came into R1's room when R1 was shouting. V9 stated that V9 asked why R1 was shouting, and that R1 said that it was R1's roommate (R2) again. V9 stated that V9 told R1, You (R1) have to calm down. By shouting, think of your head. On 5/29/24 at 11:35 am, V10 (CNA) stated that V10 routinely works on R1 and R2's floor. V10 stated that R1 is alert and oriented, and that V10 assists R1 with all ADL care except feeding R1. V10 stated that R1 would use call light and or would shout out for help, and V10 would come into room. V10 stated that R1 would not want R2 on R1's side of room and that R2 was touching R1's personal belongings. On 5/30/24 at 10:50 am, V2 (Director of Nursing, DON) stated that nursing staff are to treat residents with respect, perform purposeful rounding and there's not subpar nursing in this facility. When asked if R1 has the right to be free from R2 coming into R1's space and touching R1's things or person, V2 stated, Yes, that is correct. V2 stated that R2 would walk in room with a shuffle gait; that R2 would walk over to R1's bedside; and that (R2) is harmless. When asked if a resident should feel safe to not have another resident touching them, V2 stated, No, they should not experience that. V2 further stated, regarding R2 staff know to keep an eye on them, they do purposeful rounding, make sure he is getting enough to eat and give R2 something to do. On 5/30/24 at 12:54 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility with the responsibility is to ensure safety of the residents. V1 stated that on 5/7/24, V1 was notified of R1's allegation of R2 touching R1 inappropriately. V1 stated that V1 interviewed R1 on 5/7/24, and asked R1 where R2 touched R1. V1 stated that R1 said that R2 was by R1's bedside and that R1 touched over (R1's) diaper to indicate where R2 had touched R1. V1 stated that R1 then showed V1 the video on R1's cellular phone with no sound, with a date stamped of 5/6/24 after dinner around 6:30 pm, and V1 could clearly see that it was R2 in the video at R1's bedside. Facility policy titled Abuse Prevention and Reporting-Illinois with effective date of 11/28/2016 and last revision date of 10/24/2022, documents, in part, Guidelines: This facility affirms the right of our residents to be free from abuse . or mistreatment. This facility therefore prohibits abuse . and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse . and mistreatment of residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment . Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means . Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . Sexual abuse includes, but is not limited to, . sexual assault . 'Sexual abuse' is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area . Generally, sexual contact is nonconsensual if the resident . does not want the contact to occur. Facility policy titled Behavior Management and dated August 2006 documents, in part, Behavior management of residents in the facility is the responsibility of the interdisciplinary team, which includes nurses, nursing assistants, social service staff, activity staff and facility administration. Residents with a diagnosis of dementia or mental illness may display inappropriate or unacceptable behavior.

Based upon record review and interview the facility failed to ensure that three of three residents (R1, R5, R8) reviewed for medication administration were free from significant medication errors. This failure resulted in R1 and R5 sustaining critical high (above 300) blood sugars. Findings include: R5's diagnoses include type II diabetes mellitus with hyperglycemia. R5's (3/20/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). On 4/10/23 at 2:26pm, R5 stated, About a week ago Saturday we had no Nurse on the floor (2nd floor) for all 3 shifts. They (Nurse) did my blood sugar the following day and it was 500 because I didn't get my medication. On (4/7/23) R1's blood sugar was 551 (critical high) at 7:30am. R5's POS (Physician Order Sheet) includes but not limited to (12/17/22) Glipizide (Oral Hypoglycemic) 10mg (milligrams) twice daily, Metformin (Oral Hypoglycemic) 1,000mg twice daily, Humalog (Insulin) 10 units before meals and Lantus 58 units at bedtime. R5's (April 2023) MAR (Medication Administration Record) affirms scheduled medications were not documented on 4/4 and 4/7. R5's (4/7/23) Humalog and/or blood sugar were not documented at 4:00pm, Metformin & Glipizide were not documented at 6:00pm, and Lantus was not documented at 9:00pm (as scheduled). __ R1's diagnoses include diabetes mellitus. R1's (4/2/23) POS includes but not limited to Lantus (Insulin) 10 units every morning and at bedtime for diabetes. R1's (3/2/23) BIMS determined a score of 15. On 4/11/23 at 1:57pm, R1 denied medication administration concerns however R1's (April 2023) MAR affirms scheduled medications were not documented on 4/2, 4/3 and 4/8. On 4/2/23 & 4/3/23, R1's Lantus is not documented at 6:30am and 9:00pm. R1's (6:30am) blood sugars were 347 (critical high) on 4/2/23 and 349 (critical high) on 4/3/23. __ R8's diagnoses include schizoaffective disorder, depressive type. R8's (3/21/23) BIMS determined a score of 13 (cognitively intact). On 4/10/23 at 2:44pm, R8 stated, There was a problem with them not giving me enough Clozapine so I let the Administrator know, he (Administrator) said he would take care of it. R8's POS includes but not limited to (12/21/22) Clozapine (Antipsychotic) 300mg at bedtime and Clozapine 25mg once daily. R8's (April 2023) MAR affirms scheduled medications (including Clozapine) are not documented 4/7, 4/8, 4/9 and 4/10. On 4/18/23 at 12:07pm, V30 (Physician) stated, Both of them could cause some problems. They (residents) could get hyperglycemia or other problems like mental status not being controlled if they're not receiving medication. The (undated) Medication Administration policy states medications are administered in accordance with written orders of the prescriber. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.

Based upon observation, interview and record review the facility failed to provide fall prevention interventions on two of three residents (R1, R8) care plans, failed to ensure staff were aware of (R1, R5, R8) fall prevention interventions and failed to implement fall prevention interventions for two of three residents (R1, R8) reviewed for falls. These failures resulted in R1 sustaining acute rib fractures on the left from a fall on 2/12/23. Findings include: 1.R1's diagnoses include absence of right leg below knee. R1's (2/9/23) fall evaluation determined a score of 60 (high risk). R1's (2/24/23) Physical Therapy Evaluation & Plan of Treatment states patient requiring SUP (Supination) for slide board transfers. Chair/bed to chair transfer = Dependent. R1's (3/2/23) functional assessment affirms (2 person) physical assist is required for transfers. R1's (9/17/20) care plan includes risk for falls related to right leg below knee amputation however interventions exclude SUP for slide board transfers and/or 2 persons assist during transfers. R1's (2/12/23) incident report states patient fell on the floor in her room during transfer. R1's (3/2/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). On 4/10/23 at 1:56pm, R1 stated, I was on my bed, and they (2 staff) went to help me get in the chair. They (staff) tried and then they (staff) dropped me. There was one (staff) on each side by my arm. Four (4) of my ribs got fractured when I fell on the floor. A gait belt was inquired in use during (2/12/23) transfer. R1stated, No, I have a sliding board and affirmed a sliding board was also not in use. On 4/10/23 at 2:24pm, V4 (Certified Nursing Assistant) affirmed she was currently assigned to R1. V4 stated, She calls when she needs assisted. She has a slide board. She has slip resistant socks and a boot that helps her balance. V4, stated Half go on the wheelchair, half on the bed and one side on the wheelchair let up. V4 inquired how many staff are required to transfer R1. V4 replied, One person. [R1 requires 2 persons assistance]. On 4/11/23 at 1:30pm, V13 (Registered Nurse) stated, The CNA (Certified Nursing Assistant) was about to transfer her (R1). I asked her (CNA) to step away and before I stepped next to her (R1) she (R1) had fallen over. It happened essentially as soon as the CNA stepped away. V13 stated, I thought it would be quicker for me to transfer (R1) and the CNA to assist another resident needing help. V13 inquired if R1 transfers by himself. V13 replied, Yes. V13 stated, I don't recall if there's an order to be transferring her (R1) with two (2) individuals or using a lift. V13 reviewed R1's care plan and stated Nope, nothing about a slider board. On 4/12/23 at 11:52am, V17 (Minimum Data Set Coordinator) stated, The intervention when she came back (from the hospital) was to make her a mechanical lift. V17 stated, It will show up on their care plan in PC (electronic program). V17 stated, The DON (Director of Nursing) will usually let the staff know if there's something new. On 4/12/23 at 2:11 pm, V 21 (Medical Director) inquired about potential harm when a resident falls, V21 stated, It could be anything it can be something small it can be something big. I don't have a crystal ball I can't say for sure. V 21 stated, There could be no injury there could be a large injury potentially anything could be possible. A scrape to anything it could be anything. V 21 stated, Right away the patient should be assessed and sent out for evaluation. If there's head trauma, we have to send them right away it depends on the assessment. R1's (2/13/23) Abdomen & Pelvis CT (Computed Topography) includes acute rib fractures on the left. 2. R5's diagnoses include morbid obesity and unsteadiness on feet. R5's (2/6/23) fall risk assessment determined a score of 80 (high risk). R5's (3/20/23) functional assessment affirms set up is required for transfers and locomotion (uses walker). R5's (12/16/22) care plan includes risk for falls. On 4/10/23 at 2:24pm, V 5 (Agency Nurse) affirmed he was currently assigned to R5. V 5 stated, I could find out but the system is down so I can't and affirmed he was unaware. V 5 advised that the facility phone and Internet were not working. R5's (3/20/23) BIMS determined a score of 15 (cognitively intact). On 4/10/23 at 2:26 pm, R5 stated, I did have a couple falls, they (staff) tell me four (4). 