Every finding on record at Kenwood Vlge NRSG and RHB CTR

Based on observations, interviews and record reviews, the facility failed to prepare food that was attractive and met nutritive value. This applies to 135 residents (census of 147 residents minus 12 residents with gastronomy tubes) receiving food from the facility's kitchen. Findings include:On 8/15/2026 at 9:41 AM, R9 stated the food tasted like war. R9 said they cooked out all the flavors and the food was always overcooked. On 8/15/2026 at 11:35 AM, R10 stated that the facility's food was not palatable and that R10 often ordered outside food. R10 said the food is often served cold especially the eggs during breakfast. R10 also said they are usually hungry in the evening because their last meal was 5:00 PM and they did not receive anymore food until around 8:00 AM the following day. On 8/15/2026, between 12:35 PM to 12:50 PM, only four of the 12 residents eating in the 2nd floor dining room ate the baked potato, stuffing (country fried steak biscuit batter), and mashed zucchini. Those items remained on the plates of the other 8 residents. On 8/15/2026 at 1:34 PM, V5 (Dietary Director) provided the surveyor with a lunch tray that included the same lunch menu items that the residents received. Upon opening or removing the plastic from the meal tray, there was a strong neck-jerking reaction from the smell of the baked potatoes because of the bacterial odor. The biscuit topping that covered the country fried steak had the appearance of cornbread stuffing because it was overly battered. The sauteed zucchini was overcooked and mushy. V5 stated they prepare sauteed zucchini by putting frozen zucchini in a pan of water and cooking it. V5 said sauteing or stir frying the frozen zucchini in oil would be too labor intensive and they do not have the staff for this task. And V5 said their frozen zucchini turns into mush, and it's overcooked because of the amount of time it stays on the steam table before being served. On 8/15/2026 at 3:09 PM, V8 (Certified Nursing Assistant) of two years stated they received resident complaints about the quality of the facility's food.On 8/16/2026 at 10:13 AM, R10 stated R10 did not touch yesterday's lunch because it did not look appetizing. On 8/16/2026 at 12:37 PM, V5 took the food temperature of today's lunch items and hot tray holding temperature passed with the following results: Vegetables: 155oF - Soft and OvercookedNoodles: 153.3oF - Soft and Overcooked V5 agreed that the mixed vegetables were overcooked but not the noodles (V5 stated it was a matter of opinion.) V5 said vegetables were mushy because the surveyor was smashing them with a light-weight plastic fork. V1 observed the overcooked vegetables and noodles and stated that they were overcooked and not acceptable. On 8/16/2026 at 12:46 PM, R10 stated that today's menu which included mixed vegetables and pasta noodles was mushy and overcooked. R10 said this means most of the nutrients were probably loss. R10 added that R10 believes the facility is doing their best but because of R10's diabetes diagnosis, R10 said R10 must avoid certain foods. On 8/16/2026 at 2:56 PM, V3 stated it was their expectation that residents' food looked presentable, taste well and hot foods served hot. On 8/16/2026 at 3:08 PM, V1 stated it was their expectation that residents' food should be good, tasty and served according to the appropriate temperatures.The facility policy Hot Food Service Temperature dated January 2026 states, in part, 1. Food will be prepared in methods that maintain nutritional integrity and palatability.

Based on observations, interviews and record reviews, the facility failed to assist 4 dependent residents with dressing and getting out of bed. This applies to four residents R2, R3, R4, and R8 out of 10 residents reviewed for activities of daily living (ADL). Findings include:On 8/15/2026 at 9:47 AM, roommates R2 and R5 were lying on their beds flat on their backs while still in their hospital gowns. Strong urine, feces and bodily odors permeated throughout their rooms. R2 said they promised to lift them and change them after lunch. R5 declined an interview with the surveyor. On 8/15/2026 at 10:04 AM, R3 and his roommate (R6) were lying in bed flat on their backs. R3 said they do not raise me from bed, but I want them to. R3 stated they lost R3's clothes about 2 years ago so R3 wears a hospital gown. R3's hospital gown had several drops of a thick brown substance around the collar area. R6 was also lying in bed wearing a hospital gown. R6 did not want to talk.On 8/15/2026 at 10:11 AM, roommates R4 and R7 were lying in beds flat on their backs. R4 said R4 is always lying in their beds wearing hospital gowns. R4 stated they do not know why they do not dress them in regular clothes. R4 said R4 prefers to be dressed in street clothes. R4 added that R6 is always lying in bed with R6's hospital gown on. R6 firmly stated I do not like this. R7 was asleep and not available for an interview. On 8/15/2026 at 9:52 AM, R8 was lying in bed flat on R8's back. R8 said they slept in hospital gown overnight. R8 added They use to raise me, put me in my wheelchair, and put me in street clothes every morning. Now, we must request to get up and dressed for street clothes. On 8/15/2026 at 12:28 PM, residents in rooms R3, R4, R6, R7 and R8 were all sitting upright and eating lunch with their hospital gowns still on. R2 and R5 were still lying flat on their backs wearing their hospital gowns. R2's Face Sheet documents R2's diagnoses of heart failure, chronic obstructive pulmonary disease, cerebral infarction and dysphagia. R3's last quarterly Minimum Data Sheet (MDS) documented R3 is dependent and requires substantial/maximal assistance in all areas of care including showering/bathing, upper body dressing, lower body dressing and chair-to-bed transfer. R2's last quarterly Minimum Data Sheet (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14 indicating little to no cognitive impairments. R3's Face Sheet documents R3's diagnoses of diabetes, major depression, hyperkalemia, nicotine dependence, and benign prostatic hyperplasia. R3's last quarterly Minimum Data Sheet (MDS) documented R3 is dependent and requires total assistance in all areas of care including eating, showering/bathing, upper body dressing, lower body dressing and chair-to-bed transfer. R3's last quarterly Minimum Data Sheet (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14 indicating little to no cognitive impairments. R4's Face Sheet documents R4's diagnoses of cerebral infarction, diabetes, heart failure, hypertension and obesity. R4's last quarterly Minimum Data Sheet (MDS) documented R4 is dependent and requires total assistance in all areas of care including oral care, showering/bathing, upper body dressing (substantial assistance), lower body dressing and chair-to-bed transfer. R4's last quarterly Minimum Data Sheet (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12 indicating some cognitive impairments. On 8/16/2026 at 2:56 PM, V3 stated it is their expectation that nursing staff particularly Certified Nursing Assistants/CNAs visit residents' rooms to see if they want to get up. V3 said Get up means bath, shower, dress, provide other activities of daily living (ADL) then put in them in their chair or other sitting devices. On 8/16/2026 at 3:08 PM, V1 (Administrator) stated it is their expectation that CNA or nurses offer residents the opportunity to get up based on the resident's preference.

Based on interviews and record review, the facility failed to ensure that a nurse and CNA (Certified Nursing Assistant, CNA) maintained a current CPR (Cardiopulmonary Resuscitation) certification card while working in the facility.Findings include: On [DATE] at 9:45AM, a telephone interview was conducted with V4 (Former Employee), and V4 states that some staff are not CPR certified. On [DATE] at 11:31AM, V5 (Certified Nurse Assistant/CNA) states a valid, active CPR certification card is required to work as a CNA in this facility.On [DATE] at 11:51AM, V12 (CNA) states CPR certifications are required for all CNAs.On [DATE] at 12:35PM, surveyor first request was made via email for V15's (CNA) CPR certification card with request sent to V1 (Administrator), V2 (Assistant Administrator) and V3 (Director of Nursing, DON).On [DATE] at 1:27PM, V1 (Administrator) states nurses are required to have their CPR certifications as they are the only ones that would be performing CPR. V1 stated that there are 2 nurses on the unit so when 1 nurse is away/off the unit, there is always another nurse. The units are never without a nurse.On [DATE] at 2:23PM, V3 (Director of Nursing/ DON) states that during a code (when a resident is pulseless or not breathing), it's all hands on deck. Any healthcare staff, Nurses and CNAs, will initiate CPR and perform chest compressions until Emergency Medical Services (EMS) arrives. LPNs and CNAs must be CPR certified (active, current) to work here in the facility. Human Resources (HR) is responsible for tracking everyone's CPR certifications and making sure they don't expire. HR will send out notifications to staff about expiring CPR certifications reminding the staff to renew their CPR prior to expiring. V3 states the facility holds CPR classes, but staff can also take CPR renewal classes out in the community.On [DATE] at 2:48PM, during a telephone interview, V14 (Licensed Practical Nurse, LPN) states she works night shifts from 7PM until 7AM in the facility and worked the night before the last night in the facility. V14 confirms receiving an email notification from facility's HR department regarding the expiration of V14's CPR certification but cannot recall when. V14 states that V14 renewed V14's expired CPR by taking the CPR certification today ([DATE]).V14's expired CPR Certification document shows that V14 was certified for CPR on [DATE] and this CPR certificate is valid for 2 years; therefore, V14's CPR certification expired on [DATE].V14's current CPR Certification document shows that V14 was certified for CPR on [DATE], which is the same date that this surveyor requested for V14's current CPR certification.On [DATE] at 3:05PM, surveyor made a second request via email for V15's CPR certification card with this request sent to V1, V2 and V3.On [DATE] at 9:35AM, this surveyor followed up with V1 after making a final third request for V15's CPR certification card, and V1 stated that V15 has been contacted several times yesterday ([DATE]), and this morning ([DATE]) and has not been able to produce a current CPR certification card for V15.On [DATE] at 10:00AM, V16 (Human Resources Director/HRD) states all nursing staff, such as RNs (Registered Nurses), LPNs, and CNAs, must have a valid CPR certification otherwise they are not hired. V16 states she has a book with everyone's professional license and CPR certification; a note gets attached with an expiration date for follow up, and V16 emails the employee in advance of the CPR expiration date. V16 states that she sent an email to V14 (LPN) sometime in February 2026 regarding V14's CPR certification expiring in [DATE], but V16 was off on medical leave for 2 weeks and did not follow up once V16 returned to work. V16 states that V15 (CNA) was hired prior to when V16 started working at facility, and V16 has not seen a valid CPR certification for V15's employee file. V16 states she contacted V15 several times yesterday and today, but V15 has not been able to produce a valid CPR certification. V16 states that V15 will not be scheduled to work in the facility until V15 provides a valid CPR certification card. V16 states that a resident can die if staff are not properly certified in CPR.On [DATE] at 10:14AM, V3 (DON) states that the purpose for RNs, LPNs, and CNAs to be actively CPR certified is to assist a resident in the event of an accident, like when a resident stops breathing or starts choking. V3 states that the importance of nurses and CNAs keeping their CPR certifications current is to keep up to date with any changes in the CPR process, because if staff do not follow the most current CPR standards, a resident can potentially die.Facility's Daily Staff Schedules reviewed for all 3 floors in the facility for day, evening and night shifts between [DATE], and [DATE]. V14 and V15 worked various shifts on multiple dates despite not having an active CPR certification.Daily Staffing Schedules document in part, that V14 (LPN) worked 7PM to 7AM on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Daily Staffing Schedules document in part, that V15 (CNA) worked 11PM to 7AM on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Facility's Licensed Practical Nurse Job Description (revised [DATE]) reads in part, Qualifications: Current CPR Certification is required.Facility's Certified Nursing Assistant Job Description (undated) reads in part, Qualifications: Current CPR Certification is required.Facility Census Report dated [DATE] documents that 149 residents currently reside in the facility.

Based on observation, interview and record review, the facility failed to protect residents from verbal aggressions which affected two residents (R37, R66) of seven residents reviewed for abuse in a total sample of 28 residents. The escalating verbal aggressions resulted in verbal and physical assault which caused R37 to suffer psychosocial harm exhibited by increased depression, increased feeling of mania and feeling unsafe in her private space. Findings include: R66'S medical record documents, in part, the following medical diagnoses: Schizophrenia and Major Depressive Disorder. A Minimum Data Set (MDS) dated [DATE] documents that R66 is Cognitively Intact. R66's care plans include concerns with behavioral symptoms, physical and verbal aggressions towards others and depression. There is a care plan that documents that R66 is at a high risk for abuse due to impaired decision making and verbally aggressive behavior. R37's medical record documents, in part, the following medical diagnoses: Bipolar Disorder and Major Depressive Disorder. An MDS dated [DATE] documents that R37 is Cognitively Intact. R37's care plans include concerns with bipolar disorder for which R37 is prescribed an antipsychotic medication, behavioral symptoms, verbal aggressions towards peers and depression. On 3/23/26 at 11:37 AM, R37 stated, I was just assaulted by (R66). It just happened an hour ago. A nurse came running into my room when I screamed and they immediately removed (R66) from the room. R37 was visibly shaken and crying on and off. At 11:40 AM, V36 (Activity Aide) entered the room and briefly talked to R37. R37 again started crying as she recalled the assault that took place. At 11:43 AM, V36 indicated she would report the incident to personnel. R37 continued to state, (R66) has been verbally saying things to me for the last week. I really don't think she likes me. It gotten to the point where (R66) assaulted me. She came in contact with my left arm. R37 was asked if R66 hit her. R37 stated, Any unwelcome contact with my body is considered assault, is it not? We have had several instances of disagreement with verbal altercations because she is constantly opening and closing the privacy curtain. I'm over here minding my own business. There's no reason to move the separation between us. That's just plain disrespectful. All the staff knows about what has been going on. I even had staff from the therapy (social services) department come and talk to me about these altercations. R37 continued, Something like this was bound to happen because she's been at me all week. I don't feel safe. I feel like I cannot even close my eyes. R37 stated, For me to feel unsafe in my personal space is not good. I do feel unsafe. I've been asking to be moved from this room. The incessant belligerent attitude is making me feel manic and not right in my head. R37 clarified that it did not make her feel like being physically aggressive towards R66 but made R37 feel increased confusion in her own head. Then R37 switched to speaking of herself in 3rd person and stated, It makes me think like what did (R37) do in her lifetime to make someone want to assault her. On 3/24/26 at 11:52am, R66 was sitting in the day room on the 3rd floor due to staff removing her from the room after the altercation. R66 refused to talk. On 3/27/26 at 4:00 PM, V20 (Psychiatric Doctor of Nursing Practice (DNP) stated, When angry, persons with bipolar disease will experience a change in mood. Bipolar moods swing based on how things are going around you. With increased anger, this can cause manic feelings. Patients do not necessarily need to be monitored closer but may need a re-evaluation and a medication adjustment. On 3/24/26, R37 was sent to the hospital. On 3/27/26 at 4:00pm, V20 confirmed that R37 was sent out for a psychiatric evaluation and a medication adjustment after V20 was notified of R37's verbal/physical altercation with R66 and a verbal altercation with R147 on 3/24/26. On 3/24/26 at approximately 11:00am, V7 (Staffing Coordinator) and V22 (Medical Records Director) confirmed that they were assisting on the 3rd floor and they heard the verbal altercation between R37 and R66. On 3/25/26 at 9:46am, R66 stated, (R37) was on the edge since she came in here. (R37) did not like that I would open and close the curtain. (R37) didn't like that I walked past her bed all the time. So, we have had words with each other almost every day. I guess she didn't like that I would talk back. I hardly talk to people. I keep to myself. I don't feel comfortable talking to people. R66 continued to state that they would verbally fight with swear words and back and forth arguing but nothing physical. R37's electronic record documents that R37 was moved into R66's room on 3/13/26. Their first altercation was documented on 3/15/26 at 4:30am. R37's progress notes authored by V30 (LPN-Licensed Practical Nurse) document, Resident noted verbally arguing with roommate in shared room. Residents separated from each other and spoken to on 1:1 basis to de-escalate the situation. It is not documented that the Abuse Coordinator was notified. R37 and R66 remained in the same room. A second altercation was documented on 3/23/26 in R37's progress notes and authored by V32 (LPN). It reads: Resident observed engaging in verbal altercation with roommate, with both residents displaying verbally aggressive behavior toward one another. Staff intervened promptly and attempted to de-escalate the situation; however, redirection was not effective at that time. Resident remains on continuous monitoring for safety and behavioral observation. R37's Continuous monitoring documentation was requested and not received. It is not documented that the Abuse Coordinator was notified. A third altercation occurred on 3/24/25 as R37's progress notes which were authored by V31 (LPN) document at 12:06pm, Resident alleged that (R66) hit her on the left arm during a verbal altercation, in which the roommate denies. Reports from staff stated they heard/observed a verbal altercation between the two. R37 and R66's medical records document only three verbal altercations despite multiple staff members indicating that verbal aggression between the two residents happen often. R37 and R66 indicated that their verbal arguments happen every day. On 3/25/26 and 3/26/26, V28 (CNA), V29 (LPN), V33 (CNA) and V34 (CNA) all indicated that they are often scheduled to care for R37 and R66. All confirmed that R37 and R66 are verbally confrontational with each other. R37's progress notes dated 3/23/26 documents that R37 complained about certain actions that R66 does that cause her agitation. On 3/25/2026 at 10:35am, V28 (CNA) stated, One of them wants curtain pulled. (R37) didn't want (R66) to pull curtain. I had to explain that she has right to do that. There was no physical altercation. They never had verbal issues when I took care of them. Both just said they need to get out of that room - meaning they needed to be moved out of room. I didn't tell anyone. I was able to talk to both of them. On 3/25/2026 at 10:42am, V34 (CNA) stated, I am familiar with them. I take care of them regularly. They've only been in that room together less than 30 days. They argue a lot. They have a lot of verbal altercations at night. The issue is that they don't want to be in the room together. (R37) does not like being in the room with (R66). They are arguing back and forth all the time. I have come in to diffuse their arguments. I cannot remember specifically when. V34 continued to state that he can hear the verbal confrontations from the hallway. I'll come in and they will calm down. But (R37) will say she doesn't want to be in room with (R66) and walk out. V34 stated that he let V29 (LPN-Licensed Practical Nurse) know about their altercation and did not let Abuse Coordinator know. On 3/26/26 at 1:39pm, V29 (LPN) indicated that she has not reported any abuse incidents regarding R37 and R66 to the Abuse Coordinator. V29 also stated that R37 and R66 Sometimes get into it. V29 stated, I don't remember (V34) letting me know about an altercation. Must not have been major. Major is if they are verbally aggressive towards each other and if loud and disturbing to other residents. Staff interviewed were able to recall specific instances of verbal aggressions between R37 and R66, but there was no documentation of these verbal aggressions in the progress notes and they were not conveyed to the Abuse Coordinator. As a result, multiple verbal aggressions between R37 and R66 were not reported to State and not investigated as possible abuse. V28 (CNA-Certified Nurse Assistant) and V34 (CNA) both indicated that R37 and R66 requested to be moved from their shared room. Neither CNA told any other staff members. As a result, R37 and R66 remained roommates. On 3/25/36 at 11:49am, V27 (PRSC – Psychosocial Rehabilitative Service Coordinator) stated, (R37) has had issues with other residents. (R37) has disorganized thinking and believes that she's living by self. She does not know how to share living spaces. She is verbally aggressive towards other residents and staff. Issues started when (R37) was moved in with (R66). V27 indicated that R37 never approached V27 about wanting to be moved. V27 also stated that staff did not come to her with knowledge about R37 and R66 wanting to be moved out of the room. V27 stated, If we knew, we would find a new room to separate them, deescalate the situation and prevent bigger problems like what happened. V27 indicated that there is no reportable incident regarding R37 and R66. V27 stated, If I think back to what we should have done when they were having altercations, we should have considered separating them after the first incident. If they have increased verbal discussions, and they're not separated, then they're not kept safe because it could have been prevented by removing them as soon as the first incident occurred. R37's care plan regarding behavioral symptoms and dated 1/16/26 reads: Approach: Staff will ensure environmental safety reducing the need for conflict. R66's care plan regarding psychosocial well being and dated 11/3/25 reads: Approach: Provide a calm, structured environment with minimal stimuli to reduce frustration and agitation. Another care plan dated 11/7/24 reads: Approach: Report all instances of alleged abuse to the abuse coordinator. R66's care plan regarding behavioral symptoms and dated 11/7/24 reads: Approach: Maintain a calm environment and approach. The facility originally provided R37 and R66's progress notes on 3/24/26. As the abuse investigation progressed, R37 and R66's Progress Notes were edited as evidenced by the several notes in italics. It reads at the bottom of each document, Notes marked in italics indicates that a note has been marked invalid or is a history of the note edited. On 3/25/26 at 11:49am, V27 (PRSC) denied that she edited R37 and R66's Social Services progress notes. On 3/26/26 at 11:42am, V27 confirmed that she had, in fact, edited R37 and R66's progress notes on 3/24/26 after the abuse incident between R37 and R66. On 3/25/26 at 2:35pm, V1 (Administrator) stated, I am the abuse coordinator. Whenever any type of abuse occurs, they all know to call me as soon as possible. I have a 2-hour window to start an investigation and report to (State). They should separate residents, make them safe, do a physical assessment, call the family, call the doctor and the police if appropriate. With the verbal altercations, I should have been contacted immediately. Schizophrenia cannot be seen as normal and accepted behavior. It is inappropriate behavior. I do not have any reportable incidents for (R37) and (R66). I was not told about them. They should have been separated after the first verbal aggression. Different rooms and if warranted different floors. We have to separate after verbal aggressions because we never know what it is going to lead to. V1 confirmed that the only abuse investigation she has for R37 and R66 is from 3/24/26. The facility had one abuse investigation for R37 and R66 and it was dated 3/24/26. There are no other reportables for any incidents between R37 and R66. On 3/25/26, the facility submitted an undated facility policy titled Abuse Prevention Program which was not in accordance with the Long Term Care section of health care. Instead, it indicated that it was for the mental health division of State. This policy documents, in part: IV: Establishing a Consumer Sensitive Environment: This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of consumer property by establishing a consumer sensitive and secure environment. VI. Protection of Consumers: Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of investigation. The accuse consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his and her safety, as well as the safety of other consumers and employees of facility. VII: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation. On 3/27/26 at 2:16pm, V1 (Administrator) was updated that the Abuse policy submitted was not for Long Term Care. The facility then submitted an, Abuse Prevention Training Program document from the Illinois Long Term Care Council dated November 22, 2017 which reads, in part: B. Internal Reporting: Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. III. Protection: B. Resident. If the alleged perpetrator is a resident, the resident will be separated from the alleged victim and the resident's condition will be evaluated as soon as reasonably possible to determine the most suitable therapy and placement for the resident. This will be done taking in consideration the safety of other residents and employees of the facility. On 3/27/26 at 3:54pm, the facility submitted a 3rd abuse policy which was undated and titled, Abuse Prevention Policy.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) not practicing effective handwashing. These deficient practices have the potential to affect 141 residents receiving food prepared in the facility kitchen. Findings include: On 03/24/2026 at 9:42AM during initial kitchen tour with V12 (Dietary Director), the following food items were found in the walk-in cooler: 1 package of opened hot dogs, no use by date and not labeled. 2 opened hamburger buns no open date, no use by date, and not labeled.1 half pint carton of milk with expiration date of 03/15/20261 open package of lettuce wrapped in clear plastic wrap, no open date, no use by date, and not labeled.1 open package of shredded carrots wrapped in clear plastic wrap, no open date, no use by date, and not labeled.1 open package of whole turkey breast meat, no open date, no use by date, and not labeled. On 03/24/2026 at 9:54AM the following items were found in the dry storage area: Multiple boxes of food items sitting on the floor.1 opened container of tomato salsa with open date 03/10/2026. On 03/24/2026 at 10:27AM, V12 (Dietary Director), and surveyor located next to the three-compartment sink inside of the kitchen. V12 states the facility uses quaternary solution to sanitize dishes washed in the three-compartment sink. V12 observed washing a pan in the three-compartment sink and submerges the pan in the quaternary solution for approximately 15 seconds. V12 then takes the pan out of the quaternary solution and places it in the dish rack to dry. V12 then reads the directions located above the three-compartment sink and states she should have submerged the pan in the quaternary solution for more than 15 seconds. V12 does not use a test strip to test the quaternary solution in the designated sanitize compartment of the three-compartment sink. V12 states if dishware used for resident use is not sanitized correctly, then there is a risk for the residents to acquire a food borne illness from contamination. At 10:33AM, the dry, bulk storage container labeled flour observed a foam cup inside used a scooper. On 03/24/2026 at 10:34AM the following items were found in the reach in freezer:Name brand bottled water A frozen TV dinner On 03/24/2027 at 10:35AM, V12 states all opened food items stored in the walk-in coolers should be labeled with the food item, have an open date, use by date, or expiration date labeled on the food items. V12 states the facility recently had a delivery, which is why the boxes/food items were left sitting on the floor. V12 states food items stored in the dry storage room should not be stored on the floor. V12 states the facility usually places the food items on the floor after a delivery. V12 states the dry, bulk containers should not have the foam cup inside to be used as a scooper because it creates a risk for contaminating the resident's food. V12 states the brand named water bottle and frozen TV dinner should not be placed in the resident's reach in freezer. V12 states those items were an employee's personal items and should not have been stored in the freezer used for residents' use. V12 states all expired food items found in the walk-in cooler should not be stored in the walk-in cooler which is available and intended for resident use. V12 states expired food items should be discarded immediately. V12 states the tomato salsa should have been refrigerated after opening and not located in the dry storage area for resident use. V12 states if residents consume expired food items, the residents could acquire a food borne illness and become sick due to bacteria. On 03/24/2026 at 10:47AM, V13 (Dietary Aide) return demonstrates the process of handwashing in the kitchen. V13 observed washing his hands for approximately 15 seconds and then grabs a paper towel and begins to clean the dirt from the sink after performing handwashing. V13 states effective handwashing should be performed for at least 20 seconds. V13 states that his hands were not cleaned effectively since he did not wash them for the required amount of time. V13 also states that since he began cleaning dirt from the sink after washing his hands, there is a risk for contamination and spreading germs. On 03/25/2026 at 10:02AM, V11 (Cook) observed operating the blender used for preparing the pureed meals. V11 observed washing the blender in the three-compartment sink and using a towel to dry the blender. V11 repeats this process for all three food items prepared for the pureed meals. V11 does not allow the blender to air dry in between preparing the puree meals. V11 states this is the process that she normally performs when she is preparing pureed meals for the residents in the facility. Facility census dated 03/24/2026 documents that a total of 141 residents receive food from the kitchen. Facility policy dated 03/2025 titled Hand-Washing/Hand Hygiene Policy documents in part, It is the policy of the facility to assure staff practice recognized hand washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. 3. Facility staff must wash their hands for no less than 20 seconds using antimicrobial or non-antimicrobial soap and water. Keep scrubbing for 20 seconds (e.g. hum/sing the Happy Birthday song twice.) Facility policy undated, titled, Labeling and Dating Foods documents in part, Prepared and packaged foods will be labeled and rotated to decrease the risk of foodborne illnesses.cans or boxes will be behind the previously received product on the shelf or in the can rack. 3. Use by Date: [NAME] with date, day, or # of days from opened date. Use by date will be based either from manufacturer's use by date first or recommended maximum storage. Facility policy undated, titled Safe Food Preparation and Handling documents in part, Food will be discarded if it is held in the temperature danger zone for more than 4 hours. Facility document undated, titled, Three-Compartment Sink Use documents in part, Submerge all items fully and allow contact time (at least 7 seconds for chlorine and 30 seconds for Quat). Air dry all items completely before storing-towel drying is not permitted. A. use test strips matching your chemical sanitizer.B. refer to chemical strip instructions.

Based on observation, interview, and record review, the facility failed to a.) ensure that its staff follow the facility's policy and maintain proper linen handling. This failure has the potential to affect 52 residents residing in the facility, on the 3rd floor, b.) ensure staff properly provide hand hygiene during the medication administration for three residents (R15, R114, and R137) out of four residents reviewed for medication administration in a total sample of 28 residents. Findings include: On 03/24/2026 at 10:57 AM, V4 was walking in the hallway, holding a hospital gown in a bundle and then placed it in the soiled room. V4 stated that she is assigned to rooms 301 to 306 and has a total of 16 residents. V4 stated I was just getting a gown off the floor; it is not one of my rooms. V4 stated that anything that touches the floor is dirty, and the linen goes into the soiled utility room. When asked V4 if soiled or dirty linen be placed in a bag prior to placing it in the soiled utility room, V4 stated for the most part you can put it in the bag, I guess to seal in the germs and not be walking through the hallways with people's germs. V4 stated that V4 had a glove on when V4 was transporting the soiled hospital gown. V4 stated It was just a gown, but I probably should have put it in a bag, I was just working fast. On 03/26/2026 at 9:59 AM, V25 (Infection Preventionist/Licensed Practical Nurse) stated that staff are supposed to gather their materials (clear bag), wash their hands, put on gloves, roll the soiled linen, place it in a bag, do not place it on the floor, wash their bags, dispose the soiled linen in the soiled linen receptable, and then wash their hands. V25 stated that it is important for soiled linen to be placed in a bag to prevent the spread of pathogens and contaminating their clothing. Facility census dated 03/24/2026 documents that a total of 52 residents reside on the 3nd floor of the facility. Facility document dated 08/2008, titled Laundry and Bedding, soiled documents in part, soiled laundry/bedding shall be handled in a manner that prevents contamination of the air and persons handling the linen. Place and transport contaminated laundry in bags or containers or containers that are labeled or color-coded in accordance with established policies governing the handling and disposal of contaminated items. On 03/24/2026 at 9:51 AM, during a medication pass surveyor noted V14 (Registered Nurse/ RN) did not perform hand hygiene prior to the medication pass. On 03/24/2026 at 10:30 AM, V15 (Registered Nurse) did not perform hand hygiene prior to medication administration. On 03/25/2026 at 9:36 AM, V23 (License Practical Nurse/ LPN) did not perform hand hygiene prior to medication administration. On 03/25/2026 at 10:00 AM, V23 (License Practical Nurse/ LPN) did not perform hand hygiene in between residents. V23 did not perform hand hygiene prior to medication administration. On 03/26/2026 at 1:30 PM, V3 (Director of Nursing/ DON) stated nurses are expected to perform hand hygiene before medication administration, before medication is handled, after medication administration, in between residents during the medication administration. Surveyor asked V3 what can potentially happen if there is no proper hand hygiene. V3 stated that the residents are at risk for germ spreading and can become sick. Policy titled Medication Administration with review date of 10/25/2014 documents in part, handwashing and hand sanitization: the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal and parenteral preparations and medications given via enteral tubes. Sanitation can be done at regular intervals during the medication pass such as after each room, again assuming hand washing is not indicated.