3. R8's diagnoses include abnormalities of gait and mobility. R8's (3/21/23) functional assessment affirms (2 person) physical assistance is required for transfers. R8's (3/21/23) fall risk evaluation determined a score of 36 (moderate risk for falling). R8's (3/21/23) BIMS determined a score of 13 (cognitively intact). R8's comprehensive care plan excludes risk for falls and/or fall prevention interventions. On 4/10/23 at 2:44 pm, R8's was lying in bed while in high position. R8's call light was tied to the side rail however dangling below the mattress. R8 attempted to locate the call light and stated, Uh oh, I think I dropped it. It's not there. R8 stated, No, I'm not able to walk. They (staff) need like 2 people to put me in the wheelchair. R8 stated, Oh yes, I've had a few falls. I fell in the room and shortly after that I fell again going to the door to get some money. I got dizzy, collapsed and fell on the floor. On 4/10/23 at 2:55 pm, V5 (Agency Nurse) affirmed he was currently assigned to R8. V5 stated, Off the top of my head I don't know but usually they'll put a pad on the floor and the bed will be at the lowest level, but I can't really see because the system is down. R8's bed was inquired to V5. V5 responded, I would say the bed is all the way up. R8's call light inquired to V5. V5 replied, It should be clipped on her. V5 stated, No floor mats were besides R8's bed. V5 states to R8, I'm going bring your bed down because it should be low and going to give you a call light because it should be by you. R8 responded, Ok. The Fall Prevention Program (revised 11/22/22) states care plan incorporates identification of all risk/issue. Addresses each fall. Interventions are changed with each fall, as appropriate. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Safety interventions will be implemented for each resident identified at risk. All assigned Nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. The bed will be maintained in a position appropriate for resident transfers.

Based on observation, interview, and record review, the facility failed to protect residents from sexual abuse by an employee for three of three residents (R1, R2, R3) reviewed for abuse. This deficient practice caused residents to experience fear, shame, and anger. Findings include: An investigation was initiated in response to incident reports submitted to IDPH (Illinois Department of Public Health) on 02.13.2023 and 02.14.2023. Both reports alleged sexual abuse of R1 and R2 by V3 (Contract COTA-Certified Occupational Therapy Assistant). 1)R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a cognitively intact [AGE] year-old admitted to the facility on 01.24.2023 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction Due to Embolism of Right Middle Cerebral Artery, Diabetes Mellitus Due to Underlying Condition with Diabetic Autonomic (Poly)Neuropathy, and End Stage Renal Disease. On 02.16.2023 at 12:03 PM, R1 was observed sitting on the side of bed eating lunch. R1 was pleasant, neat, clean, and dressed in-patient gown. R1 agreed to speak with surveyor regarding incident involving V3 (Contract COTA-Certified Occupational Therapist). R1 said, The day it happened (01.31.2023), I was sitting on the bed, like I am now, with my legs closed. I was wearing two gowns (using one as a robe). The door was closed, the privacy curtain was drawn (to end of bed). V3 said we were going to do arm stretches. V3 came in front of me, forcing V3's knee in between my knees. Now V3 is right in my face, my head was on V3's chest. I had to move my head in order to breathe. V3 wrapped V3's arms around me, forcing V3's way to get through my gown, to get at my skin. V3 was breathing heavily into my ear. Somehow V3 got V3's hands under the waist band of my panties, onto my buttocks. V3 grabbed my butt, thrusting into my body. I said (to myself), this isn't right, V3's not supposed to be grabbing my a**. V3 touched my vagina; grabbed my hair as if V3 was going to kiss me. I put my arm between V3 and myself (demonstrated putting arm across chest). I felt V3's erection. I felt uncomfortable. I said to V3, I think I've had enough for today. I did cry out (in pain), I said, 'ow.' Then V3 said let's do some leg stretches. I was flat in bed, one leg over the knee. I had my hand over my forehead (demonstrated hand to forehead, palm out). V3 tickled the palm of my hand. In my culture when someone does that, it means they want to have sex. V3 did this twice. I told V3 it's too much, I can't, I can't, I'm in too much pain in order to end the session. This happened during my third session with V3. The second session was pretty much like the third session. V3 was pushing really close to my body, breathing heavily into my ear. During the first session, V3 did leg stretches, pushing my leg towards my head. I had on a gown but no panties (was recently admitted to facility and did have their clothing). My gown was up to here (indicates groin). I felt uncomfortable. Surveyor asked R1 why they did not report this immediately, R1 said, I was molested by a family member when I was five years old. I asked (myself) am I overthinking this, am I letting my past get the best of me? I needed to process this. After the third session, but before I made the complaint, I was afraid I would run into V3. I told my father the day it happened. I told V4 (RN-Registered Nurse), two-three days after the incident. I told V4 that I had an interaction with V3 that made me feel uncomfortable. V4 did not probe further but did reassure me that I had the right to feel safe in the facility. I reported V3 to V5 (Guest Relations) the next day (after speaking with V4). R1 said, what V3 did was wrong. V3 took advantage over the situation, the power V3 held over me. It was disgusting, horrible. R1 was tearful at times during the interview. R1's abuse/neglect care plan (initiated/revised 02.09.2023) documents in part, R1 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.17.2023) documents in part, R1 informed V1 and V9 (Police Detective) on 02.13.2023 that V3 provided R1 physical therapy on 01.31.2023 and R1 feels that V3 touched R1 inappropriately. The report does not document if allegation was substantiated or unsubstantiated. 2)R2's medical record (Face Sheet, MDS) documents R2 is a cognitively intact [AGE] year-old admitted to the facility on 04.23.2021 with diagnoses including, but not limited to: Major Depressive Disorder, Recurrent; Moderate Bipolar, Current Episode Depressed; Opioid Dependence, Other Sites of Candidiasis. On 02.26.2023 at 1:10 PM, R2 was observed sitting in their room. R2 was neat, clean and dressed appropriately, soft spoken (tracheostomy tube in place, which R2 covered with their finger in order to speak). R2 agreed to speak with surveyor. Surveyor asked R2 if they would tell surveyor about the incident between R2 and V3. R2 became upset, asking surveyor how they knew about the incident and said, I'm so tired of repeating it. How am I supposed to heal? Surveyor explained how they had knowledge of the incident and what the investigative process is in general, involved. R2 said, Okay, I'll talk to you, have a seat. R2 said, when I got here, they told me I needed therapy and I was like, okay. V7 (OT-Occupational Therapist) evaluated me. On 10.25.2022, I had a session with V3 in my room. The door was closed, the privacy curtain was drawn. I was in bed, facing the TV. I got up to walk V3 to the door because my room is my home. V3 threw me on the bed, I landed on all fours. I went to get up and V3 threw me on the bed again. V3 pulled my pants down and played with my [NAME] (genital area) but did not put V3's fingers in my vagina. Then V3 took V3's pants down or off, I was facing the window. I said, what the f*** (V3), what are you doing to me? V3 just rammed into me. The next thing I knew, V3 was pulling out. I saw V3 was coming into a glove (exam glove). V3 said give me a minute then left. I stood there in shock. I said, I can't believe this s**t just happened to me. I didn't tell anyone. I just sat there for a good hour. I felt no one would believe me if I told them. I wrote down what happened and told V5 (Guest Relations) last week. The turning point was when I heard some lady down the hall was calling the police because V3 touched her inapproiately. A bulb went on. I was mad at myself because I let it happen. I felt relieved when I told V5. I had just blocked it out. R2 appeared anxious as evidenced by pacing at times, during the interview. R2's abuse/neglect care plan (initiated 02.08.2023, revised 02.09.2023) documents in part, R2 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.14.2023) documents in part, R2 reported to V1 on 02.08.2023, that V3 allegedly raped R2 in R2's room on 10.25.2022 after providing R2 physical therapy session. The alleged employee has no known record of sexual abuse on file. MD, family, and Ombudsman were notified of the outcome of the outcome of the investigation and are happy with the outcome. The report does not document if allegation was substantiated or unsubstantiated. 3)R3's medical record (Face Sheet, MDS) document R3 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 10.11.2022 with diagnoses including, but not limited to: Alzheimer's Disease, Dementia, Paranoid Schizophrenia with Agitation, Psychosis, and Neurocognitive Disorder. On 02.16.2023 at 2:25 PM, R3 was observed sitting on the edge of bed, eating candy and watching TV. R3 agreed to speak with surveyor about the incident involving V3. R3 was pleasant and spoke clearly and concisely during the interview. V3 said, V3 came here (in resident's room), giving me exercises. Then V3 wanted to unbuckle my bra. V3 said to me, let me unbuckle your bra so you can be more comfortable. I said, no, I'm comfortable. V3 did stop. It made me feel bad. I was going to tell V3 that V3 is a pervert, but I didn't want to hurt V3's feelings. This happened sometime last year in my room. V3 did come back another day and asked me if I wanted therapy. I said no, I didn't want V3 to come and give me therapy after that (incident). V3 would stand in front of me and put V3's hands like this (demonstrated putting hands into R3's sleeves) and massage my back. V3 would massage my back, my legs. I never told V3 that my shoulders hurt. No other therapist ever massaged me. The door was closed, the (privacy) curtain was drawn.I did not report this. I was afraid they would fire V3. I told my daughter a month later. She came to the facility and spoke with V1. On 02.21.2023 at 7:24 PM via Telephone, V11 (R3's Daughter) said, I bring R3 home on weekends. (R3) mentioned, was complaining of, a lot of pain, body hurting. R3 was receiving therapy in R3's room. R3 keeps R3's bra on all the time, even while sleeping. R3 told me V3 came into R3's room and asked to remove R3's bra. Can you remove it or can I remove it so you'll be more comfortable, V3 said. R3 told me V3 was standing so close R3 that R3 could feel V3's hard penis on R3's chest; R3's face was in V3's belly. R3 didn't report V3 because R3 was afraid V3 might get fired. The day after R3 told me this, I told the facility what R3 told me. I went to the facility. I met with V1 and other staff. I told them what R3 told me. R3's Trauma-Informed Care care plan (initiated/revised 12.01.2022) documents in part R1 demonstrates difficulty in adjustment and general mood distress at times. Facility final incident report (11.30.2022) documents in part, on 11.29.2022, R3 notified V1 that V3 attempted to unstrap R3's bra during Occupational Therapy session in September 2022. R3 did not remember the date, day or tine of alleged incident. The allegation of sexual abuse was not substantiated. On 02.15.2023 at 10:30 AM, V1 said, R1 reported to V1, around 02.08.2023, that R1 initially felt uncomfortable in therapy. A concern form was completed (dated 02.03.2023). Local police were notified but not IDPH because there was no allegation of abuse. An investigation was later initiated and reported to IDPH after R1 alleged V3 touched R1's vaginal area during therapy session. R2 reported to V1 on 02.08.2023 that V3 raped R2 in R2's room after a therapy session. V1 said R1's investigation was in progress; allegation would not be substantiated; R2's allegation was not substantiated. Surveyor asked V1 if there had been any prior allegations of sexual abuse involving V3. V1 said yes, there was one last year. R3 alleged V3 attempted to remove R3's bra during therapy. The allegation was not substantiated. On 02.15.2023 at 2:44 PM, V8 (Regional Director of Rehab) said, when these allegations were brought to my attention, I informed the company's compliance department. They deferred the investigation to the facility; there is no internal investigation being conducted. V3 is on administrative leave pending outcome of facility's investigation. On 02.16.2023 at 3:31 PM, V5 (Guest Relations) said, R2 came to me some time last week and ask me what was going on in the therapy department, specifically V3. R2 said, V3 did me. I asked R2 what that meant. R2 responded V3 was in my room doing therapy with me; the door was closed. V3 was leaning over me, massaging my back. I stood up to walk V3 out, my room is like my home. V3 flipped R2 onto the bed, on R2's hands and knees, pulled R2's pants down. R2 said whoa, V3 responded, it's okay (R2), it will be over in a minute. The next thing I knew V3 was inside of me. I asked if V3 finished, R2 said yes. I asked if V3 came inside R2, R2 said in a glove. I reported it to V1. V5 said, on 02.03.2023 I came into work at 8:20 something. V14 (RN) informed me R1 needed to speak with me. I asked R1 what was wrong. R1 said during the 2nd and 3rd sessions of therapy with V3, R1 felt uncomfortable. R1 said V3 would lean over R1; V3 would go under R1's gown; R1 would put R1's arm across R1's chest as a barrier. V5 said Rl told V5 that V3 tried to put V3's knee in between R1's legs; R1 would try to keep R1's legs closed. On 02.16.2023 at 4:00 PM, V6 (Director of Rehab) said, R3's daughter mentioned sometime around Thanksgiving, that R3 was uncomfortable with V3's treatments. The daughter said R3 told her V3 may have pulled R3's bra down. I don't know what would have triggered that (V3 pulling down R3's bra). The next resident was R1. R1 said R1 felt uncomfortable during some sessions with V3; that V3 would stand too close. I don't know why V3 would massage R1 from the front. It made me feel uncomfortable when I heard that. On 2.22.2023 at 1:39 PM, V7 (Contract OTR-Occupational Therapist Registered and Licensed) reviewed the following documents: R1's Occupational Therapy Evaluations and Plan of Treatment (01.25.2022) and Treatment Encounter Notes (01.25.2022, 01.27.2022, 01.30.2022, 02.01.2022), R2's Occupational Therapy Evaluations and Plan of Treatments (10.17.2022) and Treatment Encounter Notes (10.18.2022, 10.19.2022, 10.25.2022-10.27.2022), and R3's Occupational Therapy Evaluations and Plan of Treatments (09.19.2022) and Treatment Encounter Notes (09.19.2022-09.22.2022, 09.26.2022, 09.27.2022, 09.29.2022, 09.30.2022). V7 said I performed Occupational Therapy Evaluations for R1, R2, and R3 and developed their Treatment Plans as well. V7 said that V7 did not include massage therapy as a treatment approach for R1, R2, or R3. V7 said that V3 did not document massage therapy as a therapeutic approach in R1's, R2's, or R3's Treatment Encounter Notes. V7 said, if the resident was sitting in a chair, shoulder massage should be performed while standing behind the resident; if the resident is sitting on the edge of the bed, shoulder massage should be performed while standing next to the resident. V7 said, I think it was unprofessional that V3 massaged the residents while standing in front of the. I need to have some professional distance between myself and the resident. On 02.21.2023 at 10:10 AM via telephone, V3 said, I was performing my job responsibility with them (R1, R2, and R3). One young lady, R1, I guess, I'm not exactly sure what R1 said. R1 said I touched R1's vagina. I did not. I heard that a complaint was made. Why would do that? I responded to V1. When I Based on observation, interview, and record review, the facility failed to protect residents from sexual abuse by an employee for three of three residents (R1, R2, R3) reviewed for abuse. This deficient practice caused residents to experience fear, shame, and anger. Findings include: An investigation was initiated in response to incident reports submitted to IDPH (Illinois Department of Public Health) on 02.13.2023 and 02.14.2023. Both reports alleged sexual abuse of R1 and R2 by V3 (Contract COTA-Certified Occupational Therapy Assistant). 