Based on interview and record review the facility failed to a.) offer coronavirus disease 2019 (COVID-19) vaccinations and b.) adequately document COVID-19 vaccination status for four (R25, R52, R103, R132) out of five residents reviewed for immunizations in a total sample of 28 residents. Findings include:On 03/26/2026 at 9:59 AM, V25 (Infection Preventionist/Licensed Practical Nurse) stated that the facility's infection control policies and procedures are reviewed annually and as needed by the facility's consultant. With V25 reviewed five residents' (R25, R39, R52, R103, and R132) immunizations records. V25 stated that R25 received the coronavirus disease 2019 (Covid-19) vaccine on 11/01/2024. V25 stated I am going to order it once we are out of the covid-19 outbreak. V25 stated that the first positive case for Covid-19 was February 26th, 2026. V25 stated that R52 received the Covid-19 vaccine on 09/13/2024. V25 stated that R52 refused the Covid-19 vaccine and it should have been documented in the immunization record. V25 stated that R103 received the Covid-19 vaccine on 11/01/2024. V25 stated that R103 wants the new Covid-19 vaccine, and he will get it next week. V25 stated it should be documentation that R103 refused but it is not. V25 stated that V25 did not document R132's Covid-19 vaccine refusal and it should have been documented. On 03/26/2026 at 11:57 AM, R25 stated somebody just came in to inform me that they are going to give us the shot next week. Prior to that they didn't offer it. R25 stated that staff have not offered R25 the Covid-19 since 2024. R25 stated, if they would have offered it, I would have taken it, like next week I'm going to take it. R25's current face sheet documents R25 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: hypertensive heart disease without heart failure(primary), lymphedema, multiple sclerosis, other reduced mobility.R25's MDS/Minimum Data Set Section C dated 03/19/2026 documents that R25 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R25 is cognitively intact. On 03/26/2026 at 12:05 PM, R103 stated that V25 offered the vaccine today and denied that they have offered him the Covid-19 vaccine all last year because R103 stated that R103 would have taken the vaccine. R103 stated that during the recent Covid-19 outbreak in the facility, R103 didn't hear that staff were offering the residents the vaccine. R103's current face sheet documents R103 is a [AGE] year-old individual admitted to the facility on [DATE]and has diagnoses not limited to: idiopathic gout, left hand(primary), type 2 diabetes mellitus without complications(admission), essential (primary) hypertension, heart failure, unspecified, primary generalized (osteo)arthritis, chronic kidney disease, stage 3 unspecified.R103's MDS/Minimum Data Set Section C dated 03/11/2026 documents that R103 has a BIMS/Brief Interview for Mental Status score of 05/15, indicating that R103 is cognitively intact. On 03/26/2026 approximately between 12:15PM- 12:20 PM, V25 provided this surveyor with four Covid-19 vaccine consents signed by the residents reviewed for immunizations (R25, R52, R103, R132) with dates in 2025. This surveyor questioned V25 if V25 had spoken to R25, R52, R103, and R132 today regarding vaccines and V25 stated no and only did rounds in the hallway. On 03/26/2026 at 12:34 PM, R25 stated that he signed a Covid-19 vaccine consent form and signed it with today's date. R52 and R104 stated that they also signed the consents today but did not write today's date on them. R25, R52, and R104 denied that they had signed any Covid-19 vaccine consents before today. On 03/26/2026 at 1:16 PM, V25 (Infection Preventionist/Licensed Practical Nurse) stated that she remembered that the residents that were reviewed for immunization verbally told V25 that they declined the Covid-19 vaccines but V25 didn't documented it in their charts. V25 admitted that she had completed the documents (Covid-19 consents) today and V25 admitted to falsifying and tampering with the documents and adding 2025 dates. V25 admitted that falsifying documents is not ethical for nurses to do. This was reported to V1 (Administrator) and V2 (Assistant Administrator). Facility document dated January 2026 titled Acute Respiratory Infection (ARI) & Viral Respiratory Pathogens Prevention and Response Policy documents in part: This policy describes how the facility prepares for, prevents, identifies, tests, and responds to Acute Respiratory Infections (ARI) and the viral respiratory pathogens that commonly affect residents in long-term care settings. These pathogens include COVID-19 (SARS-CoV-2), influenza, RSV, and other seasonal and emerging respiratory viruses.Purpose: The facility's purpose is to maintain a safe environment by reducing the introduction and spread of viral respiratory infections. This is accomplished through early identification of illness, strong surveillance practices, appropriate testing, timely isolation or precautions, and a clear outbreak response process that is scalable based on the level of risk.Administration ensures resources are available, including vaccination supplies, PPE, viral tests, cleaning materials, and adequate staffing coverage.Preparation includes maintaining an updated vaccination program for COVID 19, influenza, and RSV when appropriate for residents. Staff are encouraged to remain up to date on vaccinations as recommended by CDC and the state health department.Facility document dated 05/08/2023 titled policy and procedure coronavirus disease (Covid-19) documents in part, purpose to reduce the risk of transmission of the Coronavirus Disease in any healthcare setting. Encourage everyone to remain will all recommended Covid-19 vaccine doses.

Based on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect a total sample of 28 residents reviewed.Findings include:On 03/24/2026 at 9:30 AM, surveyor located on the first floor of the facility. During medication administration pass with V14 (RN), surveyor observed V14 leaving the medication cart unlocked when he went to take R137 blood pressure (identified medication cart A) and walked away leaving it unattended. On 03/24/2026 at 10:30 AM, V15 (Registered Nurse) was observed during a medication pass on the first floor with Medication cart B. Surveyor observed V15 leaving the medication cart unlocked when she walked away.On 03/24/2026 1:00 PM, surveyor observed on the second floor, medication cart A was left unlocked with no nurse on site.On 03/25/2026 at 9:36 AM, surveyor located on the second floor of the facility. During medication administration pass with V23 (LPN), V23 observed leaving the medication cart unlocked when she went to take assist R115 (identified medication cart B) and walked away leaving it unattended.Facility census dated 03/24/2026 documents that a total of 38 residents reside on the 1st floor of the facility.Facility census dated 03/24/2026 documents that a total of 52 residents reside on the 2nd floor of the facility.Facility policy titled storage of medications with review date of 10/25/2014 documents in part, medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to prepare puree food at the appropriate texture. This failure has the potential to affect eleven (R4, R10, R21, R22, R26, R30, R53, R88, R91, R110, R138) residents reviewed for pureed diet prepared in the facility's kitchen, in a total sample of 28 residents. Findings Include: On 03/25/2026 at 9:50AM, V11 (Cook) observed operating the blender used for preparing the pureed meals for the residents in the facility. V11 observed preparing pureed turkey a la king. V11 observed blending the food items in the blender and states she is finished pureeing the turkey a la king for the residents to consume. Surveyor observes that large chunks of turkey meat are still located inside of the blender as V11 poured the pureed food inside of the pan. V11 then observed taking a spatula and taking out the large turkey chunks that are visible to V11. Surveyor observes the texture to be coarsely blended with larger food items contained in the pureed meal prepared by V11. V11 states she is aware that there were large chunks of turkey meat still inside the pureed meal and will now blend the meal to the required pureed texture. On 03/25/2026 at 10:06AM, V11 observed preparing pureed peas. V11 observed blending the food items in the blender and states she is finished pureeing the peas for the residents to consume. Surveyor observes that larger chunks of the skin on the peas are still located inside of the blender as V11 poured the pureed food inside of the pan. Surveyor observes the texture to be coarsely blended and V11 states she will now blend the meal to the required pureed texture. On 03/25/2026 at 10:28AM, V11 observed preparing pureed biscuits. V11 observed blending the food items in the blender and states she is finished pureeing the biscuits for the residents to consume. Surveyor observes that a thick consistency of biscuit batter is located inside of the blender as V11 poured the pureed food inside of the pan. Surveyor observes the texture to be coarsely blended with thick biscuit batter contained in the pureed meal prepared by V11. V11 then observed removing a spatula from the pureed biscuits which is noted with a thick chunk of biscuit batter. V11 states she is now aware that there are thicker consistencies of biscuit batter inside of the pureed meal and she will now blend the meal to the required pureed texture. On 03/26/2026 at 9:32AM, V24 (Registered Dietician) states the pureed diet should be a consistency where the food is not able to drip through a fork. V24 states there should not be large chunks of food located in a resident's pureed meal, and it should be the same even consistency. V24 states the resident can potentially have difficulties chewing and swallowing and could potentially aspirate if there are large chunks of food inside of their pureed meal.Facility document titled Client Index- Active Clients filtered by Consistency: Pureed documents that a total of eleven residents are ordered to receive pureed diets in the facility.Facility policy dated 04/2027 titled, Therapeutic Diets document in part, 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. 5. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. 7. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet.

Based on observation, interview, and record review, the facility failed to properly provide medication administration per physician orders for three (R15, R114, R137) residents in a total sample of 28 residents reviewed.Findings Include:On 03/24/2026 at 9:51 AM, during the medication pass there was a discrepancy noted on the first-floor medication cart A. V14 (Registered Nurse/ RN) was getting ready to administer R137 a blood pressure medication (Enalapril 20 mg). R137 has a blood pressure of 98/64. Surveyor intervened, to stop V14 from administering this medication to R137. When surveyor asked what can potentially happen if a blood pressure medication is given to a resident with a blood pressure of 98/64. V14 stated he will not administer the medication because the blood pressure can drop. On 03/24/2026 at 10:30 AM, V15 (Registered Nurse) was observed during a medication pass on the first floor with Medication cart B. During the medication pass surveyor noted a discrepancy, and this surveyor had to intervene with medication administration for linaclotide capsule 290 mcg. The medication had specific instructions to administer 30 minutes before meals. R15 had her breakfast at approximately 7:30 AM to 8:00 AM, and it was now 10:30 AM. Surveyor asked the nurse what can potentially happen if the doctors' orders are not followed. V15 stated if medication not given per providers order, it could affect the medication to properly function.On 03/25/2026 at 9:36 AM, V23 (License Practical Nurse/ LPN) was observed during a medication pass on the second floor with Medication cart B. During the medication pass there was a discrepancy noted, this surveyor intervened with the medication pass. V23 was getting ready to administer metoprolol 50 mg to R114. R114 had the following vital signs: blood pressure: 127/ 66, heart rate: 51 beats per minute. Surveyor asked V23 what can potentially happen to the resident if a beta blocker is given to the resident who has heart rate below 60 beats per minute. V23 stated R114 will usually have blood pressure in this range. Surveyor asked V23 if it is acceptable to administer a beta blocker which is known to help decrease the heart rate to a resident who presents with a heart rate of 51 beats per minute. V23 states she will re-assess the heart rate. After assessing the heart rate, it was still ranging in the low 50's.On 03/26/2026 at 12:31 PM, V3 (Director of Nursing/ DON) stated the expectation for the nurses are to follow the provider's order. V3 stated all nurses should follow the 5 rights of medication administration: right resident, right drug, right dose, right route, right time, and to use od their nursing judgement. V3 stated nurses should ensure that the residents take their medication before leaving the room, and monitor for any medication adverse effects. V3 stated vital signs must be taken prior to administering blood pressure medication, to prevent harm.Policy titled Medication Administration with review date of 10/25/2014 documents in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five rights- right resident, right drug, right dose, right time are applied to each medication being administered. Medications are administered in accordance with the written orders of the prescriber.

Based on observations, interviews and records review, the facility failed to answer call light for one resident (R36) of seven reviewed in a sample of 28.R36 is an [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, not elsewhere classified, right/left thigh. muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle wasting and atrophy, not elsewhere classified, left upper arm, hypotension, unspecified.MDS (Minimum Data Set) Section C (Cognitive Patterns) dated 03/04/2026 document R36's Brief Interview for Mental Status (BIMS) as 6/15, indicating R36 has severe cognitive impairment. Section GG (Functional Abilities) documents R36 requires partial/moderate assistance with eating, is dependent with oral hygiene, toileting, sit to laying, laying to sitting on the side of bed, chair/bed-to-chair transfer.On 03/24/2026 at 1:19PM, R36 was observed lying in bed, alert and oriented to person, place, was able to verbalize her needs. R36 stated she can use the call light. R36 pulled call light which turned yellow by her bedside switch. Call light did not light up outside of R36's door. R36 stated staff do not answer call light when she puts it on or it takes a very long time for them to come. I feel let down that they don't answer the call light. Sometimes I need water to drink or be changed and when they don't answer my call light it makes me sad that no one is helping me.On 03/24/2026 at 1:35PM, V16 (Certified Nursing Assistant -CNA/restorative Aide) was observed near the nursing station and stated she was covering for R36's CNA who was on lunch break. I was in another room assisting a resident. I didn't see R36's the call light on. V16 further stated the call lights only light up at the nursing station and not outside residents' rooms. Any nursing staff is supposed to answer call lights. There were three nursing staff standing at the nursing station. Anyone of them could have answered the call light. I saw you looking at the call light station and then looked to see which call light was on. Call light should be answered to make sure residents are safe, and their needs are met. If their needs are not met, that's neglect.On 03/26/2026 at 2:18PM, V3(Director of Nursing) stated all nursing staff are responsible for answering call lights to assist the residents. If call light is not answered on time, the resident is left waiting. If not answered timely, the resident might be needing to go to the bathroom, the resident can have an accident on themselves. It can make them unhappy. Policy titled Call light, dated 8/2025 documents:-Answer call light in a prompt, calm courteous manner.

Based on interviews and records reviewed. The facility failed to complete Preadmission Screening and Resident Review (PASRR) for one resident (R6) of seven reviewed in a sample of 28. R6 is a [AGE] year-old individual admitted to the facility on [DATE]. R6's medical diagnosis in current face sheet includes but not limited to: Schizophrenia, unspecified, bipolar disorder, unspecified, Heart failure, unspecified, Type 2 diabetes mellitus with unspecified complications.MDS (Minimum Data Set) Section C (Cognitive Patterns) dated 03/20/2026 document R6's Brief Interview for Mental Status (BIMS) as 15/15, indicating R6 has intact cognitive abilities.R6's diagnosis of Schizophrenia, unspecified, is documented as present on admission and on 08/04/2021.On 03/26/2026 at 11:40AM, V17(Social Services Director) stated she could not find R6's PASRR 1 in his medical records. Residents are supposed to have a PASRR 1 completed prior to admission to determine if resident is in an appropriate nursing home placement. If they do not have a PASRR 1 completed, facility cannot determine if the resident is in an appropriate setting to meet resident's needs. If a resident admitted without a PASRR 1, the facility's social services department is supposed to complete one. PASRR 1 results will either state no PASRR level 11 is required or refer for level 11 screening is required. Serious mental illness, intellectual disabilities, bipolar, schizophrenia, paranoia disorders require PASRR 11 assessment.V17 said the facility submits the resident PASRR 1 assessment results to an outside agency for PASRR 11 screening. The outside agency comes to the facility to screen the residents and complete level 11 PASRR. V17 stated R6 has diagnosis of schizophrenia and bipolar disorders and definitely requires a PASRR 1 screening which will most likely document R6 requires PARSS 11screening to be completed. Without any PASRR screening the facility cannot determine if we are able to take care of R6's needs because not all Skilled Nursing Facilities (SNF) provide specialized services for residents with mental health issues. R6's medical records do not document any PASRR screening for R6.R6's POS (Physician Order Sheet) Dated 10/28/2024 documents:-Risperidone tablet; 0.25 mg; amt: 1 tab; oral. Special Instructions: Give with 0.5mg tab for a total dose of 0.75mg daily. Once A Day 09:00 AM.-risperidone tablet; 0.5 mg; amt: 1 tab; oral. Special Instructions: Give with 0.25mg tab for a total dose of 0.75mg daily. Once A Day 09:00 AM.Policy titled PASSAR Guideline dated 11/2017 documents:-The objective of the PASSAR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASSAR will be evaluated annually and upon significant change for those individuals identified.-The facility will participate in or complete the level 1 screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition.

Based on observations, interviews and records review, the facility failed to follow their policy on oxygen tubing labeling for one resident (R94) of seven reviewed in a sample of 28.R94 is an [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, Cerebral infarction, unspecified, Heart failure, unspecified, Essential (primary) hypertension.MDS (Minimum Data Set) Section C (Cognitive Patterns) dated 03/20/2026 document R94's Brief Interview for Mental Status (BIMS) as 11/15, indicating R94 has moderate cognitive impairment.On 03/24/2026 at 12:43PM R94 was observed in her room lying in bed with oxygen via nasal cannula from an oxygen concentrator tank running 2.5L/Min. Oxygen tubing was not labeled; no humidifier bottle was attached to the oxygen tank.On 03/24/2026 at 12:46PM V14 (Registered Nurse-RN) Observed R94's oxygen tubing and stated it was not labelled. No humidifying jar was observed. V14 stated oxygen tubing is supposed to be labelled when changed so we know the last date it was put on and when to be changed next to prevent infections. V14 further stated the humidifier jar assists with preventing dryness and irritation to R94's nose. R94 should have a humidifier jar attached to her oxygen tank. On 03/26/2026 at 4:10PM, V3 (Director of Nursing) stated oxygen tubing is supposed to be labeled after it is changed to let other nursing staff know last time tubing was changed. It is changed every week on Thursdays. It should be labelled so that all nurses know when oxygen tubing was changed for infection control. If not changed it can cause bacteria to grow.R94's Physician Order Sheet (POS) dated 03/14/2026 documents:-Oxygen: via Nasal Cannula. Rate 2 L/Min. Special Instructions: Specify reason decreased o2 (Oxygen). As Needed (PRN).-Oxygen: Change tubing weekly and PRN. (label) Once A Day on Sun.Policy titled Oxygen Administration dated March 2004 documents:-the following equipment and supplies will be necessary when performing this procedure:-Nasal cannula or mask,Humidifier bottle.Make sure the oxygen humidifier jar is labeled properly.

Based on interview and record review the facility failed to monitor and review antibiotic use for one (R39) resident reviewed for antibiotic stewardship in a total sample of 28 residents. Findings include: R39's Facesheet documents that R39 has diagnoses not limited to: Urinary tract infection, site not specified-E.coli, MRSA/Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, Unspecified purulent endophthalmitis, unspecified eye. R39's POS/physician order sheet documents in part the following orders: Doxycycline Hyclatecapsule; 100 mg; oral Twice a Day 09:00 AM, 05:00 PM [DX: Unspecified purulent endophthalmitis, unspecified eye] start date 10/15/2025, no end date.On 03/26/2026 at 10:46AM, V25 (Infection Preventionist/IP/LPN) states R39 has been on long term antibiotic use since October 2025. V25 states it was R39's decision to be prescribed the antibiotic doxycycline and it is prescribed without an end date due to R39's diagnosis of MRSA. V25 states R39 was prescribed this antibiotic by an outside infectious disease doctor, and it has not been discontinued because R39 has not gotten the opportunity to follow up with an infectious disease doctor yet. V25 states the infectious disease doctor did not prescribe an end date for R39's doxycycline medication. V25 states all antibiotics should have an end date and she is currently working on trying to find R39 an infectious disease doctor who will take R39's insurance for follow up. V25 states she has not monitored R39's antibiotic use because she let the infectious disease doctor handle that. V25 states she has not followed up to ensure that R39's diagnoses of MRSA is susceptible or resistant to the doxycycline medication. V25 states R39 has not received culture and sensitivity laboratory testing in the facility and all of R39's testing was performed at the hospital prior to R39's admission to the facility. V25 states if residents are continuously receiving antibiotics without an end date then the residents could potentially develop MDRO/multi drug resistant organisms which leads to a compromised immune system that resists antibiotics. Facility policy dated 04/29/2025 titled Antibiotic Stewardship Program Guidelines documents in part, The purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance. The purpose of the antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. Tracking: The facility will monitor antibiotic use and outcomes from antibiotic use.

Based on observation, interview, and record review, the facility failed to provide feeding assistance for one (R10) resident in a total sample of 28 residents reviewed. Findings include: R10's face sheet documents that R10 has diagnosis not limited to: Hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, dementia, Type 2 diabetes mellitus without complications, Chronic obstructive pulmonary disease, severe protein-calorie malnutrition, Chronic kidney disease, Heart failure, Anemia. R10's MDS/Minimum Data Set, dated [DATE] documents that R10 has a BIMS/Brief Interview for Mental Status of 01/15, indicating that R10 is cognitively impaired. R10 is dependent and requires assistance with eating. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 03/24/2026 at 12:24PM, surveyor observes during lunch time that R10's lunch tray is at R10's bedside. Surveyor observes that R10 is verbal but noted with confusion and unable to make her needs known. On 03/24/2026 at 1:15PM, surveyor observes that R10's lunch tray is no longer at the bedside and is observed on the meal cart. Surveyor observes that R10's lunch meal is uneaten. Surveyor located at the meal cart with V10 (Certified Nursing Assistant) and V10 states that she is assigned to care for R10 today. V10 states that R10 refused her lunch meal which is why R10's lunch meal is uneaten and on the meal cart to be transported back down to the kitchen. V10 states that she did not encourage R10 to eat her meal because R10 kept saying no, so she placed R10's lunch meal back onto the meal cart. V10 states she informed V14 (Registered Nurse/RN) that R10 refused her lunch meal. On 03/24/2026 at 1:22PM, V14 (RN) states he is not the nurse assigned to care for R10 today and V10 did not report to him that R10 refused her lunch meal. On 03/24/2026 at 1:25PM, V15 (RN) states she is the nurse assigned to care for R10 and V10 did not inform her that R10 refused her lunch meal. V15 states R10 is alert and oriented x1 and is confused. V15 states if a resident refuses their meal, the CNAs are required to encourage the resident to eat. V15 states if the resident still refuses, then the CNAs are required to inform the nurse so that the nurse can intervene as well. V15 states if she was informed that R10 did not eat, she would have called down to the kitchen and asked for food from the substitute list. V15 states she would also offer a supplement shake if the resident is prescribed one. V15 states if residents are not offered a meal and not encouraged to eat, then they can develop malnutrition, lose weight, and decline due to not having enough nutrients. V15 states all staff were in-serviced on feeding assistance and to inform the nurse if the resident does not eat their meal. On 03/26/2026 at 1:05PM, V3 (Director of Nursing/DON) states the expectations for the nursing staff is to ensure they are feeding the residents who require feeding assistance. V3 states if residents refuse their meal, then the CNAs should let the nurses know. V3 states the CNAs should first encourage the residents to eat their meal prior to informing the nurse. V3 states if residents continue to refuse their meals, then the social services department is made aware, the resident's family is notified, and the physician is called. R10's care plan documents in part that R10 has a diagnosis of dementia with severely impaired decision-making skills. Encourage oral intake of food and fluids. Facility policy undated, titled Passing Meal Trays documents in part, Nursing will offer alternates to residents who refuse their food or request a substitute. Nursing will advise dietary of such requests.

Based on interviews and records review, the facility failed to refer three residents (R8, R13, R51) with newly diagnosed serious mental illness, intellectual disabilities or related conditions for PASARR (Pre-admission Screening and Resident Review) screenings in a total sample of 28 residents reviewed for PASARR.Findings include: 3/26/26 at 11:37 AM, V17 (Social Services Director) stated I handle the level II PASARR. A resident should have a PASARR level I completed prior to admission. We have to determine if the resident is in the appropriate setting or nursing home placement, skilled or SMHRF (Specialized Mental Health Rehabilitation Facility). If the resident doesn't have the level I, then I don't know if they are in the appropriate nursing home setting to meet their needs. The level II is required if the level I determines a serious mental illness. The resident comes with a new level I or the facility does the level I based on medical history, diagnoses. Level I is submitted to Maximus and based on review of what the facility submitted with the level 1 it will refer to a level II if there is a serious mental illness (SMI), intellectual disability (ID). If no SMI or ID, then no level II is required. Examples of SMI that would require a level II are bipolar, schizophrenia, schizoaffective disorder, paranoia. Level II is required if the resident has a SMI, ID or RC (related conditions). If diagnosed with a SMI, ID or RC after admission, or if there is an increase in behaviors then a level II is required. R8 has a diagnosis of dementia, anxiety, psychosis. Due to the new diagnoses another level I should have been done to determine if a level II was needed to determine if the facility is meeting their needs and to determine if they are in the appropriate setting. R51 has diagnosis of violent behavior, psychosis dated 1/28/25. These are new diagnoses after the level I was completed. There should have been a referral for another level I to determine if a level II was required to determine if the facility is meeting their needs and to determine if they are in the appropriate setting. R8 Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome, review date 1/6/26, has a determination of No Level II Required – No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/related condition). R8 face sheet, documents diagnoses that include but are not limited to unspecified psychosis not due to a substance or known physiological condition, date diagnosed 2/20/2026; dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, date diagnosed 2/20/2026. According to R8 Physician Order Report, R8 has an active order for Risperidone oral tablet. R51 Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome, review date 2/12/24, has a determination of No Level II Required – No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/related condition). R51 face sheet, documents diagnoses that include but are not limited to unspecified psychosis not due to a substance or known physiological condition, date diagnosed 1/28/2025; violent behavior, date diagnosed 1/28/2025; unspecified dementia, date diagnosed 1/28/2025. According to R51 Physician Order Report, R51 has an active order for Quetiapine oral tablet. Facility policy PASSAR Guideline, 11/2017, documents in part: The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. R13's Facesheet documents that R13 was admitted to the facility on [DATE] with diagnoses not limited to: major depressive disorder and psychotic disorder with hallucinations. R13's Interagency Certification of Screening Results OBRA-I Initial Screen dated 04/16/2019 indicates that R13 has no reasonable basis for suspecting MI (mental illness). There is no documentation to show that R13 has a Level II PASARR screening. On 03/26/2026 at 12:34PM, V19 (Admissions Director) states he is responsible for performing the level I PASARR screenings for the residents upon admission. V19 states he is still in training and in the process of still trying to fully understand the PASARR process. V19 states he is aware that he is responsible for checking to make sure resident's information is correct such as medications and diagnoses, name, date of birth , and medical record number. V19 states usually, the hospital completes a resident's PASARR prior to the facility admitting the resident to the facility and he ensures that the DON/determination of needs score is on the PASARR screening so that the facility can get paid. V19 states a new PASARR Level I is needed for a resident if the resident has a severe mental illness/SMI diagnosis. V19 states if information entered on the resident's Level I PASARR screening is incorrect, then this can result in the PASSAR screening results being incorrect, which requires a new screening to be completed. V19 states R13's current OBRA screening is inaccurate and requires a new level I PASARR screening to be completed due to R13's severe mental health diagnosis. Facility policy dated 11/2017, titled PASARR Guideline documents in part, The objective of the PASARR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. a. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder {SMI/SMD}, intellectual disability {ID} or related condition. b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will not admit an individual, the facility will refer the potential admission to the State PASARR representative for the Level II screening process. c. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. admission decision will be determined and notification to the State PASARR representative, resident and resident representative will be completed.

Based on interview and record review, the facility failed to ensure that staff followed their Abuse policy by not reporting resident to resident verbal altercations to the Abuse Coordinator which affected three residents (R37, R66 and R147) of seven residents reviewed for abuse in a total sample of 28 residents. Findings include: R66'S medical record documents, in part, the following medical diagnoses: Schizophrenia and Major Depressive Disorder. A Minimum Data Set (MDS) dated [DATE] documents that R66 is Cognitively Intact. R66's care plans include concerns with behavioral symptoms, physical and verbal aggressions towards others and depression. There is a care plan that documents that R66 is at a high risk for abuse due to impaired decision making and verbally aggressive behavior. R37's medical record documents, in part, the following medical diagnoses: Bipolar Disorder and Major Depressive Disorder. An MDS dated [DATE] documents that R37 is Cognitively Intact. R37's care plans include concerns with bipolar disorder for which R37 is prescribed an antipsychotic medication, behavioral symptoms, verbal aggressions towards peers and depression.On 3/24/26 at 11:37am, R37 stated, (R66) has been verbally saying things to me for the last week. I really don't think she likes me. R37 continued to state, We have had several instances of disagreement with verbal altercations because she is constantly opening and closing the privacy curtain. I'm over here minding my own business. There's no reason to move the separation between us. That's just plain disrespectful. All the staff knows about what has been going on. I even had staff from the therapy (social services) department come and talk to me about these altercations. On 3/25/26 at 9:46am, R66 also confirmed that she has had words with R37 almost every day. R66 continued to state that they would verbally fight with swear words and back and forth arguing but nothing physical.R37's electronic record documents that R37 was moved into R66's room on 3/13/26. Their first altercation was documented on 3/15/26 at 4:30am. R37's progress notes authored by V30 (LPN-Licensed Practical Nurse) document, Resident noted verbally arguing with roommate in shared room. There is no documentation that the abuse coordinator was notified. A second altercation was documented on 3/23/26 in R37's progress notes and authored by V32 (LPN). It reads: Resident observed engaging in verbal altercation with roommate, with both residents displaying verbally aggressive behavior toward one another. There is no documentation that the abuse coordinator was notified. R37 and R66's medical records document only three verbal altercations despite staff indicating that verbal aggression between the two residents happen often. None of these verbal altercations were reported to the abuse coordinator. On 3/25/26 and 3/26/26, V28 (CNA - Certified Nurse Assistant), V29 (LPN), V33 (CNA) and V34 (CNA) all indicated that they are often scheduled to care for R37 and R66. All confirmed that many times R37 and R66 are verbally confrontational with each other. V27 (PRSC - Psychosocial Rehabilitative Service Coordinator) was also involved in conducting follow ups after R37 and R66's verbal aggressions. V27, V28, V29, V33 and V34 did not report these incidents between R37 and R66 to the abuse coordinator. On 3/24/26, during the evening shift, R37 was moved from the 3rd floor to the 1st floor. R37's new roommate was R147. R147's face sheet documents a primary admission medical diagnosis of Chronic Pulmonary Obstructive Disease. R147 is Cognitively Intact. On 3/24/26 at 8:06pm, R147's progress notes read, in part: Resident notified (V15-Registered Nurse (RN) and staff of (R37) being verbally aggressive towards her and visitor. Resident is voicing concern for safety with presence of (R37). On 3/26/26 at 11:00am, R147 stated, (R37) wanted to talk all smart and threatened me. She told me that I better get out of her way or she would hurt me. Nobody else was in the room. (R37) was angry because they put her in a room with me. She did not hit me, just verbally attacked me. R37 continued to state, I was shaken up a bit. But she's not here anymore. I think this is definitely considered abuse in my mind.On 3/25/26 at 3:11pm, V15 (RN) indicated that she was the evening nurse for R37 and R147 on 3/24/26. V15 stated, There was verbal aggression that took place with (R147). I walked in on the incident as (R37) was yelling at (R147) to cover her mouth. I waited and wanted to see if they would get along. V15 stated that the abuse coordinator was not notified because it was just loud talk back and forth.On 3/25/26 at 2:35pm, V1 (Administrator) stated, I am the abuse coordinator. Whenever any type of abuse occurs, they all know to call me immediately. I have a 2-hour window to start an investigation and report to (State). V1 continued, With the verbal altercations, I should have been contacted immediately. Schizophrenia cannot be seen as normal and accepted behavior. It is inappropriate behavior. I do not have any reportable incidents for (R37) and (R66). I was not told about them. V1 indicated that she was only aware of the one verbal/physical altercation between R37 and R66 on 3/24/26. Regarding the R37 and R147 altercation on 3/24/26, V1 stated, It was not because of aggression towards residents. I did not have to report that because it was (directed against) staff. V1 was updated that R37's verbal aggression was directed towards R147. V1 stated, Staff did not tell me and they should have. I heard nothing about this. The incident between R37 and R147 was not reported to State until 3/26/26 at 12:45pm - two days after the incident took place. On 3/25/26, the facility submitted an undated facility policy titled Abuse Prevention Program which was not in accordance with the Long-Term Care section of health care. Instead, it indicated that it was for the mental health division of State. This policy documents, in part: V. Internal Reporting and identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment and misappropriation of consumer property they observe, hear about, or suspect to the Executive Director immediately, or to an immediate supervisor who must then immediately report it to the Executive Director. Initial Reporting of Allegations -When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of consumer property has occurred, the consumer's representative, if any, and the Department of Public Health's (Mental health) office shall be informed by telephone, email or fax. This report shall be made as soon as practical, but not later than 24 hours after the allegation is made. On 3/27/26, V1 (Administrator) was updated that the Abuse policy submitted was not for Long Term Care.The facility then submitted an, Abuse Prevention Training Program document from the Illinois Long Term Care Council dated November 22, 2017 which reads, in part: B. Internal Reporting: Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. V. Reporting and Response: C: Initial Report: An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. On 3/27/26 at 3:54pm, the facility submitted a 3rd abuse policy which was undated and titled, Abuse Prevention Policy. On 3/27/26 at 3:56pm, it was clarified with the V1 (Administrator) and V2 (Assistant Administrator) that this was the 3rd submission of a facility Abuse policy and that all three versions were different. V1 and V2 expressed understanding.