1)R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a cognitively intact [AGE] year-old admitted to the facility on 01.24.2023 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction Due to Embolism of Right Middle Cerebral Artery, Diabetes Mellitus Due to Underlying Condition with Diabetic Autonomic (Poly)Neuropathy, and End Stage Renal Disease. On 02.16.2023 at 12:03 PM, R1 was observed sitting on the side of bed eating lunch. R1 was pleasant, neat, clean, and dressed in-patient gown. R1 agreed to speak with surveyor regarding incident involving V3 (Contract COTA-Certified Occupational Therapist). R1 said, The day it happened (01.31.2023), I was sitting on the bed, like I am now, with my legs closed. I was wearing two gowns (using one as a robe). The door was closed, the privacy curtain was drawn (to end of bed). V3 said we were going to do arm stretches. V3 came in front of me, forcing V3's knee in between my knees. Now V3 is right in my face, my head was on V3's chest. I had to move my head in order to breathe. V3 wrapped V3's arms around me, forcing V3's way to get through my gown, to get at my skin. V3 was breathing heavily into my ear. Somehow V3 got V3's hands under the waist band of my panties, onto my buttocks. V3 grabbed my butt, thrusting into my body. I said (to myself), this isn't right, V3's not supposed to be grabbing my a**. V3 touched my vagina; grabbed my hair as if V3 was going to kiss me. I put my arm between V3 and myself (demonstrated putting arm across chest). I felt V3's erection. I felt uncomfortable. I said to V3, I think I've had enough for today. I did cry out (in pain), I said, 'ow.' Then V3 said let's do some leg stretches. I was flat in bed, one leg over the knee. I had my hand over my forehead (demonstrated hand to forehead, palm out). V3 tickled the palm of my hand. In my culture when someone does that, it means they want to have sex. V3 did this twice. I told V3 it's too much, I can't, I can't, I'm in too much pain in order to end the session. This happened during my third session with V3. The second session was pretty much like the third session. V3 was pushing really close to my body, breathing heavily into my ear. During the first session, V3 did leg stretches, pushing my leg towards my head. I had on a gown but no panties (was recently admitted to facility and did have their clothing). My gown was up to here (indicates groin). I felt uncomfortable. Surveyor asked R1 why they did not report this immediately, R1 said, I was molested by a family member when I was five years old. I asked (myself) am I overthinking this, am I letting my past get the best of me? I needed to process this. After the third session, but before I made the complaint, I was afraid I would run into V3. I told my father the day it happened. I told V4 (RN-Registered Nurse), two-three days after the incident. I told V4 that I had an interaction with V3 that made me feel uncomfortable. V4 did not probe further but did reassure me that I had the right to feel safe in the facility. I reported V3 to V5 (Guest Relations) the next day (after speaking with V4). R1 said, what V3 did was wrong. V3 took advantage over the situation, the power V3 held over me. It was disgusting, horrible. R1 was tearful at times during the interview. R1's abuse/neglect care plan (initiated/revised 02.09.2023) documents in part, R1 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.17.2023) documents in part, R1 informed V1 and V9 (Police Detective) on 02.13.2023 that V3 provided R1 physical therapy on 01.31.2023 and R1 feels that V3 touched R1 inappropriately. The report does not document if allegation was substantiated or unsubstantiated. 2)R2's medical record (Face Sheet, MDS) documents R2 is a cognitively intact [AGE] year-old admitted to the facility on 04.23.2021 with diagnoses including, but not limited to: Major Depressive Disorder, Recurrent; Moderate Bipolar, Current Episode Depressed; Opioid Dependence, Other Sites of Candidiasis. On 02.26.2023 at 1:10 PM, R2 was observed sitting in their room. R2 was neat, clean and dressed appropriately, soft spoken (tracheostomy tube in place, which R2 covered with their finger in order to speak). R2 agreed to speak with surveyor. Surveyor asked R2 if they would tell surveyor about the incident between R2 and V3. R2 became upset, asking surveyor how they knew about the incident and said, I'm so tired of repeating it .how am I supposed to heal? Surveyor explained how they had knowledge of the incident and what the investigative process, in general, involved. R2 said, Okay, I'll talk to you, have a seat. R2 said, when I got here, they told me I needed therapy and I was like, okay. V7 (OT-Occupational Therapist) evaluated me. On 10.25.2022, I had a session with V3 in my room. The door was closed, the privacy curtain was drawn. I was in bed, facing the TV. I got up to walk V3 to the door because my room is my home. V3 threw me on the bed, I landed on all fours. I went to get up and V3 threw me on the bed again. V3 pulled my pants down and played with my [NAME] (genital area) but did not put V3's fingers in my vagina. Then V3 took V3's pants down or off, I was facing the window. I said, what the f*** (V3), what are you doing to me? V3 just rammed into me. The next thing I knew, V3 was pulling out. I saw V3 was coming into a glove (exam glove). V3 said give me a minute then left. I stood there in shock. I said, I can't believe this s**t just happened to me. I didn't tell anyone. I just sat there for a good hour. I felt no one would believe me if I told them. I wrote down what happened and told V5 (Guest Relations) last week. The turning point was when I heard some lady down the hall was calling the police because V3 touched her inapproiately. A bulb went on. I was mad at myself because I let it happen. I felt relieved when I told V5. I had just blocked it out. R2 appeared anxious as evidenced by pacing at times, during the interview. R2's abuse/neglect care plan (initiated 02.08.2023, revised 02.09.2023) documents in part, R2 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.14.2023) documents in part, R2 reported to V1 on 02.08.2023, that V3 allegedly raped R2 in R2's room on 10.25.2022 after providing R2 physical therapy session. The alleged employee has no known record of sexual abuse on file. MD, family, and Ombudsman were notified of the outcome of the outcome of the investigation and are happy with the outcome. The report does not document if allegation was substantiated or unsubstantiated. 3)R3's medical record (Face Sheet, MDS) document R3 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 10.11.2022 with diagnoses including, but not limited to: Alzheimer's Disease, Dementia, Paranoid Schizophrenia with Agitation, Psychosis, and Neurocognitive Disorder. On 02.16.2023 at 2:25 PM, R3 was observed sitting on the edge of bed, eating candy and watching TV. R3 agreed to speak with surveyor about the incident involving V3. R3 was pleasant and spoke clearly and concisely during the interview. V3 said, V3 came here (in resident's room), giving me exercises. Then V3 wanted to unbuckle my bra. V3 said to me, let me unbuckle your bra so you can be more comfortable. I said, no, I'm comfortable. V3 did stop. It made me feel bad. I was going to tell V3 that V3 is a pervert, but I didn't want to hurt V3's feelings. This happened sometime last year in my room. V3 did come back another day and asked me if I wanted therapy. I said no, I didn't want V3 to come and give me therapy after that (incident). V3 would stand in front of me and put V3's hands like this (demonstrated putting hands into R3's sleeves) and massage my back. V3 would massage my back, my legs. I never told V3 that my shoulders hurt. No other therapist ever massaged me. The door was closed, the (privacy) curtain was drawn I did not report this. I was afraid they would fire V3. I told my daughter a month later. She came to the facility and spoke with V1. On 02.21.2023 at 7:24 PM via Telephone, V11 (R3's Daughter) said, I bring R3 home on weekends. (R3) mentioned, was complaining of, a lot of pain, body hurting. R3 was receiving therapy in R3's room. R3 keeps R3's bra on all the time, even while sleeping. R3 told me V3 came into R3's room and asked to remove R3's bra. Can you remove it or can I remove it so you'll be more comfortable, V3 said. R3 told me V3 was standing so close R3 that R3 could feel V3's hard penis on R3's chest; R3's face was in V3's belly. R3 didn't report V3 because R3 was afraid V3 might get fired. The day after R3 told me this, I told the facility what R3 told me. I went to the facility. I met with V1 and other staff. I told them what R3 told me. R3's Trauma-Informed Care care plan (initiated/revised 12.01.2022) documents in part R1 demonstrates difficulty in adjustment and general mood distress at times. Facility final incident report (11.30.2022) documents in part, on 11.29.2022, R3 notified V1 that V3 attempted to unstrap R3's bra during Occupational Therapy session in September 2022. R3 did not remember the date, day or tine of alleged incident. The allegation of sexual abuse was not substantiated. On 02.15.2023 at 10:30 AM, V1 said, R1 reported to V1, around 02.08.2023, that R1 initially felt uncomfortable in therapy. A concern form was completed (dated 02.03.2023). Local police were notified but not IDPH because there was no allegation of abuse. An investigation was later initiated and reported to IDPH after R1 alleged V3 touched R1's vaginal area during therapy session. R2 reported to V1 on 02.08.2023 that V3 raped R2 in R2's room after a therapy session. V1 said R1's investigation was in progress; allegation would not be substantiated; R2's allegation was not substantiated. Surveyor asked V1 if there had been any prior allegations of sexual abuse involving V3. V1 said yes, there was one last year. R3 alleged V3 attempted to remove R3's bra during therapy. The allegation was not substantiated. On 02.16.2023 at 2:44 PM, V8 (Regional Director of Rehab) said, when these allegations were brought to my attention, I informed the company's compliance department. They deferred the investigation to the facility; there is no internal investigation being conducted. V3 is on administrative leave pending outcome of facility's investigation. On 02.16.2023 at 3:31 PM, V5 (Guest Relations) said, R2 came to me some time last week and ask me what was going on in the therapy department, specifically V3. R2 said, V3 did me. I asked R2 what that meant. R2 responded V3 was in my room doing therapy with me; the door was closed. V3 was leaning over me, massaging my back. I stood up to walk V3 out, my room is like my home. V3 flipped R2 onto the bed, on R2's hands and knees, pulled R2's pants down. R2 said whoa, V3 responded, it's okay (R2), it will be over in a minute. The next thing I knew V3 was inside of me. I asked if V3 finished, R2 said yes. I asked if V3 came inside R2, R2 said in a glove. I reported it to V1. V5 said, on 02.03.2023 I came into work at 8:20 something. V14 (RN) informed me R1 needed to speak with me. I asked R1 what was wrong. R1 said during the 2nd and 3rd sessions of therapy with V3, R1 felt uncomfortable. R1 said V3 would lean over R1; V3 would go under R1's gown; R1 would put R1's arm across R1's chest as a barrier. V5 said Rl told V5 that V3 tried to put V3's knee in between R1's legs; R1 would try to keep R1's legs closed. On 02.16.2023 at 4:00 PM, V6 (Director of Rehab) said, R3's daughter mentioned sometime around Thanksgiving, that R3 was uncomfortable with V3's treatments. The daughter said R3 told her V3 may have pulled R3's bra down. I don't know what would have triggered that (V3 pulling down R3's bra). The next resident was R1. R1 said R1 felt uncomfortable during some sessions with V3; that V3 would stand too close. I don't know why V3 would massage R1 from the front. It made me feel uncomfortable when I heard that. On 2.22.2023 at 1:39 PM, V7 (Contract OTR-Occupational Therapist Registered and Licensed) reviewed the following documents: R1's Occupational Therapy Evaluations and Plan of Treatment (01.25.2022) and Treatment Encounter Notes (01.25.2022, 01.27.2022, 01.30.2022, 02.01.2022), R2's Occupational Therapy Evaluations and Plan of Treatments (10.17.2022) and Treatment Encounter Notes (10.18.2022, 10.19.2022, 10.25.2022-10.27.2022), and R3's Occupational Therapy Evaluations and Plan of Treatments (09.19.2022) and Treatment Encounter Notes (09.19.2022-09.22.2022, 09.26.2022, 09.27.2022, 09.29.2022, 09.30.2022). V7 said I performed Occupational Therapy Evaluations for R1, R2, and R3 and developed their Treatment Plans as well. V7 said that V7 did not include massage therapy as a treatment approach for R1, R2, or R3. V7 said that V3 did not document massage therapy as a therapeutic approach in R1's, R2's, or R3's Treatment Encounter Notes. V7 said, if the resident was sitting in a chair, shoulder massage should be performed while standing behind the resident; if the resident is sitting on the edge of the bed, shoulder massage should be performed while standing next to the resident. V7 said, I think it was unprofessional that V3 massaged the residents while standing in front of the. I need to have some professional distance between myself and the resident. On 02.21.2023 at 10:10 AM via telephone, V3 said, I was performing my job responsibility with them (R1, R2, and R3). One young lady, R1, I guess, I'm not exactly sure what R1 said. R1 said I touched R1's vagina. I did not. I heard that a complaint was made. Why would do that? I responded to V1. When I start therapy (skilled sessions), look at the evaluation to see what the treatment plan is. I focus on short term goal and core strength is a big part of it. Core activation is a big part of my treatment method to promote sitting and standing balance. Yeah, so I do a lot of stretching of the shoulders, lower back. I did shoulder stretches and massage. I try to get them in the state of mind where they relax. It takes a little to get used to each other when I have a new patient until we figure it out. I'll do the neck and shoulder in front of her while she's sitting on the side of the bed; hamstrings, lower back and hip when supine in bed, I'm on the side of the bed. I didn't touch anybody inappropriately. I wasn't sexually inappropriate to any resident. The facility's Abuse Prevention and Reporting policy and procedures effective 11.26.16 and revision date 10.22.22 included the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods 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. This will be done by but not limited to the following: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. 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. -Sexual Abuse includes, but is not limited to, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area. Generally, sexual contact is nonconsensual if the resident either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. Orientation and Annual Training of Employees to cover but not limited to the following: Sensitivity to resident rights and resident needs. Establishing a resident sensitive environment. Concern identification and follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's grievance procedures. Residents and families will be informed of the facility's grievance procedures. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (minimum data set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have

Based on observation, interview and record review the facility failed to implement interventions to reduce the risk of accidents for 1 resident (R53) of 6 residents reviewed for falls. This failure resulted in R53 sustaining multiple falls and sustained a [CONDITION(S)]. Findings include: On 12/06/22 at 12:35 PM, observed R53 pushing wheeled bed table from R53's room toward the doorway of the room wearing dark blue regular socks. There were no non-skid strips on the socks. On 12/06/22 at 12:40 PM, V18 (Restorative Aide) stated that R53 likes to push his over the bed table out of his room and down the hall. V18 stated R53 is sometimes difficult to redirect and is at high risk for falling. On 12/07/22 at 11:24 AM, V14 (MDS/Restorative Coordinator) stated that R53 has dementia and is very confused. V14 stated that R53 has a short attention span, is difficult to redirect and won't stay involved in activities. V14 stated that R53 has been having multiple falls back-to-back. V14 stated that any resident who has a fall is accessed for injury by the nurse on duty, and that the nurse on duty then notifies the doctor and family and completes a post fall evaluation form. V14 stated every fall is discussed with a team made of up the DON, Therapy Director and herself and care plans would then be modified. V14 stated all care plan interventions should be specific and evaluated for effectiveness. During interview on 12/08/22 at 09:42 PM, V18 stated that R53 is allowed to walk unassisted and that R53 is constantly getting up and down throughout the day unless he (R53) is sleeping. V18 stated that R53 does not want to sit down for very long and wants to be constantly walking around. V18 estimated R53 will sit down for a total of 15 minutes and then get up to walk around, and then sit back down for 15 minutes and then get back up again to walk around in his (R53)'s room and on the unit. V18 stated R53 has had multiple falls and that the staff tries to keep a closer eye on him (R53) but that it is hard because he (R53) is so active. V18 stated that she (V18) has known R53 for over one year and that R53's mental status has been decreasing. V18 stated that R53 is more forgetful, has greater difficulty understanding/following direction, and does not always respond to verbal cues. V18 stated R53 now requires extensive assistance with ADL care. V18 stated that interventions in place to help prevent R53 from falling include R53 wearing non-skid socks. On 12/08/22 at 9:54 AM V22 (Director of Rehabilitation) stated that R53 has a history of falls and that R53 was referred to physical and occupational therapy due to falls. Occupational therapy was discontinued 10/21/22, and physical therapy is still working with R53 on functional ambulation, balance, and transfers. On 12/8/22 at 12:20 PM, V3 (Acting Director of Nursing/Nurse Consultant) stated that anytime a resident has a fall an investigation needs to be done to look at reasons for the fall. V3 stated that The Morse Fall Scale