Based on observation, interview and record review the facility failed to ensure a residents right to telephone use. This failure has the potential to affect all 52 residents that reside on the second floor.Findings include:3/24/26 at 12:33 PM, R51 said the telephone that the residents use is not available.3/25/26 at 11:52 AM, observed staff members searching for resident cordless telephone handset. Staff were going to resident rooms looking for it and asking residents if they had it. Observed staff members using the telephone base to page the telephone. They did not hear anything to alert them to where the handset was. Staff stated the handset is probably dead.3/25/26 at 12:00 PM, V21 (Certified Nursing Assistant) stated they had not found the resident telephone yet. The telephone is for all residents to use. The only other telephone is the nurse's phone. Sometimes the residents forget to bring the telephone back when they use it. For bed-bound residents, we go and get the telephone back. Typically, it is the same residents that use the telephone all the time. We checked to see if they had it and then checked all the residents. The resident will wait if the telephone is not available if another resident has it.3/25/26 at 12:06 PM, V38 (Licensed Practical Nurse) stated if we allow the resident to use the nurse telephone then we allow them to say hello. The hospitals and doctors call on the nurse's telephone, so the residents don't use the nurse's telephone for long. If we cannot find the residents telephone or if it needs charging, we ask the family member to call back later to talk to the resident.3/25/26 at 12:18 PM, R51 said they went to use the resident telephone twice today and it was not available. They didn't have it. Yesterday they didn't have it. R51 said it is frustrating. R51 said they want to call someone to bring them money, so they can't call so they have no money. R51 said the facility did not offer another telephone for them to use.3/25/26 at 12:55 PM, observed staff still searching for the telephone handset. 3/25/26 at 12:56 PM, V23 (Licensed Practical Nurse) stated when the resident asks for the telephone, we give it to them, and they usually hand it back. They may take it to their room. When the residents receive a call, we transfer the call to their cordless telephone. If the resident is bedbound then we deliver the handset to their room.3/26/26 at 4:06 PM, V1 (Administrator) stated the residents should have access to a telephone so they can talk to loved ones or whoever they want to speak to. It is their right to make calls and receive calls. V1 stated the telephone still hasn't been found. Residents' Rights for People in Long-term Care Facilities documents in part: Your facility must provide services to keep your physical and mental health, and sense of satisfaction. You have the right to receive phone calls in private.

Based on observation, interview, and record review, the facility failed to protect residents from physical abuse. This failure affects two of three residents (R2 and R3) reviewed for abuse in a total sample of five residents.Findings include:R2 is a [AGE] year-old male. R2 diagnoses are but not limited to seizures, schizoaffective disorder, alcohol abuse, obesity, hypertension, major depressive disorder, and reflux. R2's BIMS (Brief Interview for Mental Status) dated 3/05/2026, notes R2 is alert.R3 is a [AGE] year-old male. R3 diagnoses are but not limited to lung disorders, end stage renal disease, heart failure, dependence on renal dialysis, HIV, anemia, and hyperkalemia. R3's BIMS dated 12/09/2025, notes R3 is alert.Progress note dated 2/08/2026, notes hospital transfer. R2 observed with head lacerations and minimal bleeding following an incident involving another resident. R2 has a known diagnosis of primary epileptic seizure disorder. Lacerations noted with minimal bleeding present.Progress note dated 2/08/2026, notes R3 was sent out to local hospital for psych evaluation. Resident was in a physical altercation with another resident.On 3/14/2026, at 1:44 PM, R2 stated, I went upstairs to the third floor. I do not remember the resident's name on the third floor. I said something to him. He threw a cup of something and hit me on the head. I went to the hospital, and they put stitches that absorbed in my head. It left a mark on my head, but I did not touch him. I used to live on the third floor, and they moved me down here.During this interview, R2 was seen with a small, dark, healed mark on his forehead.On 3/14/2026, at 2:52 PM, R3 stated, I remember all of it. I will never forget it. I go to the front to get coffee in the morning. Every time I go back to my room R2 said, goofy mother****, I am going to get you. The next day he said the same thing. I was standing down by my room. R2 came by my room. R2 wanted to fight me. I had my coffee mug. R2 came to me. I cracked him with my coffee cup and got him off me. R2 had blood coming on his face. The staff were all in the front until they heard commotion. I do not know what was wrong with him. I did not get hurt but I did get sent out. The police wanted to lock me up because I busted him on his head with a coffee cup. The nurse told the cop that the resident was crazy and did not have any sense. I got sent to the crazy house. I am not crazy. I was protecting myself. I never said anything to him. I do not go to the first floor unless I must because I do not want to be bothered by him. I feel safe and I am ok.On 3/14/2026, at 3:12 PM, V10 (LPN) stated, R3 was telling me his side of story. He said the other guy attacked him. He could not get R2 off him. He stated he hit the other guy out of self-defense. He wacked him with a cup or something. R2 stated that R3 was saying something to him and was triggering him. On 3/14/2026, at 3:31 PM, V5 (LPN) stated, I was the nurse on duty. I did not witness anything. I was on the opposite side of the hallway taking blood sugars. The aide had come down the hallway. She told me they are down there fighting. I went down the hallway. I called a code for aggressive residents to get all staff there. R2 was bleeding on the top of his head. I applied pressure, called the administrator, physician and 911. I asked R3's roommate what happened but the police were there. R2 was fighting R3 in the hallway. It started at their door. R2 stated he did not have any pain. The other nurses got him cleaned up. R3 was sent out. R2 was sent to the hospital due to history of seizures.On 3/14/2026, at 5:03 PM, V1 (Administrator) stated, R2 was the one that initiated it. He was aggressive to R3. R2 got in R3's face. R3 was walking down the hall and R3 hit R2. I interviewed both residents. They were separated and monitored. Well-being checks were conducted. The physician and the families were contacted. They were placed in separate areas. They are in psych social programs now.Facility policy titled Abuse Prevention Policy, undated, notes abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury resulting in physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and requires medical attention. Physical abuse includes hitting, slapping, pinching, and kicking.

Based on review of records and interview, the facility failed to acquire preadmission screening and resident review due to being outstanding for three (R1, R2, and R3) out of three residents in a total sample of three resident reviewed. These failures affect three residents (R1, R2, and R3) in determining correct care settings for residents with serious mental illness.Findings include:On [DATE] at 1:24 PM, V3 (Social Service Director) stated that the outstanding reports mean that their PASRRs have expired, and they have to do another PASRR level I screening for those residents. V3 stated that other reasons that PASRRs level I are needed is when there is a new onset MI (mental illness) diagnosis. V3 stated that it is important to submit requested reports for the completion of PASRRs because V3 stated basically if a resident has a mental health illness, we need to make sure we are following their plan of care, if they need psychosocial therapy groups, and also it is part of billing, and also to determine if they are in the appropriate setting. With V3 reviewed R1, R2, and R3's PASRRs and V3 stated that R1 is due for PASRR level I because R1's PASRR level I expired on [DATE]. V3 stated that R2 is due for a PASRR level I because R2's PASRR level II expired on [DATE]. V3 stated that R3's PASRR level II expired on [DATE] so R3 will need to have another PASRR level I done.R1, an [AGE] year-old resident, initially admitted in the facility on [DATE]. R1 has diagnoses not limited to dementia and delusional disorders.Record reviewed documents that R1 has an initial Level 1 Pre-admission Screening and Resident Review/PASARR dated [DATE], documents in part Exempted Hospital Discharge 30 Day Approval-A 30 day or less stay in the NF is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. Diagnosis of delusional disorder found in provided documentationR2, a [AGE] year-old resident, initially admitted in the facility on [DATE]. R2 has a diagnosis not limited to schizophrenia.Record reviewed documents that R2 has an initial Level 1 Pre-admission Screening and Resident Review/PASARR dated [DATE], documents in part PASRR Determination: Short Term Approval without Specialized Services. Date Short Term Approval Ends: [DATE].R3, a [AGE] year-old resident, initially admitted in the facility on [DATE]. R3 has diagnoses not limited to bipolar disorder, schizoaffective disorder.Record reviewed documents that R3 has an initial Level 1 Pre-admission Screening and Resident Review/PASARR dated [DATE], documents in part PASRR Determination: Short Term Approval without Specialized Services. Date Short Term Approval Ends: [DATE].Facility's Pre-admission Screening and Resident Review (PASRR) policy dated 11/2017 documents in part the objective of the PASARR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined.

Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. This started a month ago. I have everything written down. It started on 9/14/25 at 6:15 PM, I came back from the hospital. I was in the hospital for multiple seizures. When I came back from the hospital [R2] keeps calling me white boy and he [R2] tells me that I'm faking my amnesia. I learned his [R2] name from one of the staff. Every day he [R2] sees me on the hallway he would laugh and mock me. I told [V6 (Receptionist)] that I'm not comfortable around [R2] and that he keeps calling me names. [V6] said he would report it, but no one came to talk to me. On 9/29/25 before 10:30 AM, I was in my room and my door was wide open. [R2] passed by and stopped. [R2] was laughing. I mumbled as***le quietly. I said it to myself not to him [R2]. [R2] heard it and he said if he hears that again he would punch me in the face or kill me. I think the CNA [Certified Nursing Assistant] heard it but I don't know her name. Right after [R2] told me that I reported it [V6] and I asked who I should speak with about racial and sexual harassment. Because almost every day [R2] would call me fa**ot and white boy. The same day at 10:45 AM, [V7 (Psychiatric Rehabilitation Services Aide)] came to my room. [V7] is my social worker. I told [V7] about the racial, sexual, and violent harassment from [R2]. I told [V7] that [R2] laughs at me, that [R2] says he will kill me and that he would call me white boy, fa**ot, and tr*ny. It's a derogatory way of saying transgender. It's sexual harassment. I feel very upset, scared, and unsafe. Why I'm here. I can't sleep at night. [R2] is two doors down from my room. Sometimes staff are not around. At any point [R2] can easily come while I'm sleeping and stab me. They did not move [R2] from my floor. Every day I would see [R2] and he is always sitting up the front lobby. I feel unsafe. [R2] roams around the whole first floor by himself and he would always follow where I'm at. After [V7] left then one of the nurses came to my room so she can document. The nurse's name is [V13 Licensed Practical Nurse)]. [V13] came to my room at 11:10 AM. [V13] wanted to know what happened and I told her everything. The next day on 9/30/25 at 10:15 AM, [V7] came to visit me in my room. [V7] said they spoke with [R2] that they are going to do something. They did not tell me what they were going to do. [V7] asked me if I wanted to change my room. I told her [V7] that I like my room and I like the first floor and that I don't want to move. [V7] said they will do something with [R2]. On 10/2/25 at 11:55 AM, I went down the hall to put my empty lunch tray on the cart. When I passed by [R2's] room, he was sitting on his wheelchair by the door. [R2] laughed at me and called me a white boy. I said you're still an as***le and I kept going. [R2] followed me out of his room. I saw him [R2] following me so I went to the office by the exit door in the lobby. There were two women in the office. I think they are the head of nursing. I told them what was going on that I'm being chased by [R2] and threatening to kill me. One of them asked me if I wanted to change rooms. I said no. I said I'm not the one creating trouble. This is happening on a daily basis. I did not get their names because there's a lot of things going on in my head. They did not say a word. They just told me to go back to my room. They were the nursing managers. I was emotionally distraught. I did not know what to do. On the same day at 2:30 PM, [V10 (Social Service Director)] the head of social services came to my room. I explained what happened to [V10]. I told her [V10] that [R2] was chasing me threatening to kill me. [V10] wanted me to change rooms. I told her [V10] I should not have to change my room. [V10] asked me if I felt safe on this floor, and I said absolutely not. [V10] asked me if I would feel safe if [R2] is placed on the other floor. I said I would feel safe then. If [R2] was transferred to a different floor, I would feel safe even at night when I'm sleeping. They still have not moved [R2]. On 10/16/25 at 5:00 PM, [R2] was outside. I was coming out of the van from my doctor's appointment. I saw him [R2] and followed me holding his phone up to my face and laughing. [R2] called me an ugly-fa**ot-tr*ny. No one heard or witnessed the incident. [R2] does not threaten me when anybody is around.On 10/17/25 at 11:04 AM, Surveyor observed R2 outside wheeling himself on a wheelchair. Surveyor made an introduction and asked if [R2] can be interviewed. R2 stated, No. I don't have time for that. I'm waiting for my bus to go for an appointment. Surveyor asked if [R2] is familiar with [R1]. R2 stated, I don't know who that is. I don't know what you're talking about. I got to go. You better be careful young lady. R2 ended the conversation.On 10/17/25 at 10:52 AM, V6 (Receptionist) and stated that the abuse coordinator is V2 (Director of Nursing). V6 stated that two or three weeks ago morning time, R1 reported to V6 that R2 was saying all types of crazy things to R1. V6 said R1 did not say exactly what were said. V6 stated that he reported R1's complaints to V1 (Administrator). V6 stated that R2 is still residing on the first floor and would always hang out at the first-floor lobby every day. V6 stated that he hears R2 say bad words to other residents but not specially towards R1. V6 stated he never heard R2 threatens anybody. On 10/17/25 at 11:12 AM, V7 (Psychiatric Rehabilitation Services Aide/PRSA) stated that R1 and R2 can move independently with their wheelchairs. V7 said that on end of September, I was asked to do a wellbeing check with R1. I went to her [R1] room. [R1] said that [R2] had said a couple of words to [R1]. [R1] said [R2] called her a white boy and mumbled something. [R1] told me that [R2] threaten to kill [R1] if she says something to him [R2]. I asked her [R1] what was her feeling. [R1] said she was uncomfortable in the room and she did not sleep well at that time when I asked her. [R1] said she felt unsafe. I told her [R1] that I would tell the corporate people know to address her concerns. I reported it to [(V4 (Nursing Consultant)] right after I talked to [R1]. [V4] told me she would address it and that I make sure [R1] is okay. [V4] said she would take care of it. [R2] was not moved to a different floor. I did not talk to [R2]. I asked [R1] if she wanted to move but she said no. I'm not sure who talked to [R2]. I am not sure if it was investigated. The administrator [V1] does that. I never witnessed any negative interaction between [R1] and [R2]. That was the first time I heard they were having disagreement.On 10/17/25 at 11:46 AM, V10 (Social Service Director) stated that if it's verbal allegation of abuse and if it's threatening, the aggressor will be sent out for psychiatric evaluation. V10 stated, Any types of abuse allegation even if it's unwitnessed, we notify the abuse coordinator. Abuse coordinator will report to the State Agency right away no more than 2 hours. Initial investigation should be conducted right away and thorough and complete investigation should be done. Final investigation is sent to the State within 5 business days. It's important to conduct a complete and thorough investigation of any abuse allegation to make sure all the residents in the facility are safe. To prevent a resident from getting harmed. V10 stated that she has not witnessed any negative interactions between R1 and R2. V10 stated that R2 is verbally aggressive towards staff and residents. R2 curses staff and residents. Calling them names. V10 stated, It was reported to me on a Monday in September. It was the end of the month. I received the call from [V7] stating that [R1] reported that [R2] was threating to kill [R1]. It was reported to me that [R2] was calling [R1] white boy, fa**ot, and tr*ny. I reported it to the person in charge who was the acting administrator at that time. I reported it to [V4]. I also reported it to [V11 (Assistant Director of Nursing)] because [V2 (Director of Nursing)] was not available and [V1] was off sick. [V1's] been on medical leave. I reported it to the next person in charge. I could not get a hold of [V2] she was on some type of meeting, so I verbally reported it to [V11]. And then I notified everybody on the group chat. When [V1] is not here, [V4] or [V2] would be the abuse coordinator. I talked to [R2] that same day and he admitted it. [R2] said that he told [R1] that he was going to punch [R1] because [R1] called [R2] an as***le. [R2] admitted that he threatened to kill her [R1]. I let management know. I told them. They did not send [R2] out and they did not separate [R2] from [R1]. I talked to [R1] she told me that she does not feel safe. [R1] told me she was scared and that she does not feel safe. I reported it to [V4]. I also brought it up in the morning meeting the next day. [R1] and [R2] are both alert and oriented. On 10/17/25 at 12:08 PM, V2 (Director of Nursing) stated that she is the abuse coordinator if V1 (Administrator) is on vacation or on leave. V2 stated that V1 has been out on leave for 2 and a half weeks now. V2 stated, If there is a resident to resident abuse, we make sure we separate the residents and we make sure that they are safe. We have 2 hours from the time of incident to do initial investigation and reporting to IDPH [Illinois Department of Public Health]. Initial investigation is important to get accurate statements. To determine if it's abuse and to determine what's the next step. These applies to any type of abuse allegation. [V1] had an all staff abuse in-service before she went on leave. The types of abuse are mental, verbal, sexual, misappropriation of funds, neglect, seclusion. Physical abuse is when resident strikes another resident or staff strikes another resident. Threatening to kill somebody would be a verbal abuse. It could be mental abuse depending on the reaction and how the resident feels. My office is by the exit door in the lobby. The only interactions I've seen between [R1] and [R2] were friendly. They were friends joking around with each other. I've never had a conversation with [R1] about an abuse allegation. She's [R1] never brought any complaints. On September 29 around noon, [V13 (Licensed Practical Nurse)] told me that [R1] stated [R2] was going to kill [R1]. I let [V1] know. I called her [V1]. I told [V1] what the situation was. [V1] directed me what to do. We had [V10] talk to [R1] and [R2]. I spoke to [R2] and he denied the allegation. [R2] said that [R1] said something to him. I asked both [R1 and R2] parties if they were okay. They said they were okay. They denied that they feel threatened, and they were fine. They did not want to move rooms or floor. We do investigation if we determine if it's abuse and if we determine its abuse, then we report it to IDPH. It was not reported to IDPH because it was not determined as abuse. Police were not called. It was not proven as abuse. They both said that they were fine, and they both said that they were not in fear. V2 said that R1's allegation against R2 was not investigated or reported to IDPH because it was not determined as abuse. Surveyor asked V2 to provide documentation of the complete investigation of R1's abuse allegations, but facility did not provide. 10/17/25 at 12:37 PM, V11 (Assistant Director of Nursing) stated she's been working in the facility since September 15th. V11 stated that if there is abuse allegation the process should be immediately reported to the abuse coordinator which is the administrator [V1]. V11 stated V1 is out sick. V11 stated, Generally, they have someone in her [V1] seat as acting administrator at that time if not, then [V2]. If there is negative interactions, separating both parties away from each other to ensure safety. If there is potential harm, we have to investigate see if there is any witnesses and take statements. The investigation should be done immediately when it's reported. If there is allegation of abuse initial investigation and reporting are sent to IDPH within 24 hours. The types of abuse are verbal, physical, emotional, mental abuse, financial abuse, seclusion and neglect. An example of verbal abuse is name calling, verbal threats such threatening to kill somebody. Mental abuse could be insults, calling name or threatening. I did not receive any report from any resident about abuse allegation. I have never witnessed any resident being abused by another resident. V11 stated she is familiar with R1 and R2. V11 said, From the time I've been here, I have witnessed them being friends and talking with each other. They stopped talking to each other in the last couple of weeks, but nothing negative I have witnessed personally.On 10/17/25 at 1:47 PM, V12 (Licensed Practical Nurse) stated that she is familiar with R1 and R2. V12 stated, Everytime, I work in the facility I see [R2] on the first floor. [R2's] room was one room down from [R1] then they move him [R2] on the other side on October 10th. Still on the same floor. [R1] came out one day very flustered. I don't' remember the day. It was in the afternoon. I was at the nurses' station at that time. I heard [R1] said that [R2] said something to her. [V4] and [V2] came out and said what's going on. Because [R1] was flustered. I went down the hall and [V2] asked me if I see or hear anything. I said I did not witness anything. I don't remember if they asked [R1] why she was flustered. [R2] is very argumentative with staff and patients. [R1] never bothers anybody.On 10/17/25 at 2:04 PM, a phone interview was conducted with V13 (Licensed Practical Nurse). Surveyor asked about R1 and R2's abuse allegation on 9/29/25. V13 stated, It was end of September. I was on lunch when I came back [V14 (Certified Nursing Assistant)] told me that [R1] and [R2] had an argument. I interviewed [R1] because [R2] already left for dialysis. [R1] said that since she came back from her last episode of amnesia, [R2] has being mean to her [R1] calling her white boy. [R1] said he did not touch her. Nobody was hurt or touch. [R1] did not tell me that he threatened to kill her. [R1] said to me that [R2] threatened to punch her. After that I reported it to the Social Worker [V7]. I didn't notify their doctors. I am not aware if they call the police. I'm not sure when they moved [R2] to a different room. [R2] was still on the first floor.On 10/17/25 at 2:15 PM, V4 (Nursing Consultant) stated that V1 went on leave on September 30. As of October 1st, V4 came to the facility for support. V4 stated she was not in the facility when R1 and R2's September 29 incident happened. V4 stated, I was in Florida. I was not made aware at that time. I heard that [R1] and [R2] had an unwitnessed argument. Back and forth exchange of words. That [V7] talked to [R1]. [V7] reported the allegation to [V2] I think. [V2] reported it to [V1]. They did not deem it reportable because it was not one sided. They said [R1] lashed out as well verbally. I would consider it verbal abuse the calling names and threatening to kill someone. It could be mental abuse.On 10/17/25 at 3:07 PM, a phone interview was conducted with V14 (Certified Nursing Assistant). Surveyor asked about R1 and R2's incident that happened on 9/29/25. V14 stated, I don't quite remember what happened. I witnessed [R2] was in the hallway and [R1] was in her room. [R2] was in the hallway by her [R1] door talking loud to [R1]. I think I heard [R2] said he was going to beat [R1] up. I reported it to the nurse [V13] right away. I separated them. [R2] went back to his room and [R1] stayed in her room. [R2] was put on one-on-one supervision. I don't remember if they call the police. I don't remember anything else what happened next.On 10/17/25 at 4:25 PM, a phone interview was conducted with V15 (Physician/Medical Director). V15 stated that threatening to kill or beat up someone is a type of verbal abuse. V15 stated that all abuse allegations should be thoroughly investigated for the safety of the residents. V15 stated that the aggressor should be sent out for a psychiatric evaluation.On 10/17/25 at 5:32 PM, a phone interview was conducted with V16 (Nursing Supervisor) and stated that R2 was moved to a different room (still first floor) on 10/10/25 not on 9/29/25. On 10/18/25 at 10:10 AM, a phone interview was conducted with V1 (Administrator). V1 stated she was not made aware of R1's allegations against R2 until yesterday (10/17/25). V1 stated she's on medical leave started on 9/28/25. V1 stated that V2 or V4 covers for her during her leave of absence, and they will serve as the abuse coordinators. V2 is the point of contact. V1 stated nobody notified her about R1 and R2's incident that happened on 9/29/25. V1 stated she was not aware R1 and R2 was having continued disagreements. V1 stated, Knowing what I know and their [R1, R2] history in the past they have denied any wrongdoing. These residents have history of being verbally aggressive with each other and being inappropriate. To them this is how they talk to each other. [R1] and [R2] use profanity a lot but [R2] does it more. They do that to each other. I don't hear them threatens each other. We tell them it's not acceptable in the facility. We keep them apart. They are aggressive and inappropriate a lot. I don't think it's intentional or abusive to each other because that's how they talk. V1 stated that it is important to follow the facility's abuse policy and procedures to protect the residents. R1's clinical records show and admission date of 5/1/25 with included diagnoses but not limited to unspecified convulsion, major depressive disorder, and gender identity disorder. R1's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 13 which means R1 is cognitively intact. R1 uses a wheelchair and able to wheel herself with supervision. R1's progress notes dated 9/29/25 at 12:21 PM documented by V13 reads in part: Writer assessed resident: resident stated he's been coming pass my room all the time calling me white boy, but I just brush it off, but today after I mumbled as***le he told me he would punch me in the face or kill me. Writer notified social services. The resident is being closely monitored and is being kept separated from each other. No physical harm was done.R1's progress notes dated 9/29/25 at 12:55 PM documented by V7 reads in part: ALLEDGED ALIGATION OF ABUSE BY PEER: DAY 1/3 CO-PEER MADE INAPPROPRIATE/THREATENING STAEMENTS TO HER [R1]: Writer met with the resident [R1] due to report that a co-peer made negative statements to her. She [R1] was asked what happened and stated that she was sitting by her room door and the other resident rolled by and he called her [R1] boy and when she responded back, he [R2] told her that if she said anything else to him that he would kill her [R1]. She [R1] stated that this is not the first time he said something to her. Writer asked her why she did not say anything to staff before now, and she said she just didn't. Writer encouraged her to make staff aware any time someone is making her feel uncomfortable due to negative statement or actions toward her She [R1] was asked if she feels safe and she stated that she did not. Writer informed her that the appropriate parties will be notified and will follow up on her concerns.R1's progress notes dated 10/2/25 at 1:29 PM documented by V7 reads in part: Writer followed up with resident [R1] regarding an incident that happen between her and her peer. Writer went to the residents' [R1] room, and she told resident that she continues to have problems with co-peer. Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [R1] stated she is getting tired of the situation, and something has to be done. Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer. Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. V4 provided a copy of the initial investigation and reporting sent to IDPH dated 10/17/25 at 1:37 PM. The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway. Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation. The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation. The investigator will report the conclusions of the investigation in writing to the Executive Director or designee within five working days of the reported incident. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on interviews and record reviews, the facility failed to affirm the right of their residents to be free from verbal and mental abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. This started a month ago. I have everything written down. It started on 9/14/25 at 6:15 PM, I came back from the hospital. I was in the hospital for multiple seizures. When I came back from the hospital [R2] keeps calling me white boy and he [R2] tells me that I'm faking my amnesia. I learned his [R2] name from one of the staff. Every day he [R2] sees me in the hallway he would laugh and mock me. I told [V6 (Receptionist)] that I'm not comfortable around [R2] and that he keeps calling me names. [V6] said he would report it, but no one came to talk to me. On 9/29/25 before 10:30 AM, I was in my room and my door was wide open. [R2] passed by and stopped. [R2] was laughing. I mumbled as***le quietly. I said it to myself not to him [R2]. [R2] heard it and he said if he hears that again he would punch me in the face or kill me. I think the CNA [Certified Nursing Assistant] heard it but I don't know her name. Right after [R2] told me that I reported it [V6] and I asked who I should speak with about racial and sexual harassment. Because almost every day [R2] would call me fa**ot and white boy. The same day at 10:45 AM, [V7 (Psychiatric Rehabilitation Services Aide)] came to my room. [V7] is my social worker. I told [V7] about the racial, sexual, and violent harassment from [R2]. I told [V7] that [R2] laughs at me, that [R2] says he will kill me and that he would call me white boy, fa**ot, and tr*ny. It's a derogatory way of saying transgender. It's sexual harassment. I feel very upset, scared, and unsafe. Why I'm here. I can't sleep at night. [R2] is two doors down from my room. Sometimes staff are not around. At any point [R2] can easily come while I'm sleeping and stab me. They did not move [R2] from my floor. Every day I would see [R2] and he is always sitting up in the front lobby. I feel unsafe. [R2] roams around the whole first floor by himself and he would always follow where I'm at. After [V7] left then one of the nurses came to my room so she can document. The nurse's name is [V13 Licensed Practical Nurse)]. [V13] came to my room at 11:10 AM. [V13] wanted to know what happened and I told her everything. The next day on 9/30/25 at 10:15 AM, [V7] came to visit me in my room. [V7] said they spoke with [R2] that they are going to do something. They did not tell me what they were going to do. [V7] asked me if I wanted to change my room. I told her [V7] that I like my room and I like the first floor and that I don't want to move. [V7] said they will do something with [R2]. On 10/2/25 at 11:55 AM, I went down the hall to put my empty lunch tray on the cart. When I passed by [R2's] room, he was sitting on his wheelchair by the door. [R2] laughed at me and called me a white boy. I said you're still an as***le and I kept going. [R2] followed me out of his room. I saw him [R2] following me so I went to the office by the exit door in the lobby. There were two women in the office. I think they are the head of nursing. I told them what was going on that I'm being chased by [R2] and threatening to kill me. One of them asked me if I wanted to change rooms. I said no. I said I'm not the one creating trouble. This is happening on a daily basis. I did not get their names because there's a lot of things going on in my head. They did not say a word. They just told me to go back to my room. They were the nursing managers. I was emotionally distraught. I did not know what to do. On the same day at 2:30 PM, [V10 (Social Service Director)] the head of social services came to my room. I explained what happened to [V10]. I told her [V10] that [R2] was chasing me threatening to kill me. [V10] wanted me to change rooms. I told her [V10] I should not have to change my room. [V10] asked me if I felt safe on this floor, and I said absolutely not. [V10] asked me if I would feel safe if [R2] is placed on the other floor. I said I would feel safe then. If [R2] was transferred to a different floor, I would feel safe even at night when I'm sleeping. They still have not moved [R2]. On 10/16/25 at 5:00 PM, [R2] was outside. I was coming out of the van from my doctor's appointment. I saw him [R2] and followed me holding his phone up to my face and laughing. [R2] called me an ugly-fa**ot-tr*ny. No one heard or witnessed the incident. [R2] does not threaten me when anybody is around.On 10/17/25 at 11:04 AM, Surveyor observed R2 outside wheeling himself in a wheelchair. Surveyor made an introduction and asked if [R2] can be interviewed. R2 stated, No. I don't have time for that. I'm waiting for my bus to go for an appointment. Surveyor asked if [R2] is familiar with [R1]. R2 stated, I don't know who that is. I don't know what you're talking about. I got to go. You better be careful young lady. R2 ended the conversation.On 10/17/25 at 10:52 AM, V6 (Receptionist) stated that the abuse coordinator is V2 (Director of Nursing). V6 stated that two or three weeks ago morning time, R1 reported to V6 that R2 was saying all types of crazy things to R1. V6 said R1 did not say exactly what was said. V6 stated that he reported R1's complaints to V1 (Administrator). V6 stated that R2 is still residing on the first floor and would always hang out at the first floor lobby every day. V6 stated that he hears R2 say bad words to other residents but not specially towards R1. V6 stated he never heard R2 threatens anybody. On 10/17/25 at 11:12 AM, V7 (Psychiatric Rehabilitation Services Aide/PRSA) stated that R1 and R2 can move independently with their wheelchairs. V7 said that on end of September, I was asked to do a wellbeing check with R1. I went to her [R1] room. [R1] said that [R2] had said a couple of words to [R1]. [R1] said [R2] called her a white boy and mumbled something. [R1] told me that [R2] threatened to kill [R1] if she says something to him [R2]. I asked her [R1] what was her feelings. [R1] said she was uncomfortable in the room and she did not sleep well at that time when I asked her. [R1] said she felt unsafe. I told her [R1] that I would tell the corporate people to address her concerns. I reported it to [(V4 (Nursing Consultant)] right after I talked to [R1]. [V4] told me she would address it and that I make sure [R1] is okay. [V4] said she would take care of it. [R2] was not moved to a different floor. I did not talk to [R2]. I asked [R1] if she wanted to move but she said no. I'm not sure who talked to [R2]. I am not sure if it was investigated. The administrator [V1] does that. I never witnessed any negative interaction between [R1] and [R2]. That was the first time I heard they were having a disagreement.On 10/17/25 at 11:46 AM, V10 (Social Service Director) stated that if it's verbal allegation of abuse and if it's threatening, the aggressor will be sent out for psychiatric evaluation. V10 stated, Any types of abuse allegation even if it's unwitnessed, we notify the abuse coordinator. Abuse coordinator will report to the State Agency right away no more than 2 hours. Initial investigation should be conducted right away and thorough and complete investigation should be done. Final investigation is sent to the State within 5 business days. It's important to conduct a complete and thorough investigation of any abuse allegation to make sure all the residents in the facility are safe. To prevent a resident from getting harmed. V10 stated that she has not witnessed any negative interactions between R1 and R2. V10 stated that R2 is verbally aggressive towards staff and residents. R2 curses staff and residents. Calling them names. V10 stated, It was reported to me on a Monday in September. It was the end of the month. I received the call from [V7] stating that [R1] reported that [R2] was threating to kill [R1]. It was reported to me that [R2] was calling [R1] white boy, fa**ot, and tr*ny. I reported it to the person in charge who was the acting administrator at that time. I reported it to [V4]. I also reported it to [V11 (Assistant Director of Nursing)] because [V2 (Director of Nursing)] was not available and [V1] was off sick. [V1's] been on medical leave. I reported it to the next person in charge. I could not get a hold of [V2] she was in some type of meeting, so I verbally reported it to [V11]. And then I notified everybody on the group chat. When [V1] is not here, [V4] or [V2] would be the abuse coordinator. I talked to [R2] that same day and he admitted it. [R2] said that he told [R1] that he was going to punch [R1] because [R1] called [R2] an as***le. [R2] admitted that he threatened to kill her [R1]. I let management know. I told them. They did not send [R2] out and they did not separate [R2] from [R1]. I talked to [R1] she told me that she does not feel safe. [R1] told me she was scared and that she does not feel safe. I reported it to [V4]. I also brought it up in the morning meeting the next day. [R1] and [R2] are both alert and oriented. On 10/17/25 at 12:08 PM, V2 (Director of Nursing) stated that she is the abuse coordinator if V1 (Administrator) is on vacation or on leave. V2 stated that V1 has been out on leave for 2 and a half weeks now. V2 stated, If there is a resident to resident abuse, we make sure we separate the residents and we make sure that they are safe. We have 2 hours from the time of incident to do initial investigation and reporting to IDPH [Illinois Department of Public Health]. Initial investigation is important to get accurate statements. To determine if it's abuse and to determine what's the next step. These applies to any type of abuse allegation. [V1] had an all staff abuse in-service before she went on leave. The types of abuse are mental, verbal, sexual, misappropriation of funds, neglect, seclusion. Physical abuse is when resident strikes another resident or staff strikes another resident. Threatening to kill somebody would be a verbal abuse. It could be mental abuse depending on the reaction and how the resident feels. My office is by the exit door in the lobby. The only interactions I've seen between [R1] and [R2] were friendly. They were friends joking around with each other. I've never had a conversation with [R1] about an abuse allegation. She's [R1] never brought any complaints. On September 29 around noon, [V13 (Licensed Practical Nurse)] told me that [R1] stated [R2] was going to kill [R1]. I let [V1] know. I called her [V1]. I told [V1] what the situation was. [V1] directed me what to do. We had [V10] talk to [R1] and [R2]. I spoke to [R2] and he denied the allegation. [R2] said that [R1] said something to him. I asked both [R1 and R2] parties if they were okay. They said they were okay. They denied that they feel threatened, and they were fine. They did not want to move rooms or floor. We do an investigation if we determine if it's abuse and if we determine its abuse, then we report it to IDPH. It was not reported to IDPH because it was not determined as abuse. Police were not called. It was not proven as abuse. They both said that they were fine, and they both said that they were not in fear. V2 said that R1's allegation against R2 was not investigated or reported to IDPH because it was not determined as abuse. Surveyor asked V2 to provide documentation of the complete investigation of R1's abuse allegations, but facility did not provide. 10/17/25 at 12:37 PM, V11 (Assistant Director of Nursing) stated she's been working in the facility since September 15th. V11 stated that if there is abuse allegation the process should be immediately reported to the abuse coordinator which is the administrator [V1]. V11 stated V1 is out sick. V11 stated, Generally, they have someone in her [V1] seat as acting administrator at that time if not, then [V2]. If there is negative interactions, separating both parties away from each other to ensure safety. If there is potential harm, we have to investigate see if there is any witnesses and take statements. The investigation should be done immediately when it's reported. If there is allegation of abuse initial investigation and reporting are sent to IDPH within 24 hours. The types of abuse are verbal, physical, emotional, mental abuse, financial abuse, seclusion and neglect. An example of verbal abuse is name calling, verbal threats such threatening to kill somebody. Mental abuse could be insults, calling name or threatening. I did not receive any report from any resident about abuse allegation. I have never witnessed any resident being abused by another resident. V11 stated she is familiar with R1 and R2. V11 said, From the time I've been here, I have witnessed them being friends and talking with each other. They stopped talking to each other in the last couple of weeks, but nothing negative I have witnessed personally.On 10/17/25 at 1:47 PM, V12 (Licensed Practical Nurse) stated that she is familiar with R1 and R2. V12 stated, Every time, I work in the facility I see [R2] on the first floor. [R2's] room was one room down from [R1] then they moved him [R2] to the other side on October 10th. Still on the same floor. [R1] came out one day very flustered. I don't' remember the day. It was in the afternoon. I was at the nurses' station at that time. I heard [R1] said that [R2] said something to her. [V4] and [V2] came out and said what's going on. Because [R1] was flustered. I went down the hall and [V2] asked me if I see or hear anything. I said I did not witness anything. I don't remember if they asked [R1] why she was flustered. [R2] is very argumentative with staff and patients. [R1] never bothers anybody.On 10/17/25 at 2:04 PM, a phone interview was conducted with V13 (Licensed Practical Nurse). Surveyor asked about R1 and R2's abuse allegation on 9/29/25. V13 stated, It was end of September. I was on lunch when I came back [V14 (Certified Nursing Assistant)] told me that [R1] and [R2] had an argument. I interviewed [R1] because [R2] already left for dialysis. [R1] said that since she came back from her last episode of amnesia, [R2] has been mean to her [R1] calling her white boy. [R1] said he did not touch her. Nobody was hurt or touched. [R1] did not tell me that he threatened to kill her. [R1] said to me that [R2] threatened to punch her. After that I reported it to the Social Worker [V7]. I didn't notify their doctors. I am not aware if they call the police. I'm not sure when they moved [R2] to a different room. [R2] was still on the first floor.On 10/17/25 at 2:15 PM, V4 (Nursing Consultant) stated that V1 went on leave on September 30. As of October 1st, V4 came to the facility for support. V4 stated she was not in the facility when R1 and R2's September 29 incident happened. V4 stated, I was in Florida. I was not made aware at that time. I heard that [R1] and [R2] had an unwitnessed argument. Back and forth exchange of words. That [V7] talked to [R1]. [V7] reported the allegation to [V2] I think. [V2] reported it to [V1]. They did not deem it reportable because it was not one sided. They said [R1] lashed out as well verbally. I would consider it verbal abuse the calling names and threatening to kill someone. It could be mental abuse.On 10/17/25 at 3:07 PM, a phone interview was conducted with V14 (Certified Nursing Assistant). Surveyor asked about R1 and R2's incident that happened on 9/29/25. V14 stated, I don't quite remember what happened. I witnessed [R2] was in the hallway and [R1] was in her room. [R2] was in the hallway by her [R1] door talking loud to [R1]. I think I heard [R2] say he was going to beat [R1] up. I reported it to the nurse [V13] right away. I separated them. [R2] went back to his room and [R1] stayed in her room. [R2] was put on one-on-one supervision. I don't remember if they call the police. I don't remember anything else what happened next.On 10/17/25 at 4:25 PM, a phone interview was conducted with V15 (Physician/Medical Director). V15 stated that threatening to kill or beat up someone is a type of verbal abuse. V15 stated that all abuse allegations should be thoroughly investigated for the safety of the residents. V15 stated that the aggressor should be sent out for a psychiatric evaluation.On 10/17/25 at 5:32 PM, a phone interview was conducted with V16 (Nursing Supervisor) and stated that R2 was moved to a different room (still first floor) on 10/10/25 not on 9/29/25.On 10/18/25 at 10:10 AM, a phone interview was conducted with V1 (Administrator). V1 stated she was not made aware of R1's allegations against R2 until yesterday (10/17/25). V1 stated she's on medical leave started on 9/28/25. V1 stated that V2 or V4 covers for her during her leave of absence, and they will serve as the abuse coordinators. V2 is the point of contact. V1 stated nobody notified her about R1 and R2's incident that happened on 9/29/25. V1 stated she was not aware R1 and R2 was having continued disagreements. V1 stated, Knowing what I know and their [R1, R2] history in the past they have denied any wrongdoing. These residents have history of being verbally aggressive with each other and being inappropriate. To them this is how they talk to each other. [R1] and [R2] use profanity a lot but [R2] does it more. They do that to each other. I don't hear them threaten each other. We tell them it's not acceptable in the facility. We keep them apart. They are aggressive and inappropriate a lot. I don't think it's intentional or abusive to each other because that's how they talk. V1 stated that it is important to follow the facility's abuse policy and procedures to protect the residents. R1's clinical records show and admission date of 5/1/25 with included diagnoses but not limited to unspecified convulsion, major depressive disorder, and gender identity disorder. R1's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 13 which means R1 is cognitively intact. R1 uses a wheelchair and able to wheel herself with supervision. R1's progress notes dated 9/29/25 at 12:21 PM documented by V13 reads in part: Writer assessed resident: resident stated he's been coming pass my room all the time calling me white boy, but I just brush it off, but today after I mumbled as***le he told me he would punch me in the face or kill me. Writer notified social services. The resident is being closely monitored and is being kept separated from each other. No physical harm was done.R1's progress notes dated 9/29/25 at 12:55 PM documented by V7 reads in part: ALLEDGED ALIGATION OF ABUSE BY PEER: DAY 1/3 CO-PEER MADE INAPPROPRIATE/THREATENING STAEMENTS TO HER [R1]: Writer met with the resident [R1] due to report that a co-peer made negative statements to her. She [R1] was asked what happened and stated that she was sitting by her room door and the other resident rolled by and he called her [R1] boy and when she responded back, he [R2] told her that if she said anything else to him that he would kill her [R1]. She [R1] stated that this is not the first time he said something to her. Writer asked her why she did not say anything to staff before now, and she said she just didn't. Writer encouraged her to make staff aware any time someone is making her feel uncomfortable due to negative statement or actions toward her She [R1] was asked if she feels safe and she stated that she did not. Writer informed her that the appropriate parties will be notified and will follow up on her concerns.R1's progress notes dated 10/2/25 at 1:29 PM documented by V7 reads in part: Writer followed up with resident [R1] regarding an incident that happened between her and her peer. Writer went to the residents' [R1] room, and she told resident that she continues to have problems with co-peer. Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [R1] stated she is getting tired of the situation, and something has to be done. Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer. Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway. Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation. The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility.The facility's Resident Rights Guideline (no date) documents in part: Our residents have certain rights and protections under Federal law that help ensure appropriate care and services are provided. The right to a safe, clean, and comfortable, and home-like environment that allows independence as possible.