Evaluation is completed by nursing after every fall and that once the root cause for the fall is determine then there should be intervention(s) updated on the resident's care plan. The interventions should be re-evaluated and adjusted as needed or as appropriate for that resident. V3 stated that some of the root causes of falls may be cognition based and that the overall goal of the facility is to prevent future falls. On 12/8/22 at 12:33 PM, V28 (Occupational Therapist) stated R53's falls are related to cognition, mood and behavior and that R53 won't stay in one place for long. V28 states R53's physician ordered for R53 to wear a helmet however R53 refused to wear it. On 12/8/22 at 2:19 PM, V14 (MDS/Restorative Coordinator) stated that R53 required a combination of supervision and limited assistance for bed mobility, transfer, walking in room and locomotion on the unit based on the MDS dated [DATE] which is before R53 started having multiple falls. V14 stated that based on the 09/09/22 Significant Change MDS R53's functional status changed from supervision and limited assistance to extensive assistance for bed mobility, transfers, walking in room, and locomotion on unit. V14 stated that the change in function was caused by the [CONDITION(S)] injury sustained from the fall. V14 stated that a Morse Fall Scale Evaluation is to be completed by the nurse on duty after every fall and that it is the Director of Nursing responsibility to update the fall care plan within 24-72 hours after every fall. V14 stated that R53's fall on 8/22/22 was not care planned, only the intervention of putting R53 on the Falling Leaf Program was added. V14 stated that the Falling Leaf Program notifies the staff that that particular resident is at high risk for falls by using a visual picture of a leaf outside R53's door but that there are no specific interventions associated with this program. V14 stated there were no changes made to R53's fall care plans interventions after the following falls had occurred: 10/6/22, 10/20/22, 10/31/22, 11/4/22. On 12/8/22 at 3:10 PM, V27 (Nurse Practitioner) stated that R52 sustained a [CONDITION(S)] from a fall and dislocated his finger due to falls. V27 stated that the injuries were directly related to fall and that the injuries caused a change in R53's condition. V27 stated that R53 is very confused and difficult to redirect. V27 stated that R53 does not have a walking problem and that the falls are attributed to R53's cognition related to dementia. V27 stated R53 is not aware of his (R53) surroundings, does not always respond to redirection and can yell and become physical with staff. V27 stated that R53 needs one on one supervision to prevent continued falls however the facility is not able to provide one on one supervision. R53 was admitted to the facility on [DATE] with diagnosis included but not limited to Unspecified Dementia, Unspecified Protein Calorie Malnutrition, Age Related Cataract Bilateral, Hallucinations. R53's care plan dated 11/2/20 documents R53 is at high risk for falls related to cognitive impairments secondary to dementia, generalized weakness, poor safety awareness and impulsive behavior. R53's MDS (Minimum Data Set) from 07/06/22 BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impairment. R53's MDS from 07/06/22 functional status documents in part R53 required supervision (encouragement, oversight or cueing) for walking in room and locomotion on unit and limited assistance (resident highly involved in activity, staff to provide non-weight-bearing assistance) for bed mobility, transfer and walk in corridor. Per record review, on 08/22/22 at 03:48 AM, R53 had an unwitnessed fall in his (R53)'s room while trying to go to the bathroom with no acute signs of injury. No imaging ordered. R53's fall risk care plan dated 11/02/20 documents in part as an intervention on 08/22/22 as Falling Leaf. Surveyor reviewed records and no other interventions were added at that time. No Morse Fall Scale Evaluation or Post Fall Observation Assessment on 08/22/22 or 08/23/22. Per record review on 08/30/22 at 7:20 AM, R53 had an unwitnessed fall in the hallway. Morse Scale Evaluation (post fall) completed on 08/30/22 documents in part R53's score as 65 indicating high risk. Radiology scans from 08/31/22 documented in part R53 complaining of pain and limping, and findings consistent with intertrochanteric fracture. R53 was sent to the emergency room (ER) for evaluation on 08/31/22. R53's hospital discharge records document in part diagnosis Closed Avulsion Fracture of Greater Trochanter of Femur, Left. R53 was not a surgical candidate and was transferred back to the facility on [DATE]. R53's care plan was updated on 08/31/22 to include in part, provide non-skid footwear, room close to nursing station for observation, and Physical and Occupational Therapy evaluation. On 09/01/22 R53 sustained another fall. Surveyor reviewed records and there was no documentation in progress notes about this fall on this date. At 21:52 on 09/01/22, a Morse Fall Scale Evaluation was completed by nursing post fall. Nurse Practitioner progress note on 09/05/22 documents in part, upon return to the facility from the hospital (8/31/22) the following day R53 had another fall. R53 had new care plan created on 09/01/22 due to significant change status related to left [CONDITION(S)]. There were no changes made to the fall risk care plan at this time. R53's Significant Change MDS (Minimum Data Set) from 09/09/22 BIMS (Brief Interview for Mental Status) score is 05 indicating severe cognitive impairment. R53's MDS from 09/09/22 section G for functional status documents in part R53 required extensive assistance (staff providing weight-bearing support) walking in room, locomotion on unit, bed mobility, transfer, and walk in corridor. Per nursing progress notes on 09/27/22 at 18:10, R53 had a witnessed fall wherein R53 lost his balance, leaned against bathroom door, and slid down to the floor. Surveyor reviewed fall care plan and the only intervention added was redirection by staff as needed on 09/27/22. Note R53 already had an intervention in place which stated, redirect resident when noted to be agitated from 01/18/21. Per nursing progress notes on 09/29/22 at 08:12 AM, R53 had a witnessed fall in R53's room wherein he(R53) landed on his (R53)'s buttocks. Per nursing progress notes on 09/29/22 at 12:12, documents in part, R53 had another fall in the hallway wherein he (R53) lost his balance and fell to the floor. R53's left hand 4th finger noted to be abnormally aligned and moved left hand with some difficulty. R53 was transferred to the ER and returned with diagnosis Closed Dislocation of Finger of Left Hand, 4th finger with brace on 09/29/22 at 21:46. Surveyor reviewed fall care plan with new intervention added (10/4/22) for titration of [MEDICATION(S)]. Per nursing progress notes on 10/06/22 at 17:30, documents in part R53 had a fall. Morse Fall Scale Evaluation (post fall) completed on 10/06/22. Surveyor reviewed fall care plan with no new interventions added. Per nursing process notes on 10/16/22 documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed 10/17/22. Surveyor reviewed fall intervention care plan with new intervention added on 10/17/22 to remove tray immediately after all meals. Per nursing progress notes on 10/20/22 at 8:32, documents in part, R53 observed laying on the floor by the food of bed. Surveyor reviewed fall prevention care plan with no new interventions added. Per nursing process notes on 10/31/22 at 14:18, documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed on 10/31/22. Surveyor reviewed fall prevention care plan with no new interventions added. Per nursing progress notes on 11/12/22 at 7:00, documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed on 11/12/22. Surveyor reviewed fall prevention care plan with new intervention for helmet use added on 11/13/22. Per nursing progress notes on 11/14/22 at 3:10, documents in part, nursing heard a loud boom and observed resident laying on the floor next to the bed and body assessment completed with small laceration to the inside of the left ear and laceration to the left elbow and elbow was swollen. Surveyor reviewed fall prevention care plan with no new interventions added. Facility policy titled, Morse Fall Scale Evaluation and Falling Leaf Program dated 10/18/22 documents in part that the facility targets selected residents who are at risk for falls, fall risk is based on the fall risk factors, the fall scale is completed after a fall. Residents placed on the Falling Leaf Program may have a falling leaf placed outside their door, above their bed to visually identify the resident needing special precautions to avoid falls. Facility policy titled, Fall Prevention Program dated 11/21/17 documents in part, the purpose is to assure the safety of all residents in the facility, implementation of appropriate interventions to provide necessary supervision, care plan to address each fall, interventions are changed with each fall, as appropriate, and a Fall Risk Assessment will be performed after any fall incident.