Based on interviews and record reviews the facility failed to evaluate and address a resident's continued poor appetite for adequate nutrition and hydration, failed to follow the dietary's recommendation, and failed to consistently implement interventions, monitor the effectiveness of interventions and revising them as necessary for one (R1) out of four residents reviewed for nutritional services. These failures resulted in R1 being hospitalized due to hypovolemic shock, malnutrition, and dehydration.Findings Include:R1's clinical records revealed R1 was admitted in the facility on 6/23/25 and was discharged home on 7/9/25. R1's listed diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, dysphagia pharyngoesophageal phase, and major depressive disorder. R1's Minimum Data Set, dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 was cognitively intact, and was total dependent on staff's assistance for her activities of daily living (including eating). R1's weight record shows 88.3 pounds on 6/23/25. No other weights recorded for the entire stay of R1 in the facility. R1's physician orders reads in part: General diet (ordered on 6/24/25) and House Supplement 1 carton three times a day (ordered on 6/25/25).R1's progress notes dated 6/26/25 to 7/9/25 revealed no documentation of any follow-up notification to V20 (R1's Physician) or V10 (Registered Dietitian/RD) about R1's consuming 25% or less of her meals. R1's vitals report revealed R1's amount eaten for breakfast, lunch, and dinner (25% or less):6/24/25: 1-25% for dinner6/26/25: 1-25% for dinner6/29/25: 1-25% for dinner7/2/25: None eaten for breakfast7/3/25: 1-25% for breakfast and lunch7/5/25: 1-25% for breakfast and lunch7/6/25: 1-25% for breakfast and lunch7/7/25: 1-25% for breakfast and lunch7/8/25: 1-25% for breakfast and lunchR1's progress notes dated 6/25/25 at 11:41 AM documented by V10 reads in part: RD new admission referral for this 78 y/o female. admitted [DATE]. DX/PMH [Diagnoses/Primary Medical History] including but not limited to cerebral infarction, COPD, T2DM, chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, MDD, dysphagia, glaucoma, anxiety DO, bilateral primary osteoarthritis of knee, hypertensive heart disease without HF, rheumatoid arthritis, spinal stenosis, radiculopathy, retention of urine, GERD, pain in left hip, central retinal vein occlusion, brachial plexus DO, Vitamin D deficiency. Reviewed orders. NKA per EMR. Diet: general. Per progress notes, no teeth observed, no dentures, noted decreased vision in both eyes. Per EMR, PO intake 6/23-6/25 was variable 26-100% of meals, with 1 meal 1-25%. Weight on 6/23 was 88.3 [pounds], Ht: 64 (per hospital records), BMI 15.2-underweight. Wt [Weight] stability/gain beneficial d/t [due to] underweight status. Skin intact per wound report. Per progress notes, two healed/closed pressures ulcers on the left and right ankle. No edema noted. No GI problems. No recent labs. Estimated needs using IBW (55kg): 1650-1925kcals/day (30-35kcals/kg), 55g protein/day (1.0g protein/kg), 1650-1925mL/day (1ml/kcal). Recommend SLP [Speech Language Pathologist] referral for appropriate diet consistency d/t no teeth and house supplement/med pass 1 carton TID [three times a day] to promote wt stability/gain, Refer to RD as needed.R1's progress notes dated 7/4/25 at 5:32 PM documented by V34 (Licensed Practical Nurse) reads in part: R1 had inadequate meal intake and consumed 750cc fluids. Total assist with ADL's provided by staff and all care provided in resident room.R1's hospital records (7/11/25 to 7/14/25) documented in part: [R1] recently completed 2 week stay at [Nursing Home Facility Name] for respite care, [V33 (R1's Daughter)] is primary caregiver. On return home patient [R1] was noted by daughter [V33] to be altered with slurred speech. admitted with AMS [Altered Mental Status], hypotension and elevated lactic acid thought initially to be due to urosepsis however urine culture grew mixed flora. Therefore, shock due entirely to hypovolemia. Stroke workup negative for acute stroke. [R1] (90 pounds) received 7L [liters] of IV [Intravenous] fluids for resuscitation guided by lactic acid levels and bedside IVC ultrasound without signs of volume overload. Hypovolemic shock is determined to be from lack of PO [by mouth] intake of food and water during stay at nursing home for respite care. [R1] report she did not receive food or water during her time at nursing home.On 7/23/25 at 10:56 AM, V11 (Licensed Practical Nurse) stated she was one of the regular nurses who took care of R1 in the facility. V11 stated R1 barely talked, total dependent, and was on general diet changed to mechanical soft because R1 was pocketing her food. V11 stated R1 ate at least 50% of her meals but there were days R1 ate less. V11 stated she did not inform V20 (R1's Physician) because R1 had poor appetite since the first day R1 was admitted in the facility. V11 stated that R1 was not on calorie count, R1 was on one-on-one feeding and not on any supplements. V11 stated she provides the residents water during medication pass. On 7/23/25 at 11:03 AM, V12 (Restorative Aide) stated, R1 came as total assist. R1 was on Geriatric chair. R1's arms and legs were already contracted when she came. V12 stated that R1 was a picky eater and sometimes R1 would refuse to eat. V12 stated that she told the nurse but can't remember who the nurse. When R1 refuses, V12 stated they would offer substitute soup or a sandwich and would eat a little bit of that. On 7/23/25 at 11:32 AM, V13 (Certified Nursing Assistant) stated, If residents don't eat, I don't offer them alternatives. Kitchen staff come around with what food options they can have the day before. They give them what they ordered. I took care of R1. She would eat her meals at least half. Sometimes she would have just a couple of bites. She was a picky eater. I tried to give her a little more of what she likes. She was not offered substitute because I think she can only eat certain foods. I didn't tell the nurse about R1 because she's been having poor appetite since she came here to us. On 7/24/25 at 1:05 PM, V4 (Certified Nursing Assistant/CNA) stated she was of the CNAs that regularly took care of R1. V4 stated some days R1 would eat 50% and other days R1 would eat very little. V4 stated, If [R1] would not eat I tell the nurse and they give her a supplement. She [R1] was not offered alternatives just milk shakes. I offer water in the beginning of my shift and in between meals and when they asked. [R1] was offered water, and she can talk and can tell you if she's hungry or thirsty.On 7/24/25 at 1:41 PM, V7 (Agency Registered Nurse) stated that R1 had poor appetite. V7 stated that sometimes R1 would not eat. Sometimes R1 would eat just a little bit. On 7/24/25 at 9:07 AM, a phone interview was conducted with V10 (Registered Dietitian). V10 stated that on 6/25/25, she recommended speech referral to evaluate R1 for difficulty chewing because R1 had no teeth and no dentures. R1 also had poor appetite and underweight. V10 stated having no teeth could contribute to R1's poor appetite. V10 stated she recommended house supplement three times a day. V10 stated she was not notified of R1's continued poor appetite and was eating less than 25% most of her meals. V10 stated she would have ordered additional supplements, calorie count, and weekly weights. V10 stated she recommended speech therapy to work on R1's appropriate diet texture and consistency. V10 stated that with the right diet, R1 would have better appetite that matches her needs, weight stability and no weight loss. V10 stated R1 was not provided speech therapy services because V10 can't find any reports from speech. V10 further stated that if residents do not like the food and refuse to eat, staff should offer alternatives and substitutes, and it should always be available with each meal. V10 stated that having dehydration and acute malnutrition with shock could not happen in just two days. It could happen after a week of not drinking and not eating enough. On 7/24/25 at 9:29 AM, V17 (Director of Rehab) stated that speech therapy [ST] sees residents with cognition issues and dysphagia, and for dietary referrals for diet texture and consistency. ST works on what is appropriate for the resident. They work on mastication, rate of chewing, if there is food left over in the mouth if they are pocketing. V17 stated that she did not receive any referral about R1. V17 stated that if she sees any referral or if she was notified, ST would evaluate the resident within 24-48 hours. V17 stated R1 was not screened or evaluated by speech therapy. V17 stated she has no documentation about speech services provided for R1. V17 stated R1 was only provided skilled occupational therapy during R1's stay at the facility.On 7/24/25 at 10:34 AM, V34 (Licensed Practical Nurse) stated that she took care of R1 on 7/4/25. Breakfast, lunch, and dinner R1 only ate about 50-60%. R1's good with her fluids. R1 did not want to eat. The CNAs are supposed to inform the nurses if the resident did not eat or did not want to eat. If it's a pattern nurses could contact the dietitian and the doctor. V34 stated she did not inform V20 of R1's poor appetite because R1 was already seen by V10.On 7/24/25 at 2:52 PM, a phone interview was conducted with V35 (R1's Hospital Physician). V35 stated, R1 was admitted in the hospital on 7/11/25 and was discharged on 7/14/25. [V33] brought her [R1] in after getting her [R1] back from the nursing home the day before. She [R1] was not as alert and not answering questions as typically did. She [R1] had severe electrolytes imbalance, had kidney injury with elevated lactic acid level which indicated she [R1] was in shock. Initially we thought it was UTI [Urinary Tract Infection], but nothing came back with infection. She [R1] did not have UTI. She [R1] was dehydrated based on her labs and required large amount of fluids compared to her body weight to correct her kidney injury and electrolytes. She [R1] was able to eat and back to her normal mental status after we gave her the fluids. She [R1] told us that she was not given foods and fluids at the nursing facility. She weighed 90 pounds when she came in the hospital. That was documented on the 11th before she [R1] received the fluids. She [R1] required 7 liters of fluids total during her hospitalization. That amount of fluid was indicative that she [R1] was not provided enough hydration and nutrition for a longer period of time. That can't happen it just two days. To be hypovolemic, severely dehydrated and with acute malnutrition with shock to happen it could take longer than 2 days. It's a matter of days but not 2 days. If she [R1] was seen by speech therapy at the nursing home that would help identify what's an appropriate diet and fluids for her. On 7/25/25 at 10:55 AM, a phone interview was conducted with V20 (R1's Physician). V20 stated that he expects nursing to contact and notify him if his residents are not eating or having poor appetite. V20 stated he was not made aware of R1's poor appetite or eating less than 25% some of her meals in the nursing home. V20 stated that the nursing staff at the facility are pretty good of notifying him about his residents' change in condition. V20 stated dehydration and malnutrition with shock do not happen in the span of 2 days and it could result from 3 or more days of not eating or drinking. The facility's Hydration policy dated 2005 documents in part: the physician will manage fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. The physician will help monitor the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals. Adjust treatments on specific information relevant to that individual.The facility's Passing Meal Trays policy (no date) documents in part: Nursing will offer alternates to residents who refuse their food or request a substitute. Nursing will advise dietary of such requests.The facility's DIETARY SERVICES policy (no date) documents in part: It is the policy of this facility to provide a quality dietetic service using high standards of sanitation that meet the daily nutritional needs of the residents. Each resident's nutrition and hydration status is assessed and monitored. Residents shall be observed to determine acceptance of the diet. Should residents refuse foods served, or eat less than 50% of the total meal, appropriate substitutes of similar nutritive value will be offered.

Based on interview and record review, the facility failed to provide facility staff supervision of a resident (R1) in the basement dining room in a sample of 6 residents reviewed for improper nursing care. This failure resulted in R2, a wheelchair resident, being punched in the face two times by R1, an ambulatory resident with verbal and physical aggressive behaviors, causing R2 to sustain a facial skin tear, periorbital contusion and nasal fracture. Findings include: On 2/24/25 at 12:52 pm, R2 was observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was see in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 is arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 hear or see anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I see them. 2 residents (R1 and R2). They were separate already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observes R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 sees a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that R1 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room. Then back to his room. Sometimes he would want to go to other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if not someone watching. Someone (staff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one see them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) go around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of (R1) has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) with a goal of (R1) will not threaten, scream at, or curse at other residents, visitors, and/or staff. R1's Approaches (Interventions) for this specific care plan for R1 includes: Maintain a calm environment and approach to the resident with approach start date of 11/20/24; Refocus conversation when resident becomes verbally abusive with approach start date of 11/20/24; and When resident becomes verbally abusive, STOP and try the task later. Do not force the resident to do the task with approach start date of 11/20/24. On 2/25/25 at 1:21 pm, V9 (Psychiatric Rehabilitation Services Assistant, PRSA) stated that V9 is familiar with R1 and has V9's office on R1's floor. V9 stated that V9 is responsible for documentation of resident behaviors, counseling residents and updating the resident care plans. V9 stated that R1 is oriented to self and people, but has confusion; is independent in walking; becomes verbally aggressive and needs frequent redirection. V9 stated that when R1 is going downstairs to activities in the basement, staff will be monitoring him. When asked why is facility staff to be monitoring R1 in the basement, V9 stated, Because of his (R1's) aggression. We don't want him to go somewhere where something can happen. When asked about how does V9 know about R1's recent behaviors, V9 stated that V9 will receive information about R1's behaviors from the IDT (interdisciplinary) meeting (morning meeting) and by observing R1's behaviors. V9 stated that V9 will update R1's care plan when a quarterly assessment is due or when there is a behavior. This surveyor then read R1's current social services care plan to V9, which included R1 being sexually inappropriate with staff. V9 stated, Huh, (R1)? I think that must have been an error or wrong resident. When reading R1's care plan about being physically aggressive, V9 stated, What? I saw him making verbal threats. I saw him agitated but not swing at anyone. V9 stated that on 2/5/25, R1 was agitated that day with verbal outbursts, not receptive to redirection, despite asking R1 to come sit down in the dining room on the floor. V9 stated that R1 was pacing, going in and out of resident rooms, and trying to take residents' personal belongings. V9 stated that V9 tries to redirect R1 to a common area to watch him better. V9 stated that V9 tries not to agitate R1 by being to close to R1 but has to watch him to make sure he (R1) does not leave the floor without staff present. On 2/25/25 at 2:55 pm, V4 (Social Services Director, SSD) stated that R1 has displayed repeated verbally and physically aggressive behavior in the facility. V4 stated that facility staff are to be monitoring R1 when R1 is off of the floor because of (R1's) impulse behavior and it consistently happened. On 2/26/25 at 10:58 am, V2 (DON) stated that R1 is alert, ambulatory, can be combative and hostile with staff, aggressive with staff, can go in and out uninvited to other resident rooms and is hard to redirect. V2 stated that R1 did physically strike a staff member (V25, LPN). V2 stated that R1 likes food and likes coffee which helps with R1's redirection. This surveyor read to V2 a time-line from R1's Progress Notes from 10/28/24 (facility initial admission) to 2/10/25 (emergency discharge to hospital) with R1's behaviors documented, in part, of repeated verbal and physical aggression to staff; verbal aggression towards other residents; spitting at other residents; trying to steal food from residents in dining room; pacing; balling up fists with R1 threatening the lives of staff; screaming at other residents where staff needed to evacuate the floor dining room for safety; R1 throwing food trays in dining room; and R1 throwing items from the nurse's station and medication cart at the staff. This surveyor observed V2's face with eyes wide open, and V2 stating, I (V2) hadn't heard that. I wasn't aware of that. V2 stated, I absolutely was aware of his (R1's) behaviors towards staff. When asked about facility staff supervision for R1 in a communal place, like in the basement dining room, V2 stated, It's situational. If we see a behavior coming. Facility policy with revision date of 1/30/2025 and titled Safety and Supervision Guideline documents, in part, Purpose: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addressed risks for groups of residents . Resident-Oriented Approach to Safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents . Systems Approach to Safety: 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. Facility policy (undated) titled Abuse Prevention Policy documents, in part, . Procedures: . IV. Establishing a Resident Sensitive Environment: . Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur.

Based on interview and record review, the facility failed to ensure that one resident (R2) was free from abuse from two residents (R1 and R8) in a sample of 6 residents reviewed for abuse. These failures resulted in R1, an ambulatory resident, physically punching R2, a wheelchair resident, in the face causing a facial skin tear, periorbital contusion and nasal fracture, and R8, an ambulatory resident, physically hitting R2 in the back of the head. Findings include: On 2/24/25 at 12:52 pm, R2 was observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was seen in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 was arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 heard or seen anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I seen them. 2 residents (R1 and R2). They were separated already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observed R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 saw a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that V3 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room, then back to his room. Sometimes he would want to go to the other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if someone isn't watching. (saff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one saw them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) goes around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. Not since this second incident. She (R2) got beat up again by another man (R7). On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. R2's Care Plan (Problem Start date of 4/15/2023) documents, in part, the problem of Category: Psychosocial Well-Being (Abuse/Neglect) Resident (R2) is at risk for abuse due to impaired cognition, communication, and verbal and physical aggression. (R2) was the target of aggression on 1/6/25, 2/10/25 with a goal of Resident will be free of abuse/neglect daily through next review. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 is the abuse coordinator for the facility and is responsible for monitoring residents for abuse, facility staff training, and coordinating the facility's abuse prohibition program. V1 stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. When asked about an incident that occurred between R2 and R7 in the basement dining room on 1/6/25, V1 stated that R7 is no longer a resident in the facility and that the incident was witnessed by facility staff (V38, Activities Aide). V1 stated that both R2 and R7 were wheeling in their respective wheelchairs out of the basement dining room door with V38 in the room picking up activity's items from the tables when R7 began hitting R2 with R2's backpack. V1 stated that the State Agency investigated this facility reported incident on a prior survey and that physical abuse towards R2 from R7 was substantiated. V1 stated, (R2) is victim of abuse. Both times (1/6/25 and 2/10/25), yes. 2) On 3/3/25 at 9:29 am, V1 stated, Something happened over the weekend. (R2) got hit again. V1 stated that R8 walked by R2 in the hallway on their floor and just hit her (R2). V1 stated that R8 was sent out to the hospital, and R2 has been moved to a different floor. On 3/3/25 at 10:13 am, this surveyor re-interviewed R2 on R2's new floor. When asked about the incident with R8 on 3/1/25 on the floor, R2 stated, She (R8) hit me (R2). When asked where did R8 hit R2, R2 stated, Back of my head. R2 stated that R2 came out of R2's room in wheelchair and in hallway is where R8 hit R2 on 3/1/25. R2 stated that R2 feels safe in the facility and likes R2's new room and floor. On 3/3/25 at 10:42 am, when asked about the incident between R2 and R8 on 3/1/25, V29 (Certified Nursing Assistant, CNA) stated, Yes, I (V29) witnessed it. I was sitting in dining room. (R8) walked past her (R2) and hit her (R2). I said, Don't that. Why would you hit this woman (R2). She (R2) didn't do anything? And she (R8) ignored me. (V30, Agency Registered Nurse, RN) asked her (R8) too. (R8) said, 'It was an accident.' I (V29) said, 'No, you (R8) purposely hit her (R2).' (V30) asked (R8), 'Would you want someone to hit you? Then why did you hit her (R2)?' She (R8) said, 'It was an accident'. On 3/3/25 at 10:17 am, V30 (Agency RN) stated that on 3/1/25 around 9:45 to 10:00 am, V30 was sitting at the nurse's station desk charting, and V29 (CNA) alerted V30 that R8 hit R2 in the back of the head. V30 stated that V30 did not observe it, but V29 did. V30 stated that V30 kept R2 and R8 separated, and R8 told V30, It was an accident. V30 assessed R2 with no injuries, and V30 transferred R8 out to the hospital for a psychiatric evaluation. V30 informed V1 and V37 (Plant Operations Manager) who was on duty. In R2's Progress Notes, dated 3/1/25 at 10:19 am, V30 (RN) documented, in part, While charting at Nurses station Writer (V30) was informed by Nurses aide (V29) that resident above (R2) was hit in back of head while sitting in wheelchair in the hallway. Both residents (R2, R8) separated. Writer and MOD (manager on duty, V37) asked Resident (R2) what happened? Resident (R2) unable to verbalize what happened. In R8's Progress Notes, dated 3/1/25 at 10:09 am, While charting at Nurses station Writer was informed by Nurses aide that resident above (R8) hit another resident (R2) in back of head while walking pass her in the hallway. Both residents separated. Writer and MOD (V37) asked Resident (R8) what happened? Resident (R8) stated It was a (an) accident. Writer and MOD spoke with Resident informing her that behavior is unacceptable, resident verbalized understanding. On 3/3/25 at 12:36 pm, V1 and this surveyor together viewed the video camera footage in V1's office from 3/1/25 of the camera view from R2 and R8's floor dining room on north side of building facing down the hallway towards south side of the building. On 3/1/25 at 9:46:19 am, V29 (CNA) is observed in the dining room sitting watching down the hallway, and R8 walks freely out of her room; walks down the hallway to the alcohol based hand sanitizer (ABHS) dispenser on the wall near the nurse's station; pumps it 22 times to get ABHS and then walks back into R8's room. On 3/1/25 at 9:47 am, R2 is observed wheeling out of her room in R2's wheelchair and is staying on the side of the hallway (east side) and wheels past R8's room. R8 next walks out of R8's room and with an open hand, R8 hits R2 on the back of R2's head while in the wheelchair with R2's head jerking forward. V29 points to R8 who continues walking towards the nurse's station. R8's Face Sheet documents, in part, diagnoses of fibromyalgia, personality disorder (unspecified), asthma, anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, hypertension, venous insufficiency, constipation and obesity. R8's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R8 is cognitively intact. Facility policy (undated) titled Abuse Prevention Policy documents, in part, The 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. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents. Facility policy with a revision date of 10/2024 and titled Resident Rights Guideline documents, in part, . Guideline: Our residents have certain rights and protection under Federal law that help ensure appropriate care and services are provided . Our facility will treat each resident with respect and dignity and care for each resident in a manner an (and) in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation: The right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of your property by anyone.

Based on interview and record review, the facility failed to provide adequate nutrition and hydration to a resident with gastrostomy tube (G-Tube) feeding. This failure affected one resident (R1), reviewed for weight loss and dehydration. As a result, R1 consistently had significant weight loss since initial admission to the facility and was hospitalized for dehydration and Hypernatremia. Findings include: On 8/7/23 at 11am, V2(Director of Nursing) presented the weight records of R1 in pounds as dated below: 1/9/23 - 115.8; 2/15/23 - 113.8; 2; 2/27/23 - 106.2; 3/4/23 - 106.2; 5/3/23 - 96.3; May and June records showed 96.6 pounds while 7/11/23 weight was 86.2 pounds. R1 weighed 115.8 pounds on 1/9/23 and weighed 86.2 pounds on 7/11/23, which means that R1 lost an average of 29.6 pounds between January to July of 2023. R1 has diagnoses which include but are not limited to: Dementia, Cerebral Infarction, Pressure Ulcers, Aphasia, Dysphagia, Protein calorie malnutrition, and gastrostomy tube. R1's MDS (Minimum Data Status dated 7/12/23, Section K (Weight Loss) shows the following: R1 is 62 inches tall and weighs 86 pounds and had lost 5 percent or more in the last month or 10 percent or more in the last 6 months, while not on physician-prescribed weight loss regimen. R1's progress notes dated 7/14/23 at 6:25pm written by V23(Licensed Practical Nurse/LPN) states that R1 had a critically elevated sodium level of 162(normal range is 131-145). R1's laboratory report dated 6/19/23 upon arrival at the hospital was critically high at 169. R1's hospital records dated 3/8/23: Discharge Summary written by V36(Hospital Physician) - Chief Complaint was Tachycardia. On arrival, tachycardia was in the 160s. Patient had problems with Hypernatremia (Sodium was 166), (normal range is 135-145); Chronic Aspiration, Pressure Wounds. Hospital Course and Therapy states in part: After review, it was determined that the most likely cause of her tachycardia was Dehydration and losses. Recurrent Aspiration Pneumonia with acute respiratory failure. R1's hospital Records dated 6/19/23 written by V12(Hospital Attending Physician) states in part: G-Tube noted to be kinked and unkempt, replaced in the ED (Emergency Department). This hospital records also documented that there has been concerns in the past about Neglect in the nursing home. V12 documented that R1's secondary diagnoses include Hypernatremia (elevated sodium levels) and that R1 is malnourished. Hospital Discharge Summary notes states in part Likely hypovolemic in the setting of missed tube-feeds due to G-Tube dysfunction. Initial sodium 169, received Normal Saline 1150 ml in ED. This Hospital Discharge Summary also states that R1 has AKI (Acute Kidney Injury) on chronic kidney disease stage 3, and that Starvation Ketosis is now resolved. R1's Nutrition Care Plan dated 7/13/23 states that R1 is dependent on tube feeding due to dysphagia and CVA (Cerebrovascular Accident) and R1 is at risk for malnutrition. Goal states that R1 will receive adequate nutrition and hydration as evidenced by stable weight and absence of signs and symptoms of dehydration. Progress notes dated 1/9/23 at 7:30pm written by V30(LPN) states that R1 was sent to the hospital for G-Tube Malfunction. Progress notes dated 3/28/23 at 8:07am written by V10(RN) states: Resident admitted to the (hospital), Admitting Diagnosis: Sepsis related to Bleeding from G-tube site. On 8/10/23 at 12:10pm, V22(LPN) was interviewed regarding R1's last hospital visit of 8/6/23. V22 stated I sent her(R1) to the hospital because the G-Tube got disconnected. On 8/9/23 at 11:48am, V20(Nurse Practitioner) was interviewed regarding the possible cause of Dehydration for R1. V20 stated that if a resident who is dependent on G-Tube does not get enough water flush, it could cause dehydration. On 8/9/23 at 1:18pm, V24(Registered Dietitian) was interviewed regarding R1's diagnosis of Hypernatremia. V24 stated It's hard for me to say why the resident is dehydrated without observing staff there every shift. The water flush was previously 150 ml every 8 hours. Now, I increased the water flush to 150 ml five times a day. The previous feeding recommendation and water flush recommended were supposed to meet her estimated nutrient needs. V24 also stated that R1 has been having significant weight loss. On 8/16/23 at 8:58am, V34(Hospital Social Worker) was interviewed. V34 stated in part I've had (R1) as a patient 3-4 times in the past few months. She's had up to about 15 admissions in this hospital since January of this year. Several doctors have documented that the admissions were due to neglect at the nursing home because the reason for admission were issues like the G-Tube is kinked, G-Tube is coming out, Dehydration, Hypernatremia, and other issues that are due to neglect. In the last 2 admissions, there was Hypernatremia and dehydration. I don't know what's going on at the nursing home, but it doesn't sound good to me. Facility's policy on nutrition and hydration with latest revision date of August 2008, states in part: When apparently well-nourished individuals develop inadequate dietary intake of protein or calories, offer support with eating. Ensure that interventions to prevent malnutrition are compatible with the individuals wishes and advance directives. Ensure that the resident's intake of fluid is sufficient.

Based on observation, interview and record review, the facility failed to provide the necessary care to prevent frequent multiple hospitalization s of a resident. This failure affected one resident (R1), reviewed for quality of care. The facility also failed to follow physician orders for the administration of resident's medications, failed to administer the gastrostomy tube (G-Tube) water flush as ordered, and failed to provide care of a G-Tube. This failure has the potential to affect three residents (R3, R4 and R5) reviewed for gastrostomy tube care. R1 was hospitalized eleven times in the past 8 months with diagnoses which included but were not limited to Hypernatremia, Dehydration, G-Tube malfunction, and Sepsis related to bleeding from G-tube site. Findings include: 1.) R1 has diagnoses which include but are not limited to: Dementia, Cerebral Infarction, Pressure Ulcers, Aphasia, Dysphagia, Protein calorie malnutrition, and gastrostomy tube. On 8/7/23 at 2pm, V2(Director of Nursing) presented the Census report that shows the hospital visit dates of R1 as follows, with the following admitting diagnoses: 1/1/23 - 1/7/23 - Unspecified Fever 1/9/23 - 1/19/23 - G-Tube Malfunction 2/8/23 - 2/14/23 - Hyperkalemia (Elevated Potassium level) 2/17/23 - 2/23/23 - Unwitnessed Fall 3/8/23 - 3/22/23 - Abdominal Pain, Sepsis, UTI, and Pneumonia. 3/28/23 - 4/5/23 - Sepsis related to Bleeding from G-tube site. 5/16/23 - 5/27/23 - Low Hemoglobin 6/4/23 - 6/6/23 - Low Hemoglobin 6/19/23 - 7/7/23 - Shortness of Breath, Labored Breathing 7/14/23 - 7/31/23 - Hypernatremia (Elevated Sodium Level) 8/6/23 - 8/9/23 - Gastrostomy Tube Complication/Failure to Thrive R1's hospital records as dated below documented the following: 1/7/23: Hospital Course - Hypernatremia - (R1) arrived at the hospital with Sodium level of 157, likely severely dehydrated. 2/17/23: Discharge Summary written by V12(Hospital Attending Physician)- Principal/Secondary Diagnosis includes Lactic Acidosis from volume depletion/infection; Chronic Aspiration from G-Tube feeding. 3/8/23: Discharge Summary written by V36(Hospital Physician) - Chief Complaint was Tachycardia. On arrival, tachycardia was in the 160s. Patient had problems with Hypernatremia (Sodium was 166), (normal range is 135-145); Chronic Aspiration, Pressure Wounds. Hospital Course and Therapy states in part: After review, it was determined that the most likely cause of her tachycardia was Dehydration and losses. Recurrent Aspiration Pneumonia with acute respiratory failure. 3/28/23: Principal/Secondary Diagnosis - Hypotension, Dehydration, Sepsis. History of Present Illness states in part: She was also treated with IV (intravenous) fluids and free water flushes with resolution of her lactic acidosis and hypernatremia. Hospital course was complicated by bleeding around G-Tube site for which GI (Gastro-Intestinal Doctor) was consulted. 6/19/23: R1's hospital Records dated 6/19/23 written by V12(Hospital Attending Physician) states in part: G-Tube noted to be kinked and unkempt, replaced in the ED (Emergency Department). (R1) has had 9 hospital admissions since January of 2023 and that there is a concern about Neglect in the nursing home. Hospital Discharge Summary notes states in part Likely hypovolemic in the setting of missed tube-feeds due to G-Tube dysfunction. Initial sodium 169, received Normal Saline 1150 ml in ED. This Hospital Discharge Summary also states that R1 has AKI (Acute Kidney Injury) on chronic kidney disease stage 3, and that Starvation Ketosis is now resolved. On 6/21/23 at 2:01pm, V34(Hospital Medical Social Worker) documented that on 6/19/23, the nursing home neglected to care for R1 and sent R1 to the emergency room for Hypernatremia (Elevated Sodium levels). V34 added that R1's G-Tube was clogged and kinked and was likely not flushed for approximately one week, contributing to malnourishment. On 7/17/23 at 12:22pm, V35(Hospital Care Coordinator) documented that the nursing home neglected to provide care for R1. R1's Nutrition Care Plan dated 7/13/23 states that R1 is dependent on tube feeding due to dysphagia and CVA (Cerebrovascular Accident) and R1 is at risk for malnutrition. Goal states that R1 will receive adequate nutrition and hydration as evidenced by stable weight and absence of signs and symptoms of dehydration. R1's progress notes dated 7/14/23 at 6:25pm written by V23 (Licensed Practical Nurse/LPN) states that R1's sodium level was 162 (normal range is 135-145). Progress notes dated 1/9/23 at 7:30pm written by V30(LPN) states that R1 was sent to the hospital for G-Tube Malfunction. Progress notes dated 3/28/23 at 8:07am written by V10(RN) states: Resident admitted to the (hospital), Admitting Diagnosis: Sepsis related to Bleeding from G-tube site. On 8/9/23 at 11:48am, V20(Nurse Practitioner) was interviewed regarding the possible cause of Dehydration for R1. V20 stated that if a resident who is dependent on G-Tube does not get enough water flush, it could cause dehydration. V20 added that the nurses should follow the facility's policy on how to administer water flushes into resident's G-Tube. On 8/9/23 at 1:18pm, V24(Registered Dietitian) was interviewed regarding R1's diagnosis of Hypernatremia and Dehydration. V24 stated It's hard for me to say why the resident is dehydrated without observing staff there every shift. The water flush was previously 150 ml every 8 hours. Now, I increased the water flush to 150 ml five times a day. The previous feeding recommendation and water flush recommended were supposed to meet her estimated nutrient needs. On 8/10/23 at 12:10pm, V22(LPN) was interviewed regarding R1's last hospital visit of 8/6/23. V22 stated I sent her(R1) to the hospital because the G-Tube got disconnected. On 8/16/23 at 8:58am, V34(Hospital Social Worker) was interviewed. V34 stated in part: I've had (R1) as a patient 3-4 times in the past few months. She's had up to 15 admissions in this hospital since January of this year. Several doctors have documented that the admissions were due to neglect at the nursing home because the reason for admission were issues like the G-Tube is kinked, G-Tube is coming out, Dehydration, Hypernatremia, and other issues that are due to neglect. In the last 2 admissions, there was Hypernatremia and dehydration. I don't know what's going on at the nursing home, but it doesn't sound good to me. 2.) R3 has diagnosis which include but are not limited to: Gastrostomy Status, Vascular Dementia, Cerebral Infarction, and Protein calorie malnutrition. On 8/7/23 at 12:12pm with V11(LPN), R3 was observed in bed with G-Tube Stoma site having dried crust around the stoma. V11 stated that she(V11) would ensure to clean the G-Tube stoma and apply a gauze to absorb any further secretion or leakage. R3's POS (Physician Order Sheets) dated 6/11/23 states in part: Check enteral feeding stoma every shift. R3's care plan dated 8/4/23 states that R3 is dependent on tube feeding for total nutrition and hydration support due to history of CVA (Cerebrovascular Accident). 3.) R4 has diagnoses which include but are not limited to: Gastrostomy, Diabetes, and Cerebral Infarction. On 8/7/23 at 12:20pm, R4 was observed in the room with V10(LPN). R4's G-Tube stoma was observed with some brownish sticky secretion. There was no Enteral Syringe at the bedside to flush the G-Tube. The surveyor inquired from V10 if R4's G tube has been flushed. V10 stated I didn't flush it this morning. I didn't see a piston syringe. I gave the medication by mouth. She can swallow her medication, but I will flush it now. V10 later brought a 60 ml (Milliliter) Enteral piston /syringe, filled the syringe half-way with water and pushed the water through the G-Tube. V10 did not flush the tube by gravity according to facility's policy. V10 also stated I will clean the secretion on stoma. R4's POS dated 11/22/22 states: Cleanse Enteral feeding site with Normal Saline, change dressing as needed. POS dated 7/19/23 states to flush with 200ml distilled water every shift. R4's POS shows that all medications were supposed to be given by G tube. R4's Nutritional Care Plan dated 4/23/23 states that R4 is dependent on tube feeding and oral diet for adequate nutrition and hydration due to poor oral intake, swallowing difficulty, related to CVA (Cerebrovascular Accident). Intervention states to follow swallowing strategies when feeding resident to ensure safe swallowing, cleanse G-tube site as needed. 4.) R5's diagnoses include but are not limited to the Dysphagia, Cerebral Ischemia, and Aphasia. On 8/7/23 at 12:27pm, R5 was observed in the room with V10(LPN). There was no enteral piston/syringe to flush R5's G-Tube. The surveyor inquired from V10 if V10 flushed R5's G-tube during medication pass in the morning. V10 explained that she(V10) did not flush R5's G-Tube in the morning because R5 received all medication by mouth because he can swallow his medications. V10 later brought a new piston/syringe, filled the syringe half-full of water and pushed the water through R5's G-Tube. V10 did not flush the tube by gravity according to facility's policy. R5's POS shows that some of the medications are to be given by G-Tube while others were ordered for oral administration. On 8/8/23 at 1:15pm, V2(Director of Nursing) was interviewed regarding R5's medications administration route. V2 stated Usually, if the resident has a G-Tube, the medications are given by G-Tube, especially if the resident has a diagnosis of Dysphagia, like (R5). Maybe the nurse that put in the order for oral administration did not know. If the Doctor's Order says the medications should be given by G tube, the nurse should not give the medications by mouth. The resident's diet order is for pleasure feeding and medications are ordered to be given by G-Tube. Inquired from V2 about the process for G-Tube water flush for residents; V2 stated that water flush should be by gravity, and the nurse should not push the water into the G-Tube. V2 explained that if the nurse pushes the water through the G-tube, that there will be too much gas going into the resident's G-tube which will cause abdominal discomfort. V2 stated I will in-service the nurses about G-Tube. Facility's Policy on Enteral Tube Medication Administration with effective date of 10/25/2014 states in part: #11: Remove plunger from the 60 ML catheter tipped syringe and connect syringe to clamped tubing. #12: Put 15-30 ml off water and syringe and flush tubing using gravity flow. #13: Pour dissolved dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. #14: Flush with 5-10ml warm water between each medication. Pinch tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air from entering the stomach. This can cause discomfort or emesis. #Hc: Do not force-flush the tube or use a rigid object in an attempt to clear the tube. If clog is persistent, contact the MD (Medical Doctor) if the above technique fails. Facility's policy on nutrition and hydration with latest revision date of August 2008, states in part: When apparently well-nourished individuals develop in adequate dietary intake of protein or calories, offer support with eating. Ensure that interventions to prevent malnutrition are compatible with the individuals wishes and advance directives. Ensure that the resident's intake of fluid is sufficient. Facility's policy titled Medication Administration states: Medications administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to do so. #4 under Five Rights of Medication Administration states: Right Resident, Right Drug, Right Dose, Right Route, and Right Time, applied for each medication being administered. Under Administration, #2 states: Medications are administered in accordance with written orders of the prescriber.