Deficiencies at this level require more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to ensure that one resident (R13) in the sample received anti-itching medications as ordered. This failure affected R13 whose anti-itching cream was not applied, and a wrong dose of [MEDICATION(S)] was administered, for one (R13) of 34 sample residents reviewed for improper nursing care. This failure resulted in R13 crying and itching with red bumps (welts) on her skin, and unable to participate in daily activities B. Based on observation, interview, and record review, the facility failed to timely notify a physician or nurse practitioner of a resident's continued right ankle pain, swelling, and bruising, for one (R68) of 34 sample residents reviewed for improper nursing care. This failure resulted in the delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A. On 3/29/21, R13 was noted in the room scratching her body, pacing up and down the bedside, and crying. R13's arms and stomach area were visibly noted with multiple red raised bumps (welts). R13 lifted up her top and multiple red raised bumps (welts) with streaks of blood across the bumps were observed on R13's stomach. R13 told the surveyor the blood is from her scratching. R13 told the surveyor 2 tablets of [MEDICATION(S)] (anti-itching medication) was ordered by her physician, but the nurse identified as V9, LPN (Licensed Practical Nurse), gave her only one pill. R13 stated V9 told her that she was just seeking drugs. R13 stated two tablets of [MEDICATION(S)] 25mg (each) always relieve the itching, and she can go about her daily activities. R13 then picked up a medicine cup with an unidentified whitish powder in the cup, and started applying the substance on the bumps (welts), and underneath the breast area. R13 stated it (referring to the whitish powder) was given to her by one of the nurses. When this observation was brought to V9's attention, V9 told the surveyor R13's case is a different one. V9 further stated R13 is a drug seeker, and a known drug abuser, whose medication includes [MEDICATION(S)]. V9 stated he administered one pill of 25mg [MEDICATION(S)] to R13 at 9:00 AM, and it was not effective for R13. V9 repeated again (R13) is just a drug seeker. Review of R13's EMAR (Electronic Medication Administration Record) and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 did not document anywhere in the EMAR or progress note any anti-itching medication was administered at 9:00 AM. When this was shown to V9, V9 replied, I forgot to sign it out. The surveyor then asked V9 to read the physician order. V9 stated, I should have given her 2 (two) tablets of [MEDICATION(S)]. I will give the remaining one tablet and document it. V9 signed at 10:26 AM he gave 2 (Two) tablets, and it was ineffective. R13 later expressed relief of the itching, thanking the surveyor for following up on the medication dosage. On 3/29/21 at 10:41 AM, surveyor interviewed with V2 DON (Director of Nursing) in regards to facility expectation for licensed staff administering medication and following physician orders. V2 replied, The nurses are expected to administer medications as ordered and give the medications following the five R's (referring to Right resident, Right dose, Right medication, Right route and Right time.) R13's plan of care documented under focus, R13 has actual skin impairment, and goals include R13 not developing any new breakdown, and intervention includes but not limited to, following treatment per MD (Medical Doctor) order. On 4/1/21 at approximately 11:47 AM, in a telephone interview with V31 (Physician), V31 was asked if a resident's anti-itching medication, [MEDICATION(S)] 25mg tablet order, calls for two tablets to be administered, and is it acceptable for the nurse to administer one tablet. V31 stated, in part, When a medication is ordered, if the order says one to two tablets the nurse can give one or two tablets using his or her judgement, but if the order specification is for two tablets, the nurse must give two tablets, not one or three or four tablets. The facility policy on Medication Administration, with revised date 1/1/2015, presented documented that Medication must be administered in accordance with physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents may self-administer medication if the interdisciplinary team has determined that this practice is safe. The policy listed out steps to follow if a medication error occurs by the licensed nurse, that includes but not limited to, immediately notify the physician, describing the error, and the resident response in the nurse's notes. The facility Job Description for both RN (Registered Nurse) and LPN (licensed Practical Nurse) presented stated, in part, The RN and LPN are responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained. Essential duties and responsibility includes, but not limited to, preparing and administering medication as ordered, charting in nurse's note in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care and perform routine charting duties as required and in accordance with established charting and documentation policies and procedure. Findings included: B. R68 is an [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R68's Minimum Data Set (MDS), dated [DATE], documents, in part, that her Brief Interview for Mental Status (BIMS) is scored as 7, which indicates cognitive impairment. On 4/1/21 at 9:01 AM, V20 (Nurse Practitioner, NP) stated on 3/1/21, she assessed R68 and noted R68's right ankle was swollen and bruising with yellow color. V20 stated she ordered for elevation, ice and for pain management. V20 stated, I instructed the nursing staff that if (R68's) right ankle pain, swelling or bruising increased, with no improvements, to let me know. V20 stated she did not receive any notification from the nursing staff about R68's continued pain, swelling, and bruising to the right ankle. In a progress note, dated 3/1/21 at 9:50 AM, V20 documents, in part, that R68 reports right (R) ankle pain, had positive (+) R ankle swelling and + lateral R ankle bruise that was discussed with nurse on duty (NOD) . Whenever needed (PRN) Acetaminophen and [MEDICATION(S)] available. Inform NP/Attending Physician (AP) if (R68) refractory to medication or bruising/swelling fail to improve. R68's census indicates that on 3/1/21, R68 was in a room on the second floor of the facility. Facility document, titled Daily Nursing Schedule, dated 3/1/21, documents the second floor nurse from 7:00 am to 3:30 pm was V11 (Registered Nurse, RN). On 3/31/21 at 11:35 AM, V11 (RN) stated she doesn't recall V20 (NP) telling me anything on 3/1/21 about R68's right ankle swelling or bruising. V11 stated she did notice that R68's legs looked puffy and R68 had discoloration to her right ankle. V11 stated she medicated R68 for generalized pain as reported by R68. V11 stated if she sees any bruises or swelling on a resident, she will report it to the Director of Nursing (DON), do an incident report, and notify the resident's doctor and family. On 3/1/21, no nursing progress note was noted by V11 documenting R68's right lateral ankle bruising. On 4/1/21 at 9:01 AM, V20 stated she next saw R68 on 3/18/21 when she was having continued right ankle pain, and noted that R68's right ankle was more swollen and bruised than her assessment on 3/1/21. V20 stated she reviewed R68's records for her last visit and could see that R68's pain medication usage had increased within the past week. V20 stated she ordered a stat X-ray of R68's right ankle on 3/18/21. V20 stated V4 (Licensed Practical Nurse, LPN) notified her on 3/19/21 of R68's final results of the right ankle X-ray indicating a fracture. V20 stated she contacted V27 (Attending Physician) and V20 then ordered for R68 to be transferred to the hospital for evaluation and treatment. R68's Radiology Results Report, dated 3/19/21, documents, in part that the right ankle X-rays, 2 views, indicates bimalleolar fracture dislocation of the right ankle. R68's hospital records indicated on 3/22/23, R68 had an open reduction, internal fixation surgery to repair the right ankle fracture diagnosed in the facility on 3/19/21. V20 stated nursing staff should have notified her that R68 was having more and more pain to her right ankle. V20 stated, This should not have been neglected. I should have been notified earlier. V20 stated R68 experienced this harmful effect of pain with the nursing staff's delayed notification of having continued pain, swelling and bruising of the right ankle. R68's electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/21 at 2:36 PM, V13 (Wound Care Coordinator) stated on 3/18/21, V2 (Director of Nursing, DON) asked her to evaluate R68 for bruising and swelling to her right ankle. V13 stated R68's right ankle was observed with a bruise that was yellow with hints of brown and non-pitting [CONDITION(S)]. V13 stated she filled out the initial assessment report. V13 stated for any skin alteration, the staff nurse is to report it to her and she will do a full head to toe assessment as part of her investigation. On R68's Skin Condition Report,, dated 3/18/21 at 10:49 AM, V13 documented, in part, swelling and bruise under abnormal and circles R68's right ankle on the anterior side of a body diagram. On 3/31/21 at 1:32 PM, V2 (DON) stated if a resident is requiring more pain medication than normal, the nurse must question why would pain be worse and not getting better? V2 stated the nurse must report this finding to the physician. V2 stated nurses must notify a physician of any change in a resident's condition. V2 stated a change in condition would include swelling, bruising or anything that is not within the normal parameters or normal baseline for the resident. Facility policy, titled Skin Condition Assessment and Monitoring: Pressure and Non-Pressure , dated 6/8/18, documents, in part: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: . Non-pressure skin conditions (bruises/contusions .) will be assessed for healing progress and signs of complications or infection weekly . A wound assessment will be initiated and documented in the resident chart when . non-pressure skin conditions are identified by licensed nurse . At the earliest sign of . other skin problems, the resident, legal representative, and attending physician will be notified. The initial observation . will also be described in the nursing progress notes. Facility policy, titled Pain Management Program, dated 7/6/18, documents, in part: Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiologically effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. Guidelines: It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program . The pain management program includes the following components: Documentation of pain assessment and monitoring . Standards: 1. Pain assessment protocol will be initiated under any of the following situations: a. Any indication of pain . with any condition change and/or incident associated with the potential of pain . e. A significant increase in the use of PRN use of pain medication . g. Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medication. Facility policy, titled Change in Condition, dated 11/29/20, documents, in part: Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner . Responsibility: Licensed Nurses/Social Services. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: A. An accident involving a resident which results in injury or has the potential for requiring physician intervention. B. A significant change in the residents' physical, mental or psychosocial status.