Based upon observation, interview, and record review the facility failed to ensure that all nursing staff were aware of resident fall prevention interventions and failed to implement fall prevention interventions for two of four residents (R1, R2) reviewed for falls. These failures resulted in R1's (3/15/23) fall resulting in forehead laceration requiring 10 sutures. R2 fell (5/8/23) resulting in forehead knot and bruising. Findings include: 1.) R1 was discharged prior to this investigation. R1's (2/24/23) BIMS (Brief Interview Mental Status) determined a score of 11 (moderate impairment). R1's (2/24/23) functional assessment affirms (2 persons) physical assist is required for all ADL's (Activities of Daily Living). R1's (2/20/23) fall risk assessment determined a score of 13 (high risk). R1's (2/17/23) care plan states resident is at risk for falling. Keep personal items and frequently used items within reach. R1's (3/15/23) incident report states resident was observed in her room on the floor in a prone position. Open area to the forehead was noted. (R1) stated she was trying to pick up her laundry from the floor and fell out of the wheelchair. (R1) returned from the hospital with 10 sutures to forehead. On 5/23/23 at 10:13am, surveyor inquired about R1's fall prevention interventions. V17 (Licensed Practical Nurse/LPN) stated, Her interventions? I don't know exactly. The interventions that were in place is that her call light was already in reach and to monitor more closely. She likes to have her purse on her bed, that was it mostly and to monitor closely. Surveyor inquired about R1's (3/15/23) fall. V17 responded, It was brought to my attention by the housekeeper that she fell , and the patient was on the floor. The patient stated she was reaching for her soiled linen, and she fell out the chair. She had a skin tear to her forehead. Surveyor inquired if R1 sustained a laceration. V17 replied, It was an open area. Surveyor inquired about the difference between a skin tear and laceration. V17 stated, A laceration might require more medical attention. Surveyor inquired why there was soiled linen on R1's floor (if R1 requires 2 persons assist for all ADL's). V17 responded, I'm not sure. R1's (3/15/23) skin assessment affirms forehead laceration was sustained. 2.) R2's diagnoses include Alzheimer's disease, hemiplegia and hemiparesis affecting left side. R2's (4/21/23) BIMS (Brief Interview Mental Status) determined a score of 13 (cognitively intact). R2's (4/21/23) functional assessment affirms (2 persons) physical assist is required for bed mobility, transfers, and toilet use. R2's (7/22/22) fall risk evaluation determined a score of 18 (high risk). R2's care plan includes (1/26/23) history of falling related to poor balance and gait as a result of Cerebrovascular Accident with left hemiparesis and Alzheimer's type dementia with poor safety awareness. (5/11/23) Resident had a fall and is at risk for future falls. Ensure resident is placed in the middle of the bed before, during and after ADL care. Keep call light within reach at all times. R2's (5/8/23) incident report states while am care was being rendered in bed by CNA (Certified Nursing Assistant), resident let go the side bed and fell to the floor. Bruising to left frontal forehead and small knot noted. If witnessed list by whom: V13 (CNA). Therefore only 1 staff was present (R2 requires 2 persons assist). On (5/8/23) V13 wrote the following statement I turned resident on his right side to continue patient care, he rolled out of the bed and fell on the floor. I pulled the call light and call for help, then 2 CNAs came. On 5/22/23 at 12:48pm, surveyor inquired about R2's (5/8/23) fall. V14 (Licensed Practical Nurse) stated, The CNA came to me and told me that during patient care the resident rolled out of bed onto the floor. I saw him on the floor on the side of his bed. I saw I think a raised area on his left forehead. We sent him out because of the raised area and the nurse didn't see the fall. Surveyor inquired about R2's fall prevention interventions. V14 responded, He has mats on the floor and bed to the lowest position. We don't have side rails. On 5/17/23 at 11:49am, R2 was observed lying in bed sideways. R2's right shoulder was near the edge of the bed and his left foot near the opposite edge of the bed. R2's call light was on the floor. Surveyor inquired if R2 was able to walk. R2 responded, I can barely stand up. I'm so weak. R2's left side appeared to be flaccid while attempting to move therefore unable to reposition himself. Surveyor inquired about R2's (5/8/23) fall. R2 stated, I was in the bed rolling over and I fell out the bed and affirmed one CNA was present. On 5/17/23 at 11:53am, V8 (Licensed Practical Nurse) affirmed she was currently assigned to R2. Surveyor inquired about R2's fall prevention interventions. V8 stated, We make sure we keep the bed low, and the call light is in place, and we always monitor him. Surveyor inquired how R2 is always monitored by staff while lying in bed and his room is farthest from the nurse's station. V8 responded, The CNA will go, and the Nurse will go monitor. V8 subsequently entered R2's room (as requested) surveyor inquired about the location of R2's call light. V8 replied, This call light was here before then placed it on R2's bed near R2's left shoulder [R2's left arm is flaccid]. Surveyor inquired where the call light was located prior to placement. V8 stated, On the floor. Surveyor inquired about R2's positioning in the bed. V8 responded, His position, he's not use and affirmed she was at a loss for the correct word. Surveyor inquired if R2 appears comfortable. V8 replied, No, he doesn't look comfortable. Surveyor inquired if floor mats were adjacent to R2's bed. V8 stated, There's no floor mat at this time. I'm going to get help so I can move him. Surveyor inquired if R2's bed has side rails. V8 responded, No side rail. On 5/17/23 at 12:20pm (27 minutes later), R2's call light was observed on the floor. V10 (Agency Certified Nursing Assistant) subsequently entered R2's room. Surveyor inquired why R2's call light was on the floor (again). V10 stated, It looked like it was a clip but uh, it's broken then placed it on R2's bed (near R2's left shoulder) therefore inaccessible. On 5/25/23 at 11:25am, surveyor inquired about potential harm to a resident that falls. V21 (Medical Director) stated, It depends on the fall. Generally speaking, one can have injury including a possible fracture, skin laceration or if they hit their head, they can get hematoma. The falls clinical protocol (revised August 2008) states as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on interview and record review, the facility failed to prevent a resident from being physically abused by facility staff. This failure resulted in one resident (R1) obtaining an injury to the head, requiring hospitalization . This failure affects one of three residents reviewed for physical abuse in total sample of three residents. Findings include: R1 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's BIMS (Brief Interview for Mental Status) dated 09/13/2022, notes R1 is alert. R1 requires assistance from two staff members. R1's care plan notes that R1 is at risk for abuse due to R1's impaired mobility. Progress notes dated 11/04/2022, notes R1 states that a CNA (Certified Nursing Assistant) that was assigned to R1 allegedly exhibited inappropriate behavior during ADL (Activities of Daily Living) care. A head-to-toe assessment noted right side of forehead raised. On 11/12/2022 at 12:45PM, V1 (Administrator) stated, There was an allegation from R1 when the shift was ending. I was told by R1 that V2 hit R1. I was talking to R1. R1 stated V2 was not doing what R1 wanted V2 to do. R1 was offended that V2 asked R1 if R1 could walk. R1 then started talking about R1's medical experience for years. I asked R1 if V2 hit R1 and R1 said V2 was doing this and that. I asked what R1 was doing. I tried to determine if V2 hit R1. R1 had an issue with how the V2 turned R1. R1 stated V2 had an attitude and R1 called V2 a b*****. R1 did not tell me that R1 was abused. Everything is in my report. On 11/12/2022 at 2:35PM, R2 stated, V2 had pulled the curtain and I could not see. But I could still hear it. V2 hit R1 in the head. V2 spit in R1's face. R1 and V2 were doing a lot of talking. V2 stated to R1 that the family should not have put R1 in a nursing home. On 11/12/2022 at 2:36PM, R1 stated, I have never seen V2 before. I was looking at V2. I am a survivor of a stroke. V2 had on a pink and yellow top. V2 came to my bed. I told V2 I have [AGE] years of school. V2 stated to R1, that is why your family put your bony a** here. Then V2 spit on me. V2 pulled the curtain and V2 punched me in my skill. I asked the facility to send me to the hospital because I felt V2's knuckle on my skull. It happened at 4:04AM. It was the 11:00PM to 7:00AM shift. The police officer stated that the officer forgot to take pictures and that is why the officer came back to the facility. The officer stated they picked V2 up and arrested V2. V2 is in jail. On 11/15/2022 at 3:55PM, V5 (Nurse Practitioner) stated, There was a swollen area on the right side of R1's head. R1 told me that a staff member hit R1. I just noticed bruising. On 11/15/2022 at 4:10PM, V2 stated, I don't know anything about that. I am still going to work, and I am going to report that facility to the state for neglect. They wrongfully fired me. Do not call my motherf****** phone again. On 11/16/2022 at 12:24PM, V4 (Licensed Practical Nurse) stated, I do not remember what side of R1's face was injured, but I left a note. That day I was not the nurse assigned to R1. I do not know if R1's nurse was on break. The lady that was drawing R1's blood came to the nurse's station and stated that R1 needed to see a nurse right away. I went in the room to see if R1 was alright. R1 stated R1 wanted to report V2 that worked overnight to me. R1 said that they were arguing. R1 threw a cup at V2 and V2 hit and spit in R1's face. Initially, R1's face was flat but then it was raised. To me it did not look like R1 was hit on the face. It was a little bit raised. I reported it to the administrator. V2 was removed out of the building. Ambulance report dated 11/04/2022, notes crew dispatched to nursing home for R1. R1 victim of assault and battery. R1 stated eight hours ago, V2 punched R1 in the head. R1 has a very small contusion on forehead. Medical records dated 11/04/2022, notes R1 presents to the hospital with assault. R1 was reportedly assaulted by agency aide this morning and was repeatedly punched in the head. R1 had small area of swelling with TTP (Thrombotic [CONDITION(S)] Purpura-rare disorder of blood coagulation) without overlying skin changes to the right forehead. R1 is a victim of assault. Police Victim Information Notice dated 11/04/2022, notes aggravated battery towards R1. Final facility investigation dated, 11/08/2022, notes R1 reported that a staff member was rough with R1 during care. R1 stated V2 spoke to R1 in a discourteous manner, which escalated the care experience. This resulted in V2 hitting R1, according to R1. R1 was assessed from head to toe. Staff observed a small, raised area to the forehead. Abuse policy, undated, notes abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. The term willful in the definition of abuse means the individual must have acted deliberately. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on observation, interview and record review the facility failed to address significant, unplanned weight loss, and failed follow Registered Dietitian's recommendation to start oral nutritional supplements. The facility also failed notify the physician of a significant, unplanned weight loss. This resulted in a continued weight loss including a significant weight loss (>5% change over a span of 1 month and >7.5% change over a span of 3-month period) for 1 (R63) of 7 residents reviewed for nutrition for a total of 25 residents in the final sample. Findings include: On 11/01/22 at 11:19 AM, surveyor observed R63 sitting in chair at bedside with lunch tray on the table in front of him. R63 had consumed approximately 1-2 bites of rice, 100% strawberry dessert, and 100% of juice. R63 stated, I don't like it. It looks like cat food. The food is not all bad, sometimes I eat it. It depends on what they are serving. R63 refused surveyor's offer to obtain menu alternative. Surveyor did not observe any supplement on tray or observed at supplement at bedside. On 11/01/22 at 3:18 PM, V8 (Food Service Director) stated that the kitchen does not give out any oral nutritional supplements and R63 is not receiving any extra food or snacks between meals from the kitchen. V8 stated if a resident has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/01/22 at 3:25 PM, V7 (Licensed Practical Nurse) stated the nurses would give out a nutrition supplement if there is a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . After reading through all R63's paper MARs V7 stated, no. On 11/02/22 at 9:27 AM, V6 (Certified Nursing Assistant) stated that R63 only consumed one hardboiled egg, juice, and coffee this morning and that R63 is not a big breakfast eater. V6 stated that R63 will eat less on days he (R63) is served scrambled eggs because he (R63) thinks they are powdered eggs. On 11/02/22 at 10:03 AM, surveyor requested for staff to obtain R63's current weight. V33 (Restorative Aide) and V34 (Restorative Aide) weighed R63 using the mechanical lift scale in R63's room. V33 and V34 stated that this is the way R63 is usually weighed. V33 and V34 read the weight of R63 when he (R63) was fully up in the air, not touching the mattress and not rocking back and forth. When the surveyor asked how much R63 weighed V33 looked at the mechanical lift's digital scale and stated, 119.2 pounds. Surveyor viewed the mechanical lift's digital scale and confirmed the reading of 119.2 pounds. R63 stated, I used to weigh 127 pounds a couple of months ago and closer to 150 pounds when I first came into this place. Now my legs look like they are getting skinnier. On 11/02/22 at 10:33 AM, V17 (Licensed Practical Nurse) reviewed paper MARs and stated that R63 is not getting any type of supplement because there is not any order for it in the MARs. On 11/02/22 at 11:50 AM, V6 showed surveyor R63's lunch tray once R63 was finished eating. R63 consumed 100% spaghetti with meat sauce, 0% spinach, 0% bread, 0% dessert. On 11/02/22 at 1:30 PM, V17 stated that if V16 (Registered Dietitian) has a recommendation for a resident to be started on a supplement then V16 gives nursing a recommendation form and V17 would then call the physician to get the order approved. V17 stated that the physicians are very responsive and always approve V16's recommendations. V17 stated that once the supplement is approved by the physician the nurse would enter the order into the electronic medical record (EMR) and manually add the information to the paper MARs, so the nurses know to give out the supplement. V17 stated that the facility uses a (name brand) commercial oral supplement and that this supplement is in stock. Surveyor observed a carton of (name brand) commercial oral supplement on the 1st floor medication cart. On 11/02/22 at 1:55 PM, surveyor spoke with V16 (Registered Dietitian) over the phone. V16 stated that she (V16) is a consultant Registered Dietitian and one of her responsibilities is to complete high risk nutrition assessments include any weight loss changes 5% or more over 1-month period, 7.5% change or more over 3-month period, 10% change or more over 6-month period. V16 stated that she (V16) checks residents weights every visit for significant changes and addresses any weight triggers or concerns within the month they are identified. V16 stated that the EMR generates a weight report which flags residents who have had a significant weight loss and that she (V16) also manually checks the weight data to make sure it is accurate. V16 stated that all of her (V16) nutrition assessment/documentation is included in the progress note section of the EMR. V16 stated that she (V16) generates a consultant report at the end of every visit she (V16) makes to the facility which includes a list of residents seen, concerns and recommendations which are listed on separate recommendation forms. V16 stated that she (V16) emails this report and nutrition recommendation forms to V1, V2, and V8. V16 stated that the information on the nutrition recommendation form includes the resident's name, what her (V16) recommendation is and the rationale for the recommendation. V16 stated she (V16) also participates in a NARS (Nutrition At Risk & Skin) meeting monthly which is when residents who have lost weight would be discussed with the interdisciplinary team and to discuss nutrition recommendations submitted to make sure they were followed through on and that the physician was notified. On 11/02/22 at 2:30 PM, surveyor continued interview over the phone and asked V16 to review R63's weight data in the EMR and why the 22.8-pound weight loss which occurred from 08/2022 to 09/2022 was not addressed. V16 stated that typically when she (V16) sees a weight jump like that she (V16) would request for the resident to be reweighed to check the accuracy of the weight and that this request would be included on her (V16)'s consultant reports. V16 stated that it does not look like a reweight was obtained during the month of September. Surveyor asked V16 to view her(V16) September consultant reports and recommendation forms to see if she (V16) requested a reweight for R63. After reviewing her (V16) September 2022 reports V16 stated, I don't see it on the three reports I submitted in the month of September. V16 stated that she (V16) assessed R63 on 10/13/22 for unplanned weight loss and noted BMI (Body Mass Index) at that time was 19.2 which is below the desired BMI range for older adults which is between (23-27). V16 stated that she (V16) attributed R63's weight loss to poor appetite and that he (R63) was barely eating and consistently consuming <50% of meals. V16 stated that functional decline could also have contributed to some of the weight loss. V16 stated that she (V16) had recommended to start oral supplements on 10/13/22 to supplement R63's poor intake and help prevent further weight loss. V16 stated that she (V16) submitted this recommendation to V1 and V2 on 10/13/22. V16 provided a copy of this recommendation to surveyor. V16 stated there was no NARS meeting in the month of October and therefore her (V16) recommendations were not followed up with or discussed as a team. V16 stated that without the use of oral nutrition supplements R63 is at high risk for continued weight loss. Surveyor shared with V16 R63's current weight obtained 11/02/22 of 119.2 pounds and V16 stated that this amount of weight loss was very concerning and indicates another significant weight change. V16 stated R63 meets criteria for malnutrition based on the amount of weight loss, evidence of continued weight loss, low BMI and poor intake. V16 stated that the CNAs are documenting that R63 is consuming between 25-50% of meals. Surveyor asked V16 if she (V16) has ever conducted meal rounds observations with R63 or seen him (R63) eat a meal since R63 has been at the facility and V16 replied, no, I haven't done a meal round observation since he's been there and now that he's lost weight it would be appropriate to consider. Surveyor asked V16 if she (V16) has every met with R63 to review his (R63)'s food preferences and V16 stated, no because that is V8's responsibility. V16 stated that if R63 had received the nutrition supplement she (V16) had recommended it would have helped to prevent some of the weight loss which has occurred. Surveyor discussed R63's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V16 stated there is no separate weight binder. On 11/02/22 at 3:11 PM, V2 (Director of Nursing) stated that V16 sends her (V16)'s nutrition recommendations via email and then V2 prints them off and gives them to the nurses to follow through on by calling the physician. V2 stated that the order is carried out right away and that the physicians follow V16's recommendations because V16 is the nutrition expert. V2 stated that once the physician approves the recommendation nursing enters it into the EMR and the paper MAR. V2 stated that all weights are completed by the restorative department including initials, reweights, readmissions, weekly and daily if ordered. On 11/02/22 at 3:30 PM, V10 (Restorative Director) stated that all weights are entered into EMR system and that the weight sheet forms used by the restorative aides to enter the weights on are shredded as soon as they are entered into the EMR system and because of this V10 stated there are no weight data sheets available to review. V10 stated none of the residents are on daily weights right now and that if any of the residents had orders for daily weights, they would be entered into the EMR system, and that there is no separate weight binder(s). On 11/03/22 at 10:21 AM, V2 stated that she (V2) was aware of R63's weight loss based on 119.2-pound weight obtained on 11/02/22. V2 stated that restorative reported this to nursing who will then contact V8 and V16 for recommendations. V2 stated it is the nurse's duty to call the doctor and that the nurse will then write a progress note in the EMR indicating that the doctor was notified about the weight loss. On 11/03/22 at 1:46 PM, surveyor spoke with V35 (Attending Physician) over the phone. V35 stated that he was not aware that R63 had lost weight and that he (V35) has not received a recent phone call and does not recall being notified of any weight loss from 08/2022-09/2022. V35 stated, maybe he is not eating well. V35 stated that R63 is probably losing weight due to a combination of dementia, acute [CONDITION(S)] requiring a drainage tube and poor intake. V35 stated R63 does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor told V35 R63's current weight of 119.2 pounds compared to initial weight of 148 pounds upon initial admission in July 2022. V35 stated due to the weight loss identified a nutritional replacement with use of oral supplement would be recommended, calorie counts to see what R63 is actually eating and that R63 may need a tube feeding placement due to having lost so much weight. V35 stated that he (V35) was not aware that the Registered Dietitian had made a recommendation to start oral supplements last month. V35 stated that since there is no order for an oral supplement in the EMR system then either the facility did not call him (V35) or the call was not relayed however V35 stated that the nurse typically would enter a progress note into the EMR to indicate that the physician was called, and message was left with a call back requested. V35 stated that he (V35) does not see a nursing progress note indicating he (V35) was called and stated, there is your answer. V35 stated resident does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V35 stated that there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V35 stated that if the daily weights were being done at the facility R63's weight loss would have been identified earlier. On 11/03/22 at 2:05 PM, R63 stated that he (R63) does not know why he (R63) he is losing weight. R63 stated, I can feel it, look at my arms they are skinny. R63 stated that he (R63) has not been offered a supplement since he's been at the facility, but he stated, I'd take it if they gave it to me. On 11/04/22 at 8:22 AM, via email correspondence surveyor requested percentage meal intake documentation for all meals for R63 from 8/1/22 - present. V1 (Administrator) responded via email at 10:56 AM that, Unfortunately, there was no in-take recorded for (R63). R63 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R63 MDS (Minimum Data Set) dated 08/01/22 BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognition. R63's Active Orders printed on 11/01/22 documents in part, daily weights (CHF/Abnormal Weight Loss) once a day at 9:00 AM ordered 07/27/22, diet: NAS, low cholesterol/low fat, regular with thin liquids three time a day ordered 10/03/22. R63's care plan dated 08/02/22 documents in part, R63 is at high (risk) for malnutrition related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R63's Dietary progress note dated 08/08/22 at 01:12 PM completed by V16 (Registered Dietitian) documents in part, PO intake are between 25-50% for most meals, requires extensive assistance from staff during meals, open area to sacrum, BMI 22.7 is below normal weight range for advanced age, weight gain/stability is desirable for resident, will monitor weight trends. Weight used to complete this assessment was 149.6 pounds. R63's Dietary progress note dated 10/13/22 at 05:02 PM completed by V16 documents in part, weight (10/8) 127.8 pounds, BMI 19.4 is below normal weight range for advanced age, weight is stable from last month follows a period of unplanned/significant weight loss possibly related to functional declines, weight gain is desired for resident related to high risk for malnutrition and recommend adding liquid oral supplement 4 ounces twice a day to support weight gain, will monitor weight trends. Facility document titled, Weight Variance Report 05/03/22-11/03/22 for R63 documents weight as follows: (07/27/22 at 10:24 AM weight 148.4, BMI 22.56), (08/03/22 at 12:28 PM weight 149, BMI 22.65), (08/08/22 at 2:49 AM weight 149.6, BMI 22.74), (08/17/22 at 12:29 PM weight 148.2, BMI 22.53), (09/02/22 at 10:43 AM weight 126.2, BMI 19.19, -22 weight loss, -14.8% weight change in 16 days), (10/03/22 at 9:45 AM weight 127.8, BMI 19.43), (10/08/22 at 10:34 AM weight 127.9, BMI 19.43), (11/2/22 at 10:44 AM weight 119.2, BMI 18.12, -8 pound loss, -6.7% change in 25 days). V16 provided document titled, Dietary Recommendations for Physician Approval dated 10/13/22 documents in part, recommend adding (commercial liquid oral supplement) 4 ounces twice a day to support weight gain for R63. The form is not signed by R63's physician (V35). Facility document titled, Medications Flowsheet from 10/1/22-10/31/22 for R63 documents daily weight (CHF/Abnormal Weight Loss) once a day dated 07/27/22 with no entry weights documented for the month of October 2022. Facility job description titled, Consultant Dietitian Job Description undated, documents in part, providing clinical nutrition expertise on a consultation basis including nutrition assessment, maintain compliance with state and federal regulations, provide nutrition assessment not limited to significant changes, weight changes, and submit a written report to facility after each visit: directly to the administrator and the Dietary Manager and Director of Nursing for specific actions to be taken. Facility job description titled, Licensed Practical Nurse and Registered Nurse dated 10/11/2019 documents in part, receive and transcribe telephone order from physicians and record on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Facility policy titled, Weight Assessment and Intervention dated August 2008 documents in part, the nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss, weights will be recorded in the clinical record of the resident, any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation, if weight is verified and triggers a significant weight change the physician will be notified, negative trends will be assessed and addressed by the Dietitian, significant weight changes are defined as: more or less than 5% within 30 days, 7.5% or less within 90 days, and more or less than 10% within 6 months, liquid nutritional supplements may be considered if resident calorie intake remains inadequate to stabilize or increase weight, the resident's physician and resident's family/responsible party should be notified of any significant weight loss. Facility policy titled, Weight Maintenance undated documents in part, the facility to monitor the nutritional status of all residents including all significant weight change, an Evaluation of Significant and Insidious Weight Change Observation will be completed anytime there is a noted significant weight fluctuation, in the case of a significant weight change notify the physician and responsible party, the Dietitian will make recommendations and the director of nursing will refer all recommendations to the appropriate department for action and ensure physicians are informed of significant weight fluctuations or concerns regarding a change in the resident's nutritional status.

Based on interviews and record review, the facility failed to provide the necessary monitoring and supervision to ensure a safe environment for a resident and provide a quick response to assess a resident's injury or physical condition to give medical treatment for a resident who experienced an unwitnessed fall. This applies to 1 of 3 residents (R1) reviewed for falls. R1 is a physically and cognitively impaired resident (R1) who was found on the floor in a cold room unresponsive. As a result of this failure R1 became hypothermic (below normal body temperature), which required emergency medical treatment. This was identified as an Immediate Jeopardy situation. The immediate jeopardy began on 1/5/22 and was identified on 1/27/22. The Administrator was notified on 1/27/22. The immediacy was removed on 1/28/22 with the facility's acceptable removal plan. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings include: 1. R1's Face Sheet documents R1's diagnoses including but not limited to: [CONDITION(S)], unspecified, Unspecified dementia without behavioral disturbance, Hypertensive heart and [CONDITION(S)] with heart failure and stage 1 through stage 4 [CONDITION(S)], or unspecified [CONDITION(S)], Unspecified [CONDITION(S)], Pneumothorax, unspecified, Acute respiratory failure with [CONDITION(S)], Non-rheumatic tricuspid (valve) insufficiency, Hepatic failure, unspecified without coma, Dependence on supplemental oxygen, Venous insufficiency (chronic) (peripheral), Cognitive communication deficit, Weakness, Chronic diastolic (congestive) heart failure, Personal history of malignant neoplasm of breast (History of), Respiratory failure, unspecified with hypercapnia. R1's MDS (Minimum Data Sheet) dated 12/31/21 shows R1 requires extensive two-person assistance/two or more people with transfers and bed mobility. A care plan dated 1/4/22 documents, R1 as at risk for falling R/T Weakness, Dementia, unsteadiness on feet and Respiratory failure. I fell out of bed December 30, 2021, no injuries. R1's fall prevention intervention approach listed: Keep bed in lowest position with brakes locked; Provide resident with safety device floor mats at bedside. According to nursing progress note dated 1/5/22 12:52 PM, at approximately 8:15 am, it was reported to this writer during morning med pass, by CNA (Certified Nursing Assistant) staff, that R1 was on the floor by the side of bed. Upon entering room, R1 was observed on the floor on the left side of R1's bed. It was also reported that R1's window was opened. Upon assessing R1 for any possible fractures, R1 was noted to be very cold. An attempt was made to check R1's temperature with a digital thermometer. R1's temperature was registering as Low in several body areas. R1 was immediately assisted to bed and wrapped with several warm blankets. At the time BP was 48/43 and pulse was 58 bpm. 911 was called immediately and R1 was transferred to hospital. According to information obtained from local conditions.com which reports local weather conditions, the outside temperature on 1/5/22, from 6:00am to 7:30am was reported between 19.4 degrees Fahrenheit to 23 degrees Fahrenheit. The local hospital's emergency department provider note dated 1/5/22 9:05 AM documented, Per Emergency Medical Services, R1 was hypothermic in route with a blood glucose of 36. Bear [NAME] placed on R1 for significant hypothermia. Emergency Department Provider Note (dated 1/5/22 12:17 PM) documents: R1's admitting diagnosis as altered mental status and endotracheally intubated. 2. The following are interviews conducted with direct care staff members regarding the R1's fall incident of 1/5/22): On 1/11/22 at 3:14 PM, V29 (agency Certified Nursing Assistant/CNA) stated, on 1/5/22, I started work at about 7:10 AM, and when I got to the unit there was no nurse on duty. The night shift nurse left 30 minutes early and there was no nurse covering the first floor. Upon making my rounds, I saw R1 lying on the floor, wearing only an incontinent brief, and R1's window was left open. The temperatures were freezing, and R1 was laying on the floor right next to the open window. R1 was unresponsive, and extremely cold. Normally, R1 can talk, but R1 was unresponsive. R1 was freezing cold, R1 was hypothermic, and I could not get R1 to respond to me. I closed R1's window immediately because it was freezing cold in R1's room. I started calling for help but there was nobody to help me. I started shouting and nobody was on the unit to help me. Finally, I saw V28 (MDS coordinator) and V28 came to help me. V28 assessed R1 and stated that R1 was hypothermic. V28 asked another nurse that came to the floor to call 911 while V28 attempted to take R1's temperature, but R1 was so cold that the thermometer read low. V28 tried several body parts and the thermometer read low every time, that's how cold R1 was. V28 took R1's blood pressure and I think it was 45/43 or something close to that. We covered R1 immediately with as many blankets as we could find. V28 and I placed R1 into bed, and then the ambulance came. I was literally crying because someone from the night shift opened R1's window and left it opened, to the point that R1 was hypothermic. There was nobody providing care or supervision to the residents on the 1st floor, until V28 came to the unit. When I arrived at work, the CN's from the night shift were already gone and so was the night shift nurse, who went home early. R1 had several falls at the facility and R1's bed was high. R1's bed was not in a low position and there was no bed mat on R1's side of the bed. On 1/12/22 at 1:05 PM, V28 (MDS coordinator/LPN) stated, I am the MDS coordinator. The nurse that was scheduled to work on the day 1/5/22 did not come to the shift, they called off and they asked me to work the floor that day. I was working the floor filling in as a floor nurse and I arrived to work on the unit at 8:10 AM. When I arrived to the 1st floor on 1/5/22, there was no nurse on duty. When you arrived to the unit to work the floor, I was notified immediately that R1 was on the floor. The CNA came to me and told me that there is a resident, R1, on the floor. I went to R1's room immediately when I was notified that there is a resident on the floor. I saw R1 laying on the floor, wearing only a diaper, on the left side of the bed, on the side next to the window. I walked into the room and R1 was on the floor, and I touched her, and R1 was very cold, very cold to the touch. R1's room was cold. When I touched R1 and noticed that she was cold, I went to get my blood pressure cuff and the thermometer because of how cold R1 felt. I grabbed the digital thermometer, and R1 was so cold that the thermometer did not read an actual number, it just read low, so I knew that I had a hypothermic resident. R1 felt hypothermic. I attempted to check R1's body temperature on several body parts but the thermometer just read low, and I knew that I had an emergency on my hands. Another nurse came in that nurse was V18(Licensed Practical Nurse), and I asked V18 to call 911. V28 said, While V18 called 911, me and another CNA assisted the resident from the floor to the bed and we wrapped the resident in blankets. R1 was not responsive. R1's blood pressure was extremely low, and her body temperature was extremely low to the point that the thermometer was not able to actually read the temperature, so I knew that I have an emergency on my hands because I had a hypothermic resident. So V29 (agency CNA) and myself helped the resident from the floor into the bed and we wrapped her in as many blankets as I could find. The ambulance came because we called them right away. I stayed with the resident until the paramedics took the resident. The paramedics arrived very quickly. I did not see the window open, but it was reported to me by the V29 that R1's window was open. I know that R1 was extremely cold, and she was hypothermic because I was not able to get a body temperature from her. V29 found R1 on the floor and with an open window, and V29 reported that to me. R1 was very cold and unresponsive. I did everything I could to help R1 and R1 was sent to the hospital immediately. On 1/13/22 at 10:44 AM, V11 (Nursing Consultant) stated, The outgoing shift nurses and CNAs are supposed to give the incoming staff report. Giving report assures that there is continuity of care and updates the incoming staff about any clinical issues that residents may have and updates the nurse and CNA about any follow ups. If the outgoing shift fails to give report, the oncoming shift will not know what is happening to the residents. Failing to give report to the oncoming shift impedes on the resident's care. When the oncoming shift comes in, they are supposed to make rounds before they receive report. When V24 (Licensed Practical Nurse/LPN) left 30 minutes early on 1/5/22, so V24 failed to provide care and supervise the residents. Because V24 left early on 1/5/22, and failed to supervise R1, and R1 was on the floor. To my knowledge, on 1/5/22 there was no nurse covering the 1st floor, where R1 resided, from 6:30am to 8:10am, so no nurse supervision for about 2 hours. Timecard Report (dated 1/5/22) shows that V24 (LPN) punched out at 6:29am. On 1/13/22 at 7:22 PM V22 (Nurse Practitioner) stated, R1 had a few falls at the facility. R1 rolled out of bed on several occasions. If I was the director of nursing, I would have told them to put R1 closer to the nursing station. I was told that they cannot have any side rails, but R1 needs them. R1 was not in a low bed and R1 needs a low bed. For someone like R1, I would recommend a low bed and a floor mat so that R1 will not get hurt. R1 needed more monitoring. R1's fall could have been avoided if she was supervised more frequently. Since R1 had several falls previously, additional fall preventative measures should have been in place. The window should not be open with these freezing temperatures. The staff should not have opened R1's window and left R1 with an open window with these freezing temperatures to the point that R1 was hypothermic. On 1/25/22 at 10:43 AM, V23 (CNA) stated, I am the night shift CNA. I start work at 11 PM. I get off at 7 AM. I worked on the night of 1/4/22, I started my shift at 11 PM. I was not working on the 1st floor on 1/4/22 into the morning of 1/5/22, but I heard what happened to R1, when I reported for my shift on 1/5/22 at 11 PM. I heard that the resident was on the floor naked and hypothermic. I float around the facility and work different units, so I wasn't R1's permanent CNA, but I knew R1 well. R1 cannot reposition self. R1 was able to talk and was able to express needs prior to the incident. R1 was able to express that R1 was cold. I usually do rounds, and I would check on R1 every 2 hours. R1 was able to answer me if I asked R1 if she was cold. R1 was able to answer my questions, but R1 was bed bound. The expectation is that we round on the residents every two hours. On 1/25/22 at 1:57 PM, V24 (LPN) stated, I am familiar with R1. I worked with R1 maybe once or twice. I was the nurse assigned to R1 on the 7 PM to 7 AM shift on 1/4/22. I left work at 6:30 AM on 1/5/22. My shift ends at 7:30, so I left an hour earlier. I notified the 3rd floor supervisor, V34 (Night supervisor) and the V25 (CNA), I was working with on the 1st floor. I always leave at 6:30 AM when I work at the facility, and I always let someone know that I am leaving. I always notify someone that I am leaving early. On 1/5/22, the CNA I was working with, V25, was keeping an eye on the unit, and if there were any issues, then V25 (CNA) would report it to the night supervisor, V34. R1 was lying in bed with a gown on. The last time I saw R1 was at 6 AM on 1/5/22, and R1's window was closed, and R1 was sleeping in the bed. I saw R1, a total of 3 times during my shift on 1/4/22 to 1/5/22, at the start of my shift, middle of my shift and at 6 AM. During my shift there was a confused resident who was getting out of bed and walking around the hallway, so I had to redirect the resident. I had to walk up and down the hall with the confused resident when I was not able to redirect the resident. During my shift I had to redirect that confused resident about 6 times because of major confusion. V25 (CNA) was also helping me out with that resident as well by providing redirection and close monitoring. On 1/25/22 at 12:14 PM V33 (Staffing Coordinator) stated, Typically there is one scheduled CNA on the first floor. If there are 7 or more residents on the 1st floor and at least 5 of them are total care than we schedule two CNAs. On 1/4/22, I scheduled two CNAs for the first floor, so the census was roughly about 7 to 10 residents, that's why I scheduled two CNAs for that unit. On 1/4/22 there were two agency CNAs who called off for the 11 PM-7 AM shift. As a result of the call offs, V23 (CNA) was pulled to work on the 3rd floor. On the night shift, 11 PM to 7 AM there was only one CNA working on the first floor. So V25 (CNA) was the only CNA who was working on the first floor. There was one nurse and one CNA working on the first floor 11 PM to 7 AM on 1/4/22. Nurses work a 12-hour shift, and they are not supposed to leave early. The earliest they can punch out is 5 to 7 minutes before their shift is over. If a CNA is present on the floor than the nurse can punch out at the end of her shift and write down the report for the incoming nurse on paper. But nurses are not allowed to leave 30 minutes prior to the end of a scheduled shift without letting a supervisor know. Sometimes we won't know that someone left early until the payroll is being done and the actual punches are being looked at. Nobody can leave 30 minutes prior to the end of their shift without prior authorization. When a CNA is on the unit or another nurse than the nurse can leave 7 to 5 minutes before the end of their shift, but not 30 minutes. On 1/25/22 at 12:50 PM, V25 (agency CNA) stated, I saw R1 the last time during my rounds at 6:45 AM on 1/5/22, and during my rounds R1 was lying in bed. There were two residents in R1's room. The window was closed. I did not open the window. V24 (LPN), the nurse that was working with R1, left early, around 6:30 AM. V24 told me that V24 was leaving early. When I leave the facility, I punch out on my phone because I work for an agency. I was the only CNA for the 1st floor on the night of 1/4/22 11 PM to 7 AM shift. There were approximately 30 residents on the first floor on the night shift 11 PM to 7 AM on 1/4/22. From the 30 residents, approximately 10 residents were total care residents who were bed bound. I rounded on R1 hourly. There was another resident that needed my attention because that resident was getting up out of bed every 15 minutes. That resident was coming out of the room and was confused. I never took care of R1 prior to the date of 1/4/22. When I started my shift on 1/4/22, I never received report from a CNA or the nurse. All I was told was to go make rounds and make sure that everyone was ok, but I never received any information about the residents and the care they required. I did not know any of the residents when I started my shift. When I started my shift on 1/4/22 at 11 PM all the CNAs from the 3 to 11 PM shift were gone and no report was given to me. I did not know R1 and never received report from the nurse or the CNA on how to properly care for R1. I was stuck with one resident most of the night because that resident basically needed a 1 to 1 supervision because that resident was confused so I was occupied most of the night with that resident. Timecard Report (dated 1/5/22) shows that V25 (Certified Nursing Assistant) punched out at 6:56 AM. On 1/25/22 at 3:24 PM, V22 (Nurse Practitioner) stated, It would take a couple of hours for R1 to lay next to an open window, to become hypothermic. With the temperatures of 23 to 19.4 degrees outside and with the window being open, it would take several hours for R1 to become hypothermic. Another advancing factor that might contribute to the hypothermia, is that fact that R1 was not very mobile. R1 was bed bound, so it would be a contributing factor for hypothermia as well. By several hours, I mean it would take R1 lying next to an open window for about 2 to 3 hours to become hypothermic. I'm not sure, I think it would take about 2 to 3 hours. I am trying to look it up. There were 32 residents on the unit at the time and only one nurse and one CNA. Both the CNA and the nurse stated that there was one resident who was very confused and disoriented. That resident occupied most of V24 and V25's time during that shift. Daily Census Report (dated 1/4/22) documents there were 32 residing on the 1st floor unit. The surveyor confirmed via observations, record reviews and interviews the facility did the following to remove the immediacy: -The facility has contracted with two new staffing agencies to ensure adequate staff is scheduled. Staffing agency S was in place prior to 2022. Staffing Agency CH was contracted on 1/20/2022, Staffing Agency XX will be contracted 1/28/22. -The DON and Nursing scheduler will check and ensure adequate staff on each floor at the start of the shift and ensure all nursing staff complete entire shift. Initiated on 1/27/22. DON and scheduler are two separate positions. -Scheduler will call all nursing staff to cover any shortages. Initiated 1/27/22, DON will call facility at the start of each nursing shift and will verify that all nursing staff is all present. If not present, the scheduler will call nursing staff to cover any shortages. -Nursing Department Heads will take rotation to cover any nursing shortages. Initiated 1/27/22, nursing department heads will be alerted by scheduler if there is a need to cover a nursing shortage. -All Nursing Department Heads, Nursing Scheduler, and Human Resources will be in serviced on the facility providing adequate staff to render care, supervise and monitor vulnerable residents. Initiated 1/27/22 by Facility Administrator. -A written Nursing Communication Binder will be completed by each nurse by the end of their shift with pertinent information on the residents. Initiated on 1/27/22. Nursing Communication Binder will be located on each nursing station/floor. -The off going nurse will do a walking round with the oncoming nurse to ensure a visual oversight of each resident and verbally communicate pertinent information to provide continuity of resident care. -The staff nurse will give a verbal report to oncoming CNAs to ensure all pertinent information regarding the resident care is communicated. CNA's will round on their resident assignment immediately at the beginning of their shift to ensure a visual oversight. -All staff nurses will be in serviced on; Written communication binder, walking rounds with the oncoming nurse and giving a verbal report to the oncoming CNA. Initiated 1/27/22 by Director of Nursing -All CNA's will be in serviced on receiving a verbal report from the nurse when their shift begins and making rounds immediately after to ensure a visual oversight of their residents on their assignment. Initiated 1/27/22 by Director of Nursing and RN Consultant. -The Maintenance Staff checked all resident rooms to ensure the temperatures are within a comfortable range and the heating system is working properly. This was initiated on 1/28/22. -All staff will be in serviced on the facility's Cold Weather Policy and the procedures to maintain a safe and comfortable environment during the winter season. Initiated 1/28/22 by Maintenance Director and RN Consultant. The completion date for all of the above was 2/1/22.

Based on interview and record review, the facility failed to supervise and monitor a severely psychologically impaired resident(R1). This failure affects one of three residents (R1), reviewed for accidents and supervision in a total sample of three residents. This failure allowed R1 to obtain sharp objects and use those objects to cut herself in the abdomen. R1 was able to seriously injury herself twice, on two different occasions, while she was in the facility. Findings include: R1 is a [AGE] year old female former resident of the facility. Her [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE]. R1 discharged to the hospital on [DATE]. A brief review of R1's mental status, (BIMS), notes that R1 is cognitively intact, has depression, and behaviors. These behaviors include: verbal behaviors, such as threatening, screaming, cursing at others, and physical behaviors such as hitting or scratching herself. R1 also is a wanderer. Care area assessment dated [DATE], notes that R1 had a relapse of an underlying mental illness, psychiatric disorder and neurological disease. The care area also notes that she has had thoughts that she would be better off dead or hurting herself in some way. She is restless and verbalized self-harm. She exhibits inappropriate, unsafe behavior related to [DIAGNOSES REDACTED]. Suicidal Risk Observation dated 10/13/2020, notes she has a history and current episode of harming herself. She cut herself with a sharp object. She has attempted suicide. Her most recent attempt was swallowing batteries and cutting herself several times. She has had thoughts about suicide all the time. Her plan to commit suicide was by cutting herself and she is very likely to act on these thoughts. She is high risk, very likely to act on her thoughts, and there is nothing preventing her from committing suicide. Review of R1's progress notes details the following: On 10/02/2020, R1 attempted to exit the facility stating that she can't stay here because she's going to harm herself like she did previously or by ingesting something. She stated, I need to be locked down. On 10/10/2020, R1 went down to the basement, got out of the basement door. She was redirected and after several attempts she sat in the dining area in the basement. She later proceeded upstairs in the elevator. She returned to her room and was compliant with her medications. Staff will continue to have frequent rounding and monitor resident's safety. On 10/13/2020, staff informed that R1 was outside of the facility. V4 (Social Services Director) met with R1 to enquire about her concerns. R1 stated, I just want to kill myself. I don't want to be here. If I spent the night in the facility, you will not see me alive. V4 asked her if she had a plan. She refused to respond stating, I do and it is none of your business. She refused to answer further questions. She was restless and agitated without provocation. V4 counseled her and she was not receptive to counsel. She tried to escape through the back door four time within two hours. She continued to state that she did not want to be in the facility and that she wanted to go to the hospital. V4 informed R1 that the facility cannot hold her against her will. R1 was petitioned to a local hospital for psychological evaluation. R1 was given involuntary discharge and that she has a right to call for hearing with the information on the form. On 10/14/2020, R1 made several attempts throughout the day to harm herself and others stating I am going to f*** you all. R1 was petitioned out to a local hospital after calling her primary care physician. She was aggressive, restless, with mood behavior. She returned from the hospital the same day. On 10/15/2020, R1 complained of moments of restless/anxiety. On 10/16/2020, R1 was sent out 911 due to self-inflicted wound to her lower abdomen. She cut herself with a soda can that she cut in half. She refused to let the nurse access the area or take vital signs. V8 (Nurse) and the nursing assistant stayed with her until help arrived. R1 became combative with V8; kicking and swearing at the staff. The ambulance and police departments strapped her to the stretcher for follow up at the nearest hospital. R1 was in her room working on a puzzle when the nurse administered her night medications around 11:00PM. No signs of distress or anxiety was noted. The nursing assistant informed V8 of the incident. R1 was petitioned out of the facility to the nearest hospital. On 10/17/2020, V8 followed up with the hospital. R1 was admitted medically for laceration to her abdomen. On 12/12/2020, R1 is a readmission on the day shift. Her vitals are stable. But, she declined a full body assessment. On 12/13/2020, R1 pulled the call light and told V7 (Nursing Assistant) that she needed to be sent to the hospital. V6 (Nurse) went to her room to evaluate her situation because V6 and the assistant had rounded and R1 was lying quietly in bed. She did not have any prior concerns. V6 found R1 bleeding from her abdomen with a piece of glass in her hands. V6 compressed the site with towels to control the bleeding. V6 provided care until 911 arrive. R1 told the ambulance that I could not help myself. R1 refused V6 to take vitals on her. All responsible parties contacted. R1 was admitted for stab wound and psych evaluation. Facility report dated 12/13/2020, documents the incident. V6 asked R1 why she caused trauma to herself. R1 stated that I don't want to be here because you don't know how to care for me. Also, I stated that she needs a psychiatric facility. Interviews conducted 1/24/2021 to 1/25/2021, document the following: On 1/24/2021, at 11:28AM, V1 (Administrator) stated, R1 is not allowed back in the facility because we cannot care for her. I am afraid that one day she will be dead. This setting was not appropriate. I believe that she told me that she came from psychological facility. R1 was a referral. We saw that she had some issues. I thought to give her another chance. But, she has a mental illness that takes over everything else. I was giving her another chance after she had left the facility and then returned. R1 is a danger to herself and others. She is not safe by herself. My understanding is that R1 found some a sharp piece of plastic and she took the plastic and cut herself in the stomach. When staff came back to the room, R1 removed her sheets and showed that she was bleeding from the abdomen. She was on fifteen minutes checks and was ambulatory. She was not allowed to have sharp objects. I expect my staff to follow orders come up with orders. We do not do one-to-one monitoring, but fifteen minute checks. A one to one was attempted when she first hurt herself. She did not like that because she cursed us out and asked why staff was watching her. When R1 returned to the facility, she was only in the facility for 36 hours before I got a call. Staff called and told me that she had cut herself again and left the facility. My staff should have checked her room to make sure there was nothing broken and I should have attempted to put her on one-to-one supervision. On 1/24/2021, at 12:08PM, V3 (Nursing Assistant) stated, she likes one on one time. She required a lot of supervision because she attempted suicide before she came to the facility. She was not supposed to have sharp instruments. Staff is supposed to have more eyes on her because of her behaviors. She would turn into a baby when there was something in our policies that she could not do. If staff saw her with something then they would check her room. We would not go into her room, with her permission, and search preemptively. R1 knows how to do stuff to get her way. On 1/24/2021, at 12:30PM, V4 stated, when was here she has manipulative behaviors. She has exit seeking, self-harm, suicidal behaviors. We educate and console them on their behaviors. Most of the time, the incidents were at night, when she knew there was no one around. The first time she went to another room and got a can from the garbage. Before she came to the facility, my plan was to ensure that she was safe and free from harm. I was told that she did not want anyone around her. R1 is special because during the day she is fine. Several occasions the state guardian stated that R1 did not want to be in the facility. On 1/24/2021, at 8:51PM, V6 stated, when I came in for work, I noticed that R1 returned. I was passing my evening medications. She was coloring. She pulled the light and the aide went to her. She pulled the light again and she told the aide that she needed to go to the hospital. When I went there I saw some blood on her sheet. I called my colleagues and I noticed that she cut herself in her abdomen. I put some sheets on her and told her to apply pressure. She had a previous incident in our facility, we were watching her closely. No, she is not allowed to have sharp objects. I cannot answer how she got the sharp object. Yes, she is a danger to herself and others. I was not in serviced on R1. We rarely have residents like R1. When I was in the room, I saw her coloring. R1 did not want people too close to her. If not she would flip out. I just used my eyes to scan the room. I did not ask for her permission to check her person or her bed. As a nurse, I would have suggested a one on one to watch her throughout the night. She cut herself with glass in her room. On 1/24/2021, at 9:02PM, V7 (Nursing Assistant) stated, I was at the front desk talking to the nurse. She pulled the call light. I went in her room and R1 told me that she wanted to go to the hospital. I informed the nurse and the nurse went into the room and noticed that she had harmed herself. When I got to work, the other nursing assistant told me that she could not have anything sharp, batteries, or anything that could harm her in the room. Every fifteen minutes I had to check the resident. I was looking what she was doing. Majority of the time she was sleeping. I never asked her for permission to see what she had. I am not trained to work with psych residents. I just made sure she was alright. When she first got there I was informed to check her room to make sure she was ok. I would say she is a danger to herself and others. I asked her if she needed anything, she blew up. I just kept my distance. She is a one on one. I am the only certified assistant on the first floor at night. Administration knows this. When I went in there, she had a picture on her wall. R1 broke the picture on the wall and used that glass to cut herself. The facility knew that she was not supposed to have sharp objects. There could have been more staff down there with me, since I was the only certified assistant down there by myself to limit harm or risk to the resident. On 1/25/2021, at 1:46PM, V8 (Nurse) stated, R1 is a true psych patient. I was involved with the first incident of her cutting herself. She is a danger to herself and others. I was afraid of her. The CNA grabbed the can from R1 because she was getting ready to cut herself or us. I believe that she got the can from the garbage and cut herself. She was not allowed to have sharp objects. Administration needs to evaluate these residents. We have no knowledge of these residents until they come to the facility. She likes one on one attention. We are not equipped for that. I tried to keep her close to the nurse's station. I am not going to put myself in harm's way. I do not know what her state of mind is. Looking back I could have been more aware of what she was bringing in the facility. We try to keep clutter free and check on them frequently. I do not think she should have been in our facility. She knew the codes to the doors and if she wanted to leave she could. In my opinion, she should have never been in this facility. R1's care plan documents the following: R1 has a history of causing self-harm to herself with pencils and other sharp objects; presents with restless behaviors; with mental disorders with moderate to extreme social isolation (when upset), disorganized behavior, agitation, compulsive behavior, excitability, hostility, repetitive movements, and self-harm; at risk for elopement attempts evidenced by trying to leave the building to smoke without notifying staff; has a [DIAGNOSES REDACTED].) due to her attempting to harm herself. R1's care plan interventions include the following: R1 will make safe decisions with verbal cueing and assistance from staff as evidenced by no injuries or clinical decline through next review; provide daily monitoring for safety and support; when exhibiting poor judgement offer advice and guidance; observe for injuries or clinical decline; staff will encourage R1 to attend and participate in one to one intervention; staff will encourage her to report all suicidal ideation; staff will provided one to one counseling when needed; when she is experiencing suicidal ideation staff will talk to R1 about reasons why they would not attempt suicide; staff will continue to encourage resident to voice concerns to staff at all times; provided one to ones when needed; staff will anticipate resident's needs; staff will encourage resident to voice concerns all of the time; resident will have reduced behavioral episodes; allow resident to express feelings and desires.

Based on interview and record review the facility failed to provide a thorough and accurate assessment of a resident injury post fall for 1 of 4 residents (R1) reviewed for falls. This failure resulted in R1 sustaining an open fracture of right femur, with 6 inches of protruding right proximal femur through the lateral soft tissue ulceration, requiring surgical repair, potential for shock, excruciating pain and blood loss due to significant delay in treatment. This was identified as Immediate Jeopardy (IJ) situation on 10/13/2020. The Immediate Jeopardy (IJ) began on 9-29-2020. The Administrator was notified of the IJ on 10/13/20. The IJ was removed on 10/19/20. The administrator developed a policy, in-serviced all staff on the policy and implemented the policy. Findings include: On 10/5/20, R1's medical record and face Sheet showed that R1 was originally admitted to the facility on [DATE] and latest admission was 9/9/20, with [DIAGNOSES REDACTED]. R1 is a [AGE] year old quadriplegic with severe contractures. R1 was sent to local hospital seven and half hours post fall incident. R1's hospital record showed that R1 had Type 3 open fracture of shaft of right femur unspecified fracture, with 5-6 inches of protruding right proximal femur through the lateral soft tissue ulceration. R1 was hospitalized , had a surgery Femoral Osteotomy to allow closure. R1 received three units of packed red blood cells on 9/29/20 at the hospital. On 10/05/20, R1's medical record progress note dated 9/29/20 timed 5:50am, V15 RN (Registered Nurse) documented in part that R1 was observed on the floor next to bed on his right side at 5:30am. V15 documented that R1 was assisted back into the bed by two staff members with the use of mechanical lift device. V15 documented that R1 had ROM (Range of Motion) times four, no rotation /deformity /shortening noted. R1's medical record event report full body assessment V15 documented that there was no injury. V15 documented No under musculoskeletal normality or consistent with pre fall alignment observation. On 10/5/20, review of R1's medical record, progress note dated 9/29/20, both V5 (wound care Nurse) and V9 RN (Registered Nurse) did not document an assessment post fall. No event charting noted. On 10/05/20 at 12:35pm,V5 (Wound Treatment Nurse) stated on 9/29/20 when she tried to perform the wound care for R1, she noted the bed lining was saturated with blood in addition to the wound dressing which was also covered in blood to the sheets and clots of blood. V5 stated R1 was profusely bleeding from the right ischium area. V5 further stated I called the nurse in charge (referring to V9) at the time that R1 needed to be transferred to the hospital. V5 could not present any documentation of what was observed or assessed. V5 explained that she did not document the observation or assessment in R1's chart. On 10/05/20 at 1:40pm, during interview with V9 RN (Registered Nurse), V9 stated R1 was sent to the hospital for evaluation post fall incident. V9 explained that R1 fell during the night shift and when we knew something was very wrong we sent R1 to the hospital. When the surveyor asked what was wrong, V9 stated the treatment nurse (referring to V5) went to do (referring to wound care) R1's treatment, there was bleeding and red drainage from the wound site on the right hip so R1 was sent out to the hospital. When the surveyor asked V9 about his assessment of R1 site of injury, V9 replied I did not see the site like I wrote in my note it was the wound care nurse that informed me that there was heavy bleeding at the wound site. V9 stated falls are documented under events in the resident record but in this case no facility event, incident accident form was created because the fall happened on the night shift. V9 stated that he does not normally work on the floor because he is the facility [MEDICAL CONDITION] nurse. On 10/07/20 at 11:12am, telephone interview with V18 NP (Nurse Practitioner) conducted, V18 stated the nurse (Referring to V15) called stating that R1 had a fall that was unremarkable with no head trauma or injury. V18 explained that in the morning of the fall another nurse called that there was a prominent injury on (R1)'s hip and that was what prompted the sending of R1 to the hospital. When the surveyor asked V18 as to the description of the injury, V18 stated it was described that there was a deformity in the wound and the pressure ulcer was worse in condition than before. On 10/8/20 at 10:52am, V20 CNA (Certified Nurse's Aide) stated she was the CNA on duty on 9/29/20 with R1. V20 stated in part that at 4:00am she went to change R1 and then she had to go and attend to another resident so she left the room and about 10 to 15 minutes later when she returned back to R1's room and could not find R1 in bed. V20 stated after looking around for R1, R1 was noted on the floor in a corner near his bed. V20 stated she did not know how R1 got on the floor. V20 stated she called the nurse (identified as V15). V20 stated another CNA was called to help in assisting R1 back to bed because both she and V15 could not put R1 back to bed. V20 stated the dressing to R1's wound site was soaked and V15 changed the dressing. V20 added that there was a big opening on R1's butt. When the surveyor asked V20 how often rounds are made, V20 stated she makes rounds during the shift but could not say how often because all the residents are usually sleeping at night. V20 explained that the residents don't need anything and they don't call for nothing so she does not need to disturb them. On 10/8/20 at 2:40pm, interview conducted over the telephone with V15. Surveyor asked V15 what happened to R1 on 9/29/20. V15 stated, V20 CNA (Certified Nurse's Aide) informed her that R1 was on the floor in the room. V15 stated V20 had been in the room with R1 when another resident tried to elope so V20 went out looking for the resident. V20 came back stating the resident had gone down the street. V15 stated she was on the phone with the police when V20 called her to inform her that R1 was found on the floor. V15 stated R1 did not hit his head because he was noted on the floor holding on to the side of the bed. V15 stated (I) and the CNA (Referring to V20) tried to get R1 up into the bed and they could not do it, so she called another CNA for help to get him into the bed. V15 stated at this time the police came to the facility, so she went and attended to the police. V15 stated it seems R1 hit his right hip on the floor when he fell . When the surveyor asked V15 whether there was any injury to the right hip, V15 stated when she went back to put the dressing on R1's hip, the right hip was not injured because he already had sores on it. V15 stated I just put another dressing because it was bleeding but (R1) bleeds anyway. It's an unstageable ulcer that was there before and you can see the bone. V15 stated she changed the dressing because it was nasty. V15 stated she could not remember the name of the resident eloping and could not remember the name of the CNA's that worked with her because that was her first day of working on the floor. V15 stated because she was just out of orientation. V15 stated she does not know the facility procedure for falls other than to call the physician and the family. V15 explained she had never been in that kind of situation before. Review of R1's Physician order [REDACTED]. Review of R1's MDS (Minimum Data Set) facility tool in assessing residents dated 5/20/20 under Section G Functional Status for ADL (Activity of Daily Living) coded R1 3/3 for transfer showing that R1 needed extensive assistance with two + persons physical assistance, 3/2 for dressing and 3/2 for personal hygiene showing that R1 needed extensive assistance with one+ person physical assistance. R1 was coded has having a BIMS (Brief Interview of Mental Status) of 07 (seven). Review of R1's MDS (Minimum Data Set) facility tool in assessing residents dated 7/10/20 under Section G Functional Status for ADL (Activity of Daily Living) coded R1 3/3 for transfer, dressing and personal hygiene showing that R1 needed extensive assistance with two + persons physical assistance. R1 was coded has having a BIMS (Brief Interview of Mental Status) of 05 (five). On 10/13/20 at 11:00am, surveyor presented R1's emergency room fracture picture to V18 (NP), V18 explained that from the last interview with the surveyor, V18 repeated I was not here (referring to the facility), I was going by what was reported to me. V18 explained that the nurse who actually did the assessment later mentioned that there was a deformity to the wound that was why I ordered for (R1) to be sent out. V18 stated by the time he got to the facility R1 was already on the EMT Cart on his way to the hospital so he was not able to examine the site physically. When the surveyor showed V18 the emergency room picture of the deformity, V18 added, looking at this picture it is definitely a fracture. At 12:50pm, when the surveyor asked what will be V18's expectation concerning the nursing services that should be rendered to R1 post fall, V18 replied it will be for the nurse to have done a comprehensive assessment, full body exam head to toe, reporting the injury instead of saying R1 is okay when in actuality R1 was not. V18 added, and send the resident to the hospital. On 10/05/20 and 10/06/20, the facility was unable to present any thorough fall risk assessment, incident and accident report created, or an individualized plan of care that will meet R1's needs. No follow up with R1's root cause analysis of the fall, no pain assessment form created and no neuro checks documentation can be presented. Review of R1's hospital medical record showed that R1 arrived at the emergency room moaning in pain and had -6 inches protruding RT (Right) proximal femur through lateral soft tissue ulceration. Concerns [MEDICAL CONDITION] with WBC 18. Under R1's attending attestation statement dated 9/29/20 timed 2:19pm, the physician statement includes but not limited to physician documenting that I saw and physically examined (R1) of risk level high related to Threat to life or Bodily Function. R1's hospital record showed that R1 had blood transfusion on 9/9/20 before the fall incident. R1's fall risk assessment dated [DATE] showed that R1 scored 11.0 with a level recorded as level high risk. Braden scale score of 9.0 with a level recorded as severe risk for falls. On 10/06/20 at 9:09am, V2 presented Incident Packet Direction Sheet with no nurse signature stating this is what I found from yesterday but there was no nurse signature. V2 stated, V15 did not complete any incident accident report, she was due to come back and complete it. V2 stated V15 called off and has been taken off schedule at this time. We are waiting for the nurse (referring to V15) to come back and sign the form. V2 acknowledged that V15 did not perform a through and accurate assessment at the time of fall and both V5 and V9 should have documented in detail assessment done before sending R1 to the hospital. The facility Accident/Incident Management Meeting IDT (Interdisciplinary Team) form presented documents that Resident noted on the floor upon entrance of CNA. Seen by wound care, red drainage noted, MD notified and sent out for medical evaluation. R1's medical record progress note dated 9/29/20 timed 11:42am, showed that R1 was not sent to the hospital until after approximately seven and half hours post fall when V5 discovered that R1 was bleeding profusely from injury sustained from the fall incident. This resulted in delay in R1 being identified with a serious injury and receiving emergency care to repair a right femur fracture. On 10/ 13/20 3:55pm, when the surveyor asked V2 about the facility expectation of staff when a resident falls. V2 replied that they are to assess the resident accurately, thoroughly and document in the Matrix. V3 who was present at the time stated they should document in details in the progress note their assessment, fill out the pain assessessment form. V2 then added they should call the physician giving accurate and precise description of what was observed. On 10/13/20, the facility is unable to present any documentation of any resident eloping as indicated by V15. V2 and V3 stated there was no record of any resident that eloped. On 10/28/20 at 10:25am, during interview with V31 (Physician), V31 stated she could not remember R1. When the surveyor asked V31 about what will be her expectation in regards to resident who had a un-witness fall. V31 stated an assessment should be made before getting them into the bed and if they deem it necessary to send the resident to the hospital then they should. Notifying the physician and send the resident out. V31 stated if they (Nurses) see any injury they should send the resident to the hospital. V31 explained that, if the resident is bleeding from external surface the bleeding should be stopped and then send the resident to the hospital. V31 stated it is not appropriate for a resident who is bleeding to be left bleeding. When the surveyor asked is it appropriate to let a bleeding resident stay in the facility for approximately 71/2 hours before being sent to the hospital, V31 replied it is not appropriate. The facility Job Description for both LPN (Licensed Practical Nurse) and RN (Registered Nurse) essential duties and responsibility includes but not limited to charting nurse's notes in an informative and descriptive manner that reflects complete accident/incident reports and submit to Director as required. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedure. The facility policy titled Falls-clinical Protocol presented with revised date August, 2008 pointed out under assessment and recognition that the Nurse shall assess and document/report that includes but not limited to musculoskeletal function, observing for change in normal range of motion. The facility policy presented titled Evaluating Falls and Their Causes with revised date August, 2008 pointed out in part that the purpose of this policy is to provide guidelines for evaluating a resident after a fall. Guideline procedure after a resident is observed on the floor without witness includes but not limited to evaluating resident for possible injury to extremities. An incident report must be completed for resident falls.

Based on interview and record review the facility failed to conduct a head to toe assessment post fall and failed to provide emergency care in a timely manner to one resident (R1) who sustained an open femur fracture. This failure resulted in R1 being hospitalized with surgical intervention for a Type 3 open femur fracture with blood [MEDICAL CONDITION]. Findings include: R1 is a [AGE] year old quadriplegic with severe contractures. R1 was sent to local hospital seven and half hours post fall incident. R1's hospital record showed that R1 had Type 3 open fracture of shaft of right femur unspecified fracture, with 5-6 inches of protruding right proximal femur through the lateral soft tissue ulceration. R1 was hospitalized and required surgey on 9-30-2020, (Femoral Osteotomy) to allow closure. R1 required a blood transfusion of three units of packed red blood cells. The facility Accident/Incident Management Meeting IDT (Interdisciplinary Team) form presented documents that Resident noted on the floor upon entrance of CNA. Seen by wound care, red drainage noted, MD notified and sent out for medical evaluation. R1's medical record progress note dated 9/29/20 timed 11:42am, showed that R1 was not sent to the hospital until after approximately seven and half hours post fall when V5 discovered that R1 was bleeding profusely from injury sustained from the fall incident. This resulted in delay in R1 being identified with a serious injury and receiving emergency care to repair a right femur fracture. On 10/5/20, the facility was unable to present any documentation that showed they followed up on R1's condition after being sent to the hospital. Review of R1's medical record did not show any documentation showing that the local hospital was contacted to get any follow up information. On 10/05/20 at approximately 4:45pm, V1 (Administrator), V2 DON (Director of Nurse's) and V3 (Nurse Consultant) stated they are not aware of R1's fracture. V2 stated the nurses are supposed to follow up on resident's health condition upon admission to the facility unless they return back to the facility same day. On 10/07/20 at 11:12am, telephone interview with V18 NP (Nurse Practitioner) conducted, V18 stated the nurse (Referring to V15) called stating that R1 had a fall that was unremarkable with no head trauma or injury. V18 explained that in the morning of the fall another nurse called that there was a prominent injury on (R1)'s hip and that was what prompted the sending of R1 to the hospital. When the surveyor asked V18 as to the description of the injury, V18 stated it was described that there was a deformity in the wound and the pressure ulcer was worse in condition than before. On 10/8/20 at 2:40pm, interview conducted over the telephone with V15. Surveyor asked V15 what happened to R1 on 9/29/20. V15 stated V20 CNA (Certified Nurse's Aide) informed her that R1 was on the floor in the room. V15 stated, V20 had been in the room with R1 when another resident tried to elope so V20 went out looking for the resident. V20 came back stating the resident had gone down the street. V15 stated she was on the phone with the police when V20 called her to inform her that R1 was found on the floor. V15 stated R1 did not hit his head because he was noted on the floor holding on to the side of the bed. V15 stated (I) and the CNA (Referring to V20) tried to get R1 up into the bed and they could not do it, so she called another CNA for help to get him into the bed. V15 stated at this time the police came to the facility, so she went and attended to the police. V15 stated it seems R1 hit his right hip on the floor when he fell . When the surveyor asked V15 whether there was any injury to the right hip, V15 stated when she went back to put the dressing on R1's hip, the right hip was not injured because he already had sores on it. V15 stated I just put another dressing on because it was bleeding but he (R1) bleeds anyway. It's an unstageable ulcer that was there before and you can see the bone. V15 stated she changed the dressing because it was nasty. V15 stated she could not remember the name of the resident eloping and could not remember the name of the CNA's that worked with her because that was her first day of working on the floor. V15 stated because she was just out of orientation. V15 stated she does not know the facility procedure for falls other than to call the physician and the family. V15 explained she had never been in that kind of situation before. On 10/13/20 at 11:00am, surveyor presented R1's emergency room fracture picture to V18 (NP). V18 explained that from the last interview with the surveyor, V18 repeated I was not here (referring to the facility), I was going by what was reported to me. V18 explained that the nurse who actually did the assessment later mentioned that there was a deformity to the wound that was why I ordered for (R1) to be sent out. V18 stated by the time he got to the facility R1 was already on the EMT Cart on his way to the hospital so he was not able to examine the site physically. When the surveyor showed V18 the emergency room picture of the deformity, V18 added, looking at this picture it is definitely a fracture. At 12:50pm, surveyor asked what will be V18's expectation concerning the nursing services that should be rendered to R1 post fall, V18 replied it will be for the nurse to have done a comprehensive assessment, full body exam head to toe, reporting the injury instead of saying R1 is okay when in actuality R1 was not. V18 added and send the resident to the hospital. On 10/ 13/20 3:55pm, surveyor asked V2 about the facility expectation of staff when a resident falls. V2 replied that they are to assess the resident accurately, thoroughly and document in the Matrix. V3 who was present at the time stated they should document in details in the progress note their assessment, fill out the pain assess form. V2 then added they should call the physician giving accurate and precise description of what was observed. On 10/28/20 at 10:25am, during interview with V31 (Physician), V31 stated she could not remember R1. When the surveyor asked V31 about what will be her expectation in regards to a resident who had a un-witness fall, V31 stated an assessment should be made before getting them into the bed and if they deem it necessary to send the resident to the hospital then they should. Notifying the physician and send the resident out. V31 stated if they (Nurses) see any injury they should send the resident to the hospital. V31 explained that, if the resident is bleeding from external surface the bleeding should be stopped and then send the resident to the hospital. V31 stated it is not appropriate for a resident who is bleeding to be left bleeding. When the surveyor asked is it appropriate to let a bleeding resident stay in the facility for approximately 7 1/2 hours before being sent to the hospital, V31 replied it is not appropriate. Review of R1's MDS (Minimum Data Set) facility tool in assessing residents dated 7/10/20 under Section G Functional Status for ADL (Activity of Daily Living) coded R1 3/3 for transfer, dressing and personal hygiene showing that R1 needed extensive assistance with two + persons physical assistance. R1 was coded as having a BIMS (Brief Interview of Mental Status) of 05 (five). Review of R1's hospital medical record showed that R1 arrived at the emergency room moaning in pain and had 5-6 inches protruding RT (Right) proximal femur through lateral soft tissue ulceration. Concerns [MEDICAL CONDITION] with WBC 16.4 high reference range 3.5 - 11.0, RBC 2.1 L (low) reference range 4.47 - 5.91, Hemoglobin 6.3 L reference range 13.5 - 17.5g/dl, Hematocrit 22.7 L reference range 41 -53%. Platelet 520 high. Under R1's attending attestation statement dated 9/29/20 timed 2:19pm, the physician statement includes but not limited to physician documenting that I saw and physically examined (R1) of risk level high related to Threat to life or Bodily Function. The facility abuse policy presented with revised date 2/2020 pointed out that neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. The facility Job Description for both LPN (Licensed Practical Nurse) and RN (Registered Nurse) essential duties and responsibility includes but not limited to charting nurse's notes in an informative and descriptive manner that reflects complete accident/incident reports and submit to Director as required. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedure. The facility policy titled Falls-clinical Protocol presented with revised date August, 2008 pointed out under assessment and recognition that the Nurse shall assess and document/report that includes but not limited to musculoskeletal function, observing for change in normal range of motion. The facility policy presented titled Evaluating Falls and Their Causes with revised date August, 2008 pointed out in part that the purpose of this policy is to provide guidelines for evaluating a resident after a fall. Guideline procedure after a resident is observed on the floor without witness includes but not limited to evaluating resident for possible injury to extremities. An incident report must be completed for resident falls.

Based on interview and record review, the facility failed to conduct comprehensive assessment and provide appropriate services related to pain post fall for 1 of 3 residents (R1) who sustained an open femur fracture. This failure resulted in a delay of R1 being identified with a serious injury and services needed to control and manage (R1's) pain until arrival at hospital seven and half hours post fall moaning in pain. Findings include: On 10/5/20, R1's medical record and face Sheet showed that R1 was originally admitted to the facility on [DATE] and latest admission was 9/9/20, with [DIAGNOSES REDACTED]. R1 is a [AGE] year old quadriplegic with severe contractures. R1 had un-witnessed fall on 9/29/20. R1 was sent to local hospital seven and half hours post fall incident. R1's hospital record showed that R1 had Type 3 open fracture of shaft of right femur unspecified fracture, with 5-6 inches of protruding right proximal femur through the lateral soft tissue ulceration. R1 was hospitalized , surgery Femoral Osteotomy to allow closure. R1 required three units of packed red blood cells transfusion on 9/29/20 at the hospital. On 10/05/20 and 10/06/20, the facility was unable to present any thorough fall risk assessment done, incident and accident report, and individualized plan care that will meet R1's needs. No pain assessment documented and no pain management follow up documented after fall incident. Review of R1's MDS (Minimum Data Set) facility tool in assessing residents dated 7/10/20 under Section G Functional Status for ADL (Activity of Daily Living) coded R1 3/3 for transfer, dressing and personal hygiene showing that R1 needed extensive assistance with two + persons physical assistance. R1 was coded has having a BIMS (Brief Interview of Mental Status) of 05 (five). Review of R1's hospital medical record showed that R1 arrived at the emergency room moaning in pain and had 5-6 inches protruding RT (Right) proximal femur through lateral soft tissue ulceration. Concerns [MEDICAL CONDITION] with WBC 16.4 high reference range 3.5 - 11.0, RBC 2.1 L (low) reference range 4.47 - 5.91, Hemoglobin 6.3 L reference range 13.5 - 17.5g/dl, Hematocrit 22.7 L reference range 41 -53%. Platelet 520 high. Under R1's attending attestation statement dated 9/29/20 timed 2:19pm, the physician statement includes but not limited to physician documenting that I saw and physically examined (R1) of risk level high related to Threat to life or Bodily Function. R1's emergency department record showed sequence of time on 9/29/20 that R1's pain was controlled with [MEDICATION NAME] 50mcg/ml, 50mcg given IVP (Intravenous Push) at 1:55pm, 2:07pm, 3:36pm, 5:00pm, 6:41pm, and 10:55pm. This showed that R1 was administered pain medication every hour. On 10/06/20 at 9:09am, V2 stated V15 did not complete any incident accident report. She was due to come back and complete it. V2 stated V15 called off and has been taken off schedule at this time. We are waiting for the nurse (referring to V15) to come back and sign the form. V2 acknowledged that V15 did not perform a through and accurate assessment at the time of fall and both V5 and V9 should have documented in detail assessment done before sending R1 to the hospital. On 10/ 13/20 3:55pm, when the surveyor asked V2 about the facility expectation of staff when a resident falls. V2 replied that they are to assess the resident accurately, thoroughly and document in the Matrix. V3 who was present at the time stated they should document in details in the progress note their assessment, fill out the pain assessment form. V2 then added they should call the physician giving accurate and precise description of what was observed. Review of R1's MAR (Medication Administration Record) for September 2020, did not show any documentation that any pain medication was administered. V15 documented that R1 had no pain. The facility was unable to present any pain assessment form or pain management done post R1's fall incident. The facility Accident/Incident Management Meeting IDT (Interdisciplinary Team) form present documents that Resident noted on the floor upon entrance of CNA. Seen by wound care red drainage noted, MD notified and sent out for medical evaluation. R1's medical record progress note dated 9/29/20 timed 11:42am, showed that R1 was not sent to the hospital until after approximately seven and half hours post fall when V5 discover that R1 was bleeding profusely from injury sustained from the fall incident. This resulted in delay in R1 being identified with a serious injury and receiving emergency care and services needed to control and manage his pain appropriately and repair a right femur leg fracture. The facility policy on Pain Clinical Control presented with revised date August 2008 documented under Assessment and Recognition that this includes but not limited to identifying individuals who have pain or who are at risk for having pain. Under monitoring for pain the policy listed guidelines that includes the staff reassessing the individual pain and consequences of pain at regular intervals. The facility was unable to present any documentation that this guideline was followed. The facility policy titled Falls-clinical Protocol presented with revised date August, 2008 pointed out under assessment and recognition that the Nurse shall assess and document/report that includes but not limited to musculoskeletal function, observing for change in normal range of motion. The facility abuse policy presented with revised date 2/2020 pointed out that neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish.

Based upon observations, interviews, and record review the facility failed to ensure that 3 meals were provided daily, failed to monitor weights, failed to follow dietary recommendations and failed to administer vitamins/supplements as ordered for one of four residents (R2) reviewed for change in condition. These failures resulted in R2's significant weight loss of 12.32% (within 6 weeks), cachexia (muscle wasting), and failure to thrive. Findings include; R2 was admitted to the facility (5/26/20) with [DIAGNOSES REDACTED]. R2's weights (documented under vital signs) are as follows; (7/3/20) 118.8 lbs. This weight is noted to be documented 5.5 weeks after R2 was admitted . There are no additional weights. On 8/3/20 at 3:55pm, surveyor inquired about the facility policy for monitoring weights. V4 (Nurse Consultant) stated For new admissions we get the weight the same day they are admitted , weekly weights for 4 weeks, and then monthly. Surveyor inquired about R2's weights, V4 affirmed that he attempted to get additional weights from the [MEDICAL TREATMENT] center however was unable to obtain them. Dietary Assessments for R2 include the following information; (5/28/20) per hospital, dry weight was 135.5 lbs. (pounds). Recommend discontinuing multivitamin and adding renal vitamin daily, Prostat AWC 30ml (milliliters) BID (twice daily) x 6 weeks for healing open areas. Talked with renal dietician, she told writer that resident is not getting breakfast before she leaves for [MEDICAL TREATMENT]. Recommend; house supplement 1.7 (4 ounces) TID (three times daily), and increasing vitamin D3 to 2,000units daily. Per renal dietician, resident's dry weight is 124.3 lbs (8.27% loss within 2.5 weeks). (7/9/20) Weight 118.8 pounds. BMI (Body Mass Index) 19.77. Recommend; Prostat AWC 30ml BID, house supplement 1.7 (4 ounces) TID due to low BMI/weight. (12.32% within 6 weeks). On 8/4/20 at 1:39pm, surveyor inquired about R2, V10 (Registered Dietician) stated They never got a weight on this person and I'm not sure why. The most recent weight we have on her is on 7/3/20, that's it. They should have weighed her from the get go. She's kinda thin, she's at the lower end of the BMI scale. I talked with the renal dietician and she told me she wasn't getting breakfast before she left for [MEDICAL TREATMENT]. She needs additional protein because she was on [MEDICAL TREATMENT]. I recommended Prostat and they didn't add it so I recommended it again. R2's (June 2020) MAR (Medication Administration Record) affirms Prostat, renal vitamin and house supplement were not prescribed and vitamin D3 dose was not increased as recommended. Vitamin D3 (1,000 unit) was not documented as administered on 6/5, 6/28, and 6/30. R2's (July 2020) MAR indicated [REDACTED]. House supplement was prescribed TID on 7/13/20 however not documented as administered on 7/14 (all 3 entries), 7/16 (all 3 entries), 7/20 (all 3 entries), and 7/21 (1 entry). Nepro Carb Steady (Nutritional Supplement) was ordered TID on 7/20/20 however on 7/20, 7/21, and 7/22 all 3 entries are blank. Vitamin D3 (1,000 unit) was not documented as administered on 7/7, 7/10, 7/14, 7/16, and 7/20. On 8/4/20 at 12:44pm, V11 (Nurse Practitioner) stated For dietary recommendations they normally give me the forms to approve it. It could be me or the PCP (Primary Care Physician) but I normally sign those. I don't recall if they gave one to me for (R2). We did some labs on her and I suggested putting her on supplementation Nepro. Surveyor inquired about potential harm to R2 if dietary recommendations are not followed and/or supplements are not administered as ordered V11 responded I would imagine malnutrition or failure to thrive. R2's (7/23/20) hospital history & physical states; presenting with failure to thrive, cachectic appearing. Diagnosis: [REDACTED]. The Nutrition/Unplanned Weight Loss Protocol (revised August 2008) states; monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. The Physician and staff will monitor the nutritional status, response to interventions and possible complications of such interventions of individuals with impaired nutritional status. The Physician will document relevant medical observations and conclusions regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations where multiple active causes may coexist.

Based upon record review and interview the facility failed to document daily and/or weekly wound assessments as ordered, failed to obtain treatment orders for all wounds, failed to clarify treatment orders (re: affected area), failed to prescribe antibiotic medication for infected wounds, and failed to administer treatments as ordered for one of four residents (R2) reviewed for pressure ulcer. These failures resulted in R2 requiring surgical debridement of devitalized and necrotic tissue on the sacrum and foot. R2 subsequently [MEDICAL CONDITION], dry gangrene of the left foot, and tunneling sacral wound. Findings include; Progress notes affirm that R2 was admitted to the facility on [DATE] with an open area to left heel with discoloration and open area to sacrum however stage, size, exudate and/or description of the wound beds were not documented. On 7/30/20 at 1:51pm, surveyor inquired about R2's wounds V5 (Wound Care Nurse) stated I admitted her to the facility. She had a necrotic foot and an open area on her sacrum. At that time I was not the wound care nurse I called the doctor and verified the meds. He said continue the hospital orders. Surveyor inquired if R2's hospital orders included treatments, V5 responded No, but the wound care nurse is supposed to follow-up within 24 hours and implement treatments. R2's POS (Physician order [REDACTED]. Skin assessments weekly. Venelex ointment to affected area once daily. R2's (May 2020) TAR (Treatment Administration Record) affirms Venelex and weekly skin assessments from 5/27 through 5/31 were not documented. (Daily skin assessments are not inclusive). R2's (June 2020) TAR affirms Venelex was not documented on 6/3, 6/5, 6/11, 6/19, 6/25, 6/26, 6/27, and 6/30. (Daily skin assessments are not inclusive). On 7/30/20 at 2:31pm, surveyor inquired about concerns regarding R2's (5/27/20) Venelex order V4 (Nurse Consultant) responded The order says apply to their affected area but the location is not exact. Surveyor inquired what the blank spaces indicate on R2's (May/June 2020) TAR for daily Venelex and weekly skin assessments V4 stated Possibly it wasn't done. __ R2's (6/17/20) progress notes state in part; assessed patient and found open wound with red wound base on Right buttock, Stage II wound noted to site (1.5 x 1.0). Medical Doctor notified, new treatment order entered into EMAR (Electronic Medication Administration Record). R2's (July 2020) MAR and TAR affirm that there were no (right buttock) treatment orders entered on or about 6/17/20. On 8/3/20 at approximately 11:00am, V4 stated Generally if there's a wound they'll call the Physician to get orders and have the Wound Care Physician see the patient. R2 was not assessed by the wound care physician until one month after the (6/17/20) stage II (right buttock) wound was identified. R2's (7/17/20) initial (Physician) wound evaluation includes 3 wounds; 1) Sacrum: unstageable wound 2 x 2cm (centimeters) x not measurable. Thick adherent devitalized necrotic tissue 100%. Moderate purulent exudate, odor. Etiology: pressure. Surgical excisional debridement performed. treatment plan: [REDACTED]. Cover with gauze. 2) Right Foot: arterial wound 10 x 10cm x not measurable. Thick adherent necrotic tissue 100%. treatment plan: [REDACTED]. 3) Right heel arterial wound 4 x 4 x 0.5cm. Moderate purulent exudate. Thick adherent devitalized necrotic tissue 50%. Surgical excisional debridement performed. treatment plan: [REDACTED]. Cover with gauze. Recommend [MEDICATION NAME] (Antibiotic) 875/125 BID (twice daily) x 10 days. R2's (July 2020) POS affirms the following orders were entered on (7/20/20) Left foot: cleanse with NS (Normal Saline), apply [MEDICATION NAME] gauze, cover with dry dressing every other day and PRN (as needed). Sacrum: cleanse with NS, skin prep peri wound, apply Dakin's soaked gauze, cover with dry dressing daily and PRN (as needed). ([MEDICATION NAME], right foot and/or right heel treatment orders are not inclusive). On 7/30/20 at 2:35pm, surveyor inquired about treatment orders for R2's right foot and right heel as recommended on 7/17/20 by the Wound Care Physician V4 reviewed her (July 2020) TAR and stated All they have is the left foot. R2's (July 2020) treatment administration documentation was requested V4 stated We do not have wound care documentation for July. R2's (July 2020) TAR affirms daily skin assessments, left foot treatments and sacrum treatments are not documented (all entries are blank). __ R2's (7/22/20) weekly skin assessment includes only the sacrum. The following was documented; Sacrum: moderate drainage (25-75% of dressing). Exudate: purulent. Indicate what referrals may be appropriate: no referrals necessary. On 8/3/20 at 9:58am, surveyor inquired about R2's (7/22/20) wound assessment documented by V8 (Licensed Practical Nurse). V8 stated The wound nurse enters the wound assessments but I was designated that day to do it. When I assessed the wound there was dark, it was pink, and there was no drainage. Surveyor inquired if R2 had any other wounds V8 replied I think it was one on her foot. On 8/3/20 at 11:29am, surveyor requested R2's weekly wound assessments from 5/26/20 through 7/22/20. V4 presented only one assessment (dated 7/22/20) and stated There was a process but it was not in place so we don't have them. On 8/3/20 at 3:53pm, surveyor relayed concerns regarding care and services provided to R2 wounds V4 (Nurse Consultant) stated For change in condition we notify the physician to obtain orders and notify the appropriate members like wound care. __ R2's medical records affirm she incurred significant weight loss of 12.32% (within 6 weeks) while residing at the facility. On 8/4/20 at 12:44pm, surveyor inquired if V11 (Nurse Practitioner) was aware that R2 had wounds V11 responded I was not. Surveyor inquired about the potential harm to R2 if she had wounds and significant weight loss V11 stated It depends on how vigilant they are with the wound care but it would be slow wound healing I would imagine. On 8/5/20 at 2:02pm, V12 (Medical Director) stated They have to notify the attending physician or nurse practitioner for change in condition. When they don't find them they call me and I give orders what to do. For wound care recommendations they send them (in writing) to the attending physician to approve or disapprove. When the wound is purulent you're supposed to get an order to culture it and treat it. Surveyor inquired about potential harm to R2 if antibiotic and/or treatment orders were not received and/or carried out V12 responded The wound just continues to deteriorate. Surveyor inquired if he was aware of R2's significant weight loss, declining wounds and/or [MEDICATION NAME] recommendations for an infected wound V12 responded The attending is in charge of the patient. The DON (Director of Nursing) did not tell me about this patient, I did not get any calls. R2's 7/23/20 hospital history and physical states; presenting with failure to thrive, left foot with dry gangrene, and tunneling sacral wound. Presentation [MEDICAL CONDITION]. Initial labs notable for leukocytosis (increased white blood cells) 23.1. Given the extent of the gangrene, non-salvageable left foot. The (January 2017) prevention of pressure wounds policy states; routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Based on observation, interview and record review the facility failed to turn and reposition every two hours, failed to notify physician of dietary recommendations for dietary supplements for worsening pressure ulcer, failed to implement care planned interventions, failed to change soiled dressings as ordered and failed to prevent wound deterioration and implement new interventions for worsening pressure ulcers for 3 of 3 residents (R2, R3 and R4), reviewed for pressure sores, in a sample of 3. These failures resulted in wound deterioration involving all sampled residents. Findings Include: R2's face sheet [DIAGNOSES REDACTED]. R2's readmission skin integrity observation dated 4/24/15 indicates in the additional information section that R2 was readmitted with skin intact, buttock/sacrum with areas of barely blanchable [DIAGNOSES REDACTED], Stage 1. R2's readmission skin integrity observation dated 4/24/15 includes a completed date of 5/31/15 over one month after the initial assessment was done and two days after R2 was readmitted to the hospital for an infected wound. R2's Readmission Full Clinical Body assessment dated [DATE] does not indicate redness, open areas or skin breakdown was observed on R2 upon readmission. R2's Braden scale dated 4/24/15 indicates that R2 had a mild risk of developing skin breakdown with a score of 16. R2's physician progress notes [REDACTED]. R2's skin integrity observation dated 4/30/15 indicates R2's left buttock had a stage 2 pressure ulcer, sacrum had a stage 2 pressure ulcer and moisture associated skin damage to the scrotum (not identified on the initial assessment). R2's progress note dated 5/4/15 indicates that R2's physician was notified of detoriating skin condition with order obtained, noted and carried out. R2's skin integrity observation dated 5/8/15 indicates that R2's left buttocks pressure ulcer 4.5 centimeters (cm) x 5.5cm x? cm and was now unstageable, and the sacrum measured 0.7cm x 0.3 cm x <0.1cm and was a stage 2. R2's skin integrity observation and progress not does not indicate that the physician, family or dietician was notified of R2's change in condition. R2's skin integrity observation dated 5/22/15 indicates that R2's left buttock pressure ulcer measured 6.0cm x 7.0cm x 4.0 cm and was classified as a Stage 3. R2's progress note does not indicate that R2's physician and family were notified of the detoriating wound. R2's dietary progress note dated 5/26/15 includes a recommendation for Prostat AWC to further support wound healing. R2's Physician order [REDACTED]. R2's skin integrity observation dated 5/29/15 indicates that R2's left buttocks pressure ulcer measured 10.5cm x 11.7cm x 5.3 cm and was classified as a Stage 4. R2's pressure ulcer care plan dated 3/5/15 prior to R2's facility readmission does not include interventions for turning and repositioning. R2's pressure ulcer care plan indicates that R2 is at risk for developing pressure ulcers but does not include R2's newly developed pressure ulcers which were identified on 4/24/15 and 4/30/15. R2's progress notes dated 5/29/15 indicates that R2 was sent to a local wound clinic for evaluation. R2's progress note dated 5/29/15 indicates that R2 was sent directly from the wound clinic to the hospital for surgical debridement of the wound. R2's progress note dated 5/29/15 indicates that R2 was admitted to a local hospital for an infected wound. R2's hospital record dated 5/29/15 indicates that R2 was admitted with a 5X6 centimeter (cm) stage 4 sacral decubitus ulcer, with saturated gauze, malodor and brown drainage from wound. R2's hospital record indicates R2's [DIAGNOSES REDACTED]. On 6/30/15 at 11:15 am Z2 (R2's family) stated that R2 was sent to a local hospital for wound care. Z2 stated that she was not made aware of R2's wounds until 5/29/15 when R2 was sent to the hospital. Z2 stated R2's wound are so deep that you can see his bone and R2 is now on hospice because of his wounds. On 7/1/15 at 10:40 am E5 stated that she did not inform R2's family of R2's pressure ulcers. On 7/1/15 at 11:20 am Z3 (R2's Physician) stated that R2 required frequent turning and repositioning to help prevent wounds. Z3 would not confirm whether R2's pressure wounds were avoidable or unavoidable. Z3 could not recall if the facility contacted her to order R2's Prostat AWC but stated that she always follows the recommendations of the dietician when notified by the facility. R2's Minimum Data Set ((MDS) dated [DATE] indicates that R2 required two person, extensive assistance for bed mobility and was always incontinent of bowel and bladder. R3's face sheet [DIAGNOSES REDACTED]. On 6/29/15 on 10:10 am R3 was observed sitting in a wheelchair in the 2nd floor dining room without a chair pad in place. On 6/29/15 from 1:30pm through 3:35 pm R3 was observed to remain laying on the right side with no position change or incontinence check. At 3:40 pm with E4 Assistant Director of Nursing (ADON) R3 was observed with a dry incontinence brief in place. The facility's wound report indicates that R3 was admitted with a stage 3 left trochanter pressure ulcer and acquired a stage 2 pressure ulcer to the left hip while in the facility. R3's skin integrity observation dated 6/25/15 indicates that R3 has a stage 2 pressure ulcer to the left hip and a stage 3 pressure ulcer to the left trochanter. R3's skin integrity observation includes treatments to apply pressure relieving device to the chair and place R3 on the turn/reposition program. R3's Braden scale indicates R3 is at moderate risk of developing skin breakdown with a score of 13. R3's pressure care plan 4/1/15 dated includes an intervention to turn and reposition every 2 hours and as needed. R3's MDS dated [DATE] indicates that R3 requires one person, extensive assistance for bed mobility and is always incontinent of bowel and bladder. R3's Physician order [REDACTED]. On 7/1/15 at 10:00am with E5 Wound Nurse R3's wound care was observed. E5 was observed placing sanitizer cloths on R3's disposable tray with clean wound supplies. E5 was observed removing R3's dressing, removing her gloves and placing new gloves on without hand washing or sanitizing. E5 was observed cleaning R3's wound with wound cleanser solution which was stored on the tray with clean supplies, placing the wound cleanser bottle back on the tray with the wound supplies and applying a clean dressing. E5 was observed to clean R3's left trochanter wound with wound cleanser, place the wound cleanser back on the clean supply tray and cover R3's wound without hand washing, sanitizing or changing her gloves. R3 was observed cleaning the wound cleanser bottle without changing her gloves using the sanitizer wipes which were observed sitting on the clean wound supply tray. R4's face sheet [DIAGNOSES REDACTED]. On 7/1/15 at 10:10am with E5 Wound Nurse, R4's wound care was observed. R4's dressing to the right ischium was observed yellow-brown and damp. E5 was observed removing R4's soiled dressing and changing her gloves without hand washing or sanitization. E5 observed removing the wound cleanser bottom from R4's disposable wound care tray, spraying and cleaning R4's wound. E5 was observed placing the wound cleanser bottle back onto R4's clean wound dressing tray. E5 was observed removing her gloves after cleaning the wound and applying new gloves without hand washing or sanitizing. E8 Certified Nursing Assistant was observed cleaning R4's buttocks with a paper towel from the bathroom. R4's Physician order [REDACTED]. On 7/1/15 at 10:40am E5 that the wound cleanser spray is used for multiple residents. The facility's Infection Control Protocol for All nursing Procedures revised in 2008 was reviewed. The infection control policy indicates staff should wash hands thoroughly with soap and water before any procedure, and after changing or removing gloves or any personal protective equipment. This procedure was not followed. The facility's Repositioning policy revised 2008 was reviewed. The policy indicates in part that repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. The policy indicates that residents who are in bed should be on a every 2 hour turning program. This policy was not followed.

Based on interview and record review the facility failed to prevent an avoidable fall accident by positioning a bed close to a radiator for (R6) 1 of 3 residents reviewed for falls, and failed to prevent a fall incident while providing care for 1 of 3 residents reviewed for falls. This failure resulted in R6 falling onto a radiator requiring hospital treatment where R6 was assessed to have a surface area burn to 20% of her body. Findings Include: R6's face sheet [DIAGNOSES REDACTED]. R6's incident report dated [DATE] at 4:00 am indicates R6 was found on the bedroom floor with multiple skin tears noted. R6's report indicates 911 emergency was activated and R6 was transported to a local hospital and admitted . R6's incident report did not include mention of R6 suffering a fall on the radiator. On [DATE] at 10:30 am E1 Administrator stated R6 fell against the radiator cover causing the cover to become dislodged from the wall. On [DATE]at 11:00 am this surveyor observed the radiator cover in R6's last assigned room secured with a metal bracket and a screw. E1 stated the radiator cover was reapplied and secured after R6's incident. On [DATE] at 11:30 amE2 Director of Nursing (DON) stated R6 had a fall mat to the right side of the bed however there was no fall mat on the left side of R6's bed. E2 DON stated R6 always favored the right side therefore a fall mat on the left side was not an intervention. E2 DON stated R6 fell to the left side of the bed next to the heating vent. R6's progress note dated [DATE] indicates, "upon routine rounds resident was observed laying on her left side with left knee noted resting against wall with skin tear and right arm and hand noted with skin tear." On [DATE] at 11:30am R16 stated she got up at 4:00am on [DATE] to go to the bathroom and heard R6 moaning. R16 stated she went to the hall and yelled for a nurse after discovering R6 lying on the floor to the left of the bed. R16 stated she did not hear any alarms sounding when she discovered R6 on the floor. On [DATE] at 12:00 pm E7 Registered Nurse (RN) stated R6 had a low bed and a floor mat to the right side but not on the left side where R6 fell from the bed. E7 stated R6 had a bed alarm in place but it did not alarm. E7 stated the bed alarms should sound when it detects resident movement from the bed. E7 stated she was made aware of R6 laying on the floor when R16 called out into the hall for help despite E7's documentation in R6's progress note indicating R6 was observed on the floor during routine rounds. E7 stated R6 was found lying on the floor with the right side facing the wall and does not recall if the radiator cover was hanging from the wall. R6's fall care plan dated [DATE] indicates R6 is dependent on staff for transfers, is unable to ambulate and is at risk for falls. R6's fall care plan includes an intervention to ensure functioning alarm devices and to continue with a low bed with a safety mattress. R6's Minimum (MDS) data set [DATE] indicates R6 needed extensive assistance with two person assist for bed mobility with total dependence for transfers and ambulation. R6's hospital records indicate R6 was admitted to the hospital with [REDACTED]. R6's hospital record indicates R6 had the following: approximately 3% full thickness burn to left lower extremity extending from anteromedial aspect of distal thigh over knee joint; less than 1% TBSA burn characterized by a single bulla on anterolateral aspect of right knee; approximately 3 - 4% TBSA long [DIAGNOSES REDACTED]tous burn with well defined borders noted across anterior chest; approximately 3% TBSA burn overlying right bicep and characterized by [DIAGNOSES REDACTED]; approximately 3% TBSA burn on right forearm characterized by multiple bullae and [DIAGNOSES REDACTED]; less than 1% TBSA burn to dorsum of index and middle finger of left hand overlying the PIP (Proximal Interphalangeal) joint and characterized by the presence of bulbae; approximately 3% TBSA burn characterized by [DIAGNOSES REDACTED] on anteromedial aspect of right thigh extending from superior aspect of right hip ,[DATE] of the way to the knee; approximately 2 centimeters (cm) x 2 cm burn to left temple with deeper burn in the center which is likely the point of contact. R6's hospital records indicate R6 was transferred to a local hospital on [DATE] for hospice care where she expired on [DATE]. R7's face sheet [DIAGNOSES REDACTED]. R7's progress notes and event report dated [DATE] indicates R7 fell face down onto the floor from the bed while receiving incontinence care. R7's event report indicates R7 was observed with a small hematoma to the right middle brow area and was transferred to the local hospital for evaluation. R7's Minimum Data Set ((MDS) dated [DATE] indicates R7 is totally dependent requiring two person assistance with bed mobility. The facility could not provide a fall care plan for R7 upon surveyor request. On [DATE] at 11:45 am E8 Certified Nursing Assistant (CNA) stated that she was providing incontinence care and a complete linen change for R7 when R7 rolled to her left side onto the floor. E8 stated she was providing incontinence care and a complete linen change alone without assistance from another staff member despite the MDS indicating R7 requires two person assistance for bed mobility. E8 stated R7's bed does not have side rails.

Based on interviews, and record review, the facility failed to ensure the safety of one of three residents (R1) during a transfer. The facility failed to follow their policy on safe patient lifting policy. R1 was transfered without the use of lifting equipment, resulting in R1 twisting her right leg during the transfer resulting in a Right Femoral Shaft Fracture. Findings include: On 5/30/12 at 9:40am during initial tour with E9 (Assistant Director of Nursing) R1 was noted in her room in her recliner. E9 stated R1 needs total assistance with all ADL's (Activity Of Daily Living), E9 further stated that R1 needs at least two person assist with the lifting assistive device to transfer from recliner to bed and from the bed to a recliner. At 10:32 a.m. E8 (Restorative Aide) stated that R1 definitely needs two person assist with a lifting assist device in transferring from a recliner to bed or vice versa. On 5/30/12 at 11:32 a.m. E3 CNA (Certified Nurse Aide) stated that both her and E4 CNA on 1/12/12 at around 1:30 p.m. transferred R1 from the recliner into her bed without using the lifting assistive device. E3 stated during the transfer "I kind of lost my balance but R1 did not fall." E3 stated after the transfer R1 started crying that she had hurt her knees, E3 did not report this incident to E7, LPN (Licensed Practical Nurse). E3 admitted that she was supposed to report any incident of pain or injury to the charge nurse but stated "I did not make anything out of it because R1 normally cries for attention." According to facility incident report form dated 1/12/12 under the description of occurrence the writer indicated that R1 stated that "two CNA put her in bed and she (R1) felt her leg twisted a little. She remembers hearing a pop. " On 5/30/12 at 4:13pm E7 (LPN) stated that on 1/12/12 between 3:45 and 4:30pm during the change of shift rounds R1 was in her bed and was crying stating her leg hurts. E7 (LPN) stated that R1 told her that it was during transfer from her recliner to the bed that the CNA taking care of her hurt her leg when they were transferring her to bed. R1's MAR (Medication Administration Record) indicated that R1 received two tablets of pain reliever at 5:00pm. E7 stated she then contacted the physician and R1 was sent to the local community hospital center for further evaluation and treatment. R1's emergency department after care instruction dated 1/12/2012 6:25Pm indicated follow up instruction for femoral shaft fracture and E7 confirmed that R1 came back to the facility with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) under section G coded R1 under transfer as 4/3 and under toileting 4/3 (two person assist).