Based upon observation, interview, and record review, the facility failed to enter (12/9/20) treatment orders as prescribed, failed to clarify (12/11/20) treatment orders, failed to administer treatments as ordered, and failed to notify the Physician and/or Nurse Practitioner of change in wound condition for one of four residents (R7) reviewed for wound care. These failures resulted in R7 developing a wound infection including proteus mirabilis, pseudomonas aeruginosa, [MEDICAL CONDITIONS] bacteria which requires isolation. Findings include; R7's Physician order [REDACTED]. (12/11/20) Left ankle dressing: alginate 4x4, ABD, and kling daily (cleaning instructions and/or frequency are not included). R7's (November/December 2020) Treatment Administration Record affirms treatments are not documented on 11/13, 11/17, 11/18, 11/19, 11/20, 11/22, 11/23, 11/24, 12/3, 12/7, 12/9, 12/10, 12/11, and 12/12/20. R7's (12/7/20) WBC (White Blood Cell Count) was 8.3, (12/14/20) WBC was 10.1 (increasing). On (Monday) 12/14/20 at 2:00 PM, surveyor inquired about R7's current treatment orders. V7 (Licensed Practical Nurse) reviewed the EMR (Electronic Medical Record) and stated, We put calcium alginate (daily) to the left ankle. At 2:03 PM, surveyor requested to observe R7's dressing change. R7 stated, I went to the hospital on Friday (12/11/20) they were cutting my leg, like an operation. They put this dressing on at the hospital, nobody's changed it since Friday. At 2:27 PM, V7 removed R7's left lower extremity dressing and a foul odor was noted. The wound was covered with thick green purulent drainage (indicative of pseudomonas infection). V7 stated, The drainage is pus like and has an odor. Surveyor inquired about the color of the drainage. V7 responded yellowish-greenish. V7 cleansed the medial side of the wound with dakins and cleansed the lateral side of the wound with normal saline. R7 stated, You're doing it wrong. Alginate, ABD, and kling were then applied. On (Wednesday) 12/16/20 at 11:13 AM, V11 (Wound Care Nurse Practitioner) affirmed that she was unaware of R7's (12/14/20) increasing WBC's and/or changes in wound condition. Surveyor inquired about R7's treatment orders. V11 stated, I changed his treatment last week (12/9/20) they should be cleaning it with dakins 1/2 strength and wrapping it with dakins soaked gauze, an ABD, and kerlix. Surveyor inquired who enters the orders. V11 stated V2 (Director of Nursing) has been doing rounds with me and she's the one I've been sending the notes to. (12/9/20 treatment orders were not on R7's physician order [REDACTED]. At 11:42 AM, V11 removed R7's dressing and alginate was adhered to his wound. V11 stated, I'll probably use the dakins and get a culture of the wound. R7 stated, They only took the bandage off twice since Friday. V11 responded, They're supposed to be changing it every day. On 12/16/20 at 2:25 PM, V2 affirmed new treatment orders override prior orders. Surveyor inquired about concerns with R7's (12/11/20) treatment orders. V2 stated, The cleaning solution for the wound is not there it should have been entered and there's no schedule on here. On 12/22/20 at 3:49 PM, surveyor inquired about staff requirements for change in wound condition. V12 (Medical Director) stated, They should call the attending physician to take appropriate steps to prevent it from becoming a worse situation. Surveyor relayed concerns about R7's increasing white blood cells (8.3-10.1), purulent wound drainage, and odor. V12 stated, Usually I like to send them to the hospital for something like that. The white count is usually a response to an infection. The foul smell and the discharge is very concerning. Surveyor inquired about potential harm to R7 with these symptoms. V12 responded, We always worry [MEDICAL CONDITION], infection, or something worse than that like loss of limb. R7's (12/16/20) wound culture results include; proteus mirabilis, pseudomonas aeruginosa, [MEDICAL CONDITIONS] bacteria. The Skin Condition Assessment & Monitoring policy (revised 6/8/18) states non-pressure skin conditions will be assessed for healing progress and signs of complications or infection weekly. Physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration. A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes.

Based upon observation, interview, and record review, the facility failed to turn/reposition (R4) every 2 hours, and failed to administer treatments as ordered for two of four residents (R4, R5) reviewed for pressure ulcers. These failures resulted in R4 developing (facility acquired) pressure ulcers [MEDICAL CONDITION] from osteo[DIAGNOSES REDACTED] (underlying his pressure ulcers including right heel and exposed coccyx). Findings include; 1. R4's wound assessment details affirm he developed a right heel (facility acquired) deep tissue pressure injury (identified 9/20/20) and a stage 3 (facility acquired) coccyx pressure ulceration (identified 10/4/20). R4's POS (Physician order [REDACTED]. (10/14/20) Clean sacrum with normal saline, apply [MEDICATION NAME], calcium alginate and foam padding to area every Monday, Wednesday and Friday. (10/28/20) Clean right heel with [MEDICATION NAME], apply abd pad, and wrap with kerlix every night. R4's (11/11/20) progress notes state resident noted with odor from wound. Received order to send patient to hospital for evaluation. R4's skin observation documentation states; was the resident assisted/reminded to turn/reposition at least every 2 hours? Not applicable was documented on 11/7/20, 11/8/20, and 11/10/20 however R4's (9/10/20) bed mobility assessment affirms he requires extensive assistance; one person physical assist. R4's (October-November 2020) TAR (Treatment Administration Record) affirms treatments were not documented on 10/2, 10/20, 10/23, 10/24, 10/25, 10/31, 11/6, and 11/9/20 as scheduled. On 12/16/20 at 2:42 PM, surveyor inquired about documentation of R4's treatments and turning/repositioning. V2 responded, Documentation of turning should be in the administration record if it was ordered. I checked the medication and treatment administration and I don't see anything on here. The treatments are documented on the TAR if there's a blank that means it wasn't done or it wasn't documented. Surveyor relayed concerns regarding documentation of R4's treatments. V2 advised she recently hired a wound care nurse and stated, I had to terminate the last one cause wasn't nothing being done. On 12/22/20 at approximately 3:52 PM, surveyor inquired about potential harm to R4 if his wound had bone exposed. V12 (Medical Director) responded, Infection or fear of osteo[DIAGNOSES REDACTED]. R4's (11/25/20) hospital discharge summary states he was admitted because of [MEDICAL CONDITION] and fevers presumed secondary [MEDICAL CONDITION] from coccygeal and right foot osteo[DIAGNOSES REDACTED] underlying his pressure ulcers, identified on x-rays. (Computed Tomography (Pelvis) showing sacral decubitus ulcer with osteo[DIAGNOSES REDACTED] involving exposed coccyx. Bilateral foot x-rays show right cancaneal osteo[DIAGNOSES REDACTED] underlying heel ulcer). 2. R5's (12/4/20) wound assessment includes a stage 3 coccyx pressure ulceration. R5's (12/2/20) POS states cleanse sacrum with normal saline solution, apply [MEDICATION NAME] then foam dressing every other day and as needed for wound care. R5's (December 2020) TAR affirms sacrum dressing changes are not documented on 12/2 and 12/8/20 as scheduled. On 12/14/20 at 1:33 PM, R5 stated her dressing is changed Maybe once a week, I really don't know. V3 (Registered Nurse) removed R5's coccyx dressing (as requested). It was notably soiled with a yellow substance (likely urine) and bowel movement however her incontinence brief was clean and dry. V3 stated, It's a wound there, it's soiled. I see some fecal matter. The Skin Condition Assessment & Monitoring policy (revised 6/8/18) includes; Purpose: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration.