Every finding on record at La Bella of Cahokia

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 2 (R1, R2) of 4 residents reviewed for abuse in the sample of 4.Findings include: 1. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] and diagnoses including dementia, depression, hemiplegia and hemiparesis. R1's admission Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact, wheelchair dependent and no behaviors exhibited. R1's Care Plan dated 5/4/2026 addresses abuse as resident is at risk for abuse related to cohabitating with several others. 2. R2's Undated Face Sheet documents R2 was initially admitted to the facility on [DATE] with diagnoses including: dementia and bipolar disorder. R2's Quarterly MDS dated [DATE] documents he was cognitively intact, uses a walker and exhibited no behaviors. R2's Care Plan, dated 3/23/2026 addresses he is at risk for being verbally/physically inappropriate, abusive with staff and other residents r/t (related to) being short tempered and having impaired cognition. Review of the facility Incident Summary, dated 5/28/2026, documents at approximately 7:50 AM a brief resident to resident interaction in the main dining room involving (R2) and (R1.) Assessment and Investigation: residents were immediately separated and placed in different areas of the facility. Immediate nursing assessment were completed by licensed nursing staff with no signs of injury noted on either resident. (R2) was interviewed and stated that he became upset when (R1) was sitting at a dining room table where (R2) usually sits. He stood from his wheelchair, reached out and touched (R1's) wrist. (R1) then reached out tapped (R2's) chest causing him to lose balance and fall to the floor. (R2) acknowledged that he should not have reached out to touch (R1), and he meant no harm to (R1.) (R1) was interviewed and stated that he asked (R2) to move back from the table because (R2) was spitting as he was talking. (R1) became upset when (R2) tried to touch him. In his reaction, he tapped (R2's) chest. (R1) also acknowledged that he should have not touched (R2) and meant no harm to (R2.) Law enforcement responded but declined to interview either resident. Social Services met with both residents individually. Neither express any negativity towards each other. Investigation Process: The facility conducted a systematic investigation beginning on 5/28/2026, which included the following: formal interviews conducted with both residents on 5/28/2026, observation of resident interactions and behaviors. Findings/Determination: Upon completion of the investigation, review of all interviews, and consultation with all the interdisciplinary team (IDT), the facility determined: the incident did not meet definition of abuse under CMS (Centers for Medicare and Medicaid) or IDPH (Illinois Department of Public Health) standards, the interaction was non-injurious and isolated, there was no intent, ongoing risk, or pattern of behavior identified. No further incidents occurred after separation. Corrective Actions and Prevention Plan: to prevent recurrence and ensure ongoing protection, the facility implanted the following: permanent dining room and environmental separation of involved residents and care plans updated to reflect increased supervision and environmental management. Conclusion: the facility responded timely and appropriately to the allegation, ensuring immediate resident protection, thorough investigation, and interdisciplinary review. No evidence of abuse was substantiated. Measures have been implemented to reduce risk and monitor for recurrence in accordance with CMS F600. R1's Care Plan had no documentation of increased supervision or permanent dining room and environmental separation after the resident altercation with (R2) on 5/28/2026. R1's Electronic Medical Record dated 5/28/2026 had no documentation of a resident to resident altercation between R1 and R2 and no skin assessment documented after the altercation. R2's Care Plan had no documentation of increased supervision or permanent dining room and environmental separation after the resident altercation with (R1) on 5/28/2026. R2's Electronic Medical Record dated 5/28/2026 no documentation of a resident to resident altercation between R1 and R2. Handwritten Staff Statement, dated 5/28/2026 documents V31 stated, I was in the doorway (kitchen door.) I yelled fight and CNA (Certified Nurse Assistant) ran in. It was (R2) and (R1.) Signed by V1 (Administrator). On 8/21/2026 at 10:20 AM V31(Dietary Aide) stated she was in the doorway of the kitchen looking into the dining room on 5/28/2026 and she witnessed (R1) yelling at (R2), Stop spitting in our food. V31 stated (R2) yelled, I am so sick of your s***. V31 stated she witnessed (R2) swing his arm at (R1) and missed, (R1) then grabbed (R2's) shirt by the collar and shoved (R1) backwards and (R1) fell on the floor then (R2) fell on the floor as well. V31 stated she yelled to staff down the hall that residents were fighting in the dining room and several staff (names unknown) responded to the fight and separated the residents. R2's Quarterly MDS, dated [DATE] documents he was cognitively intact and exhibited no behaviors. Review of the facility Incident Summary, dated 6/21/2026, documents at approximately 4:45 PM a resident to resident interaction in the main dining room involving (R2) and (R1.) (R1) had a minimal amount of blood to his lip. Assessment and Investigation: residents were immediately separated and placed in different areas of the facility. Immediate nursing assessments were completed by licensed nursing staff. (R2) was interviewed and stated that he was sitting at a table in the main dining room. (R1) approached with his finger pointing at (R2) and (R2) became upset and reached out to tap (R1's) face. He stood from his wheelchair, lost his balance, and fell as (R1) reached out to grab his shirt. (R2) acknowledged that he should not have reached out to touch (R1) he also acknowledged that he was sitting in his regular dining room. (R1) was interviewed and stated that he saw (R2) sitting at a table where he normally sits to eat meals. He pointed his finger and asked (R2) to move from the table. (R1) also acknowledged that he should not have pointed his finger at (R2) and meant no harm to (R2.) Social Services met with both residents individually. Neither express any negativity towards each other. Investigation Process: The facility conducted a systematic investigation beginning on 5/28/2026 (wrong date documented, should be 6/21/2026), which included the following: formal interviews conducted with both residents on 6/22/2026, observation of resident interactions and behaviors. Findings/Determination: Upon completion of the investigation, review of all interviews, and consultation with all the IDT, the facility determined: the incident did not meet definition of abuse under CMS or IDPH standards, the interaction was non-injurious and isolated, there was no intent, ongoing risk, or pattern of behavior identified. No further incidents occurred after separation. Corrective Actions and Prevention Plan: to prevent recurrence and ensure ongoing protection, the facility implanted the following: staff in-serviced on permanent dining room and environmental separation of involved residents and care plans updated to reflect increased supervision and environmental management. Conclusion: the facility responded timely and appropriately to the allegation, ensuring immediate resident protection, thorough investigation, and interdisciplinary review. No evidence of abuse was substantiated. Measures have been implemented to reduce risk and monitor for recurrence in accordance with CMS F600. An Undated Written Statement V6 (Licensed Practical Nurse/LPN) documented, On 6/21/2026 during dinner I heard staff yelling for help. I went to the dining room and observed (R2) on the floor on all fours. I and another staff member assisted (R2) off the floor. I then proceeded to talk with (R1) who stated (R2) came over to him, grabbed his face and punched him in the mouth. I assessed (R1's) mouth and noticed bleeding coming from his bottom row of teeth. Writer notified Administrator and DON of altercation. On 8/20/2026 at 12:15 PM V22 (LPN) stated recalled the resident to resident altercation between (R1) and (R2) on 6/21/2026. V22 stated she didn't see the altercation between (R1) and (R2) but she was assigned to (R1) and assessed his mouth was bleeding and (R1) told her (R2) punched him in the mouth and that was the second time it had occurred. R1's Health Status Note, dated 6/21/2026 at 4:50 PM documented this writer was called to the dining room d/t (due to) residents yelling and causing commotion in in the dining room. Upon arrival resident was sitting in his chair with blood noted around his teeth, yelling at another resident. Resident (R2) was on the ground. The other resident was assessed and assisted to a chair. Residents were separated, skin checks performed, DON (Director of Nurses), Admin (Administrator), POAs (Power of Attorneys) and providers notified. Witnesses stated that the other resident was the aggressor and was upset over a spot in the dining room and that resident defended himself when striking back and landing the other resident on the floor. Police report made. Resident asked if he would like to be seen at the hospital. He respectfully declines and denies pain. R1's Skin Issues Note, dated 6/21/2026 at 4:58 PM V22 (LPN) documents loose tooth on right side, bloody front teeth. On 8/20/2026 at 12:15 PM V22 (LPN) stated she recalled the altercation between (R1) and (R2) in June 2026. V22 stated she overheard yelling in the dining room and when she got to the dining room she observed (R1) had a bloody mouth and (R2) was on the floor. V22 stated (R1) reported that (R2) punched him in the mouth and (R2) stated (R1) threw him on the floor. V22 stated she assessed (R1) after the altercation and noted he was bleeding from his mouth. V22 stated she couldn't recall if V22 had a loose tooth but if she documented that then that what her assessment findings were. V22 stated she separated the residents and there were no further altercations that she is aware of. R1's Social Services Progress Note, dated 6/22/2026 at 10:48 AM documents resident was involved in an incident with another resident that resulted in a physical altercation. Resident was redirected. Appropriate safety precautions were implemented to ensure the well-being of all parties involved. situation was addressed, and resident will continue to be monitored and supported as needed. R2's Health Status Note, dated 6/21/2026 at 4:54 PM V19 (LPN) documented upon arrival to dining room resident was sitting in walker chair. States having a physical altercation with another resident states peer attempted to hit him but was not struck. Stated falling forward out of seated walker landing on both hands and knees. Denies hitting head. Alert and oriented x4. Assisted back to room using seated walker. Torn shirt removed. Skin assessment done at this time. No open or bruises areas noted. Resident complains of pain with PRN (when needed) pain medication given complaints of knee pain. On 8/20/2026 at 9:10 AM R1 was sitting in a wheelchair on the patio smoking a cigarette. R1 stated he was upset because another resident (R2) hit him two times on two different occasions and staff aren't doing anything about it. R1 stated the first fight (date unknown) they were in the main dining room and he went to shake his fist in (R2's) face because he was sitting in his spot at the table and (R2) blocked his fist and punched him in the jaw and then he grabbed (R2's) shirt and (R2) stood up and when he grabbed his shirt (R2) fell on the floor. R1 stated staff yelled and responded and separated them and his understanding was that (R2) wasn't allowed in the main dining room anymore, so they don't fight anymore. R1 stated the second fight (date unknown) (R2) was in the main dining room again and they got into it and (R2) hit him in the right lower jaw and it was bleeding and he had a loose tooth which fell out a few days later. R1 opened his mouth and had missing tooth on the bottom right side. R1 stated he was very upset because the second fight shouldn't have occurred because (R2) wasn't supposed to be in the main dining room after the first fight to keep them apart from one another. On 8/20/2026 at 9:30 AM, R2 stated he had two fights with (R1) at the facility. R2 stated the first fight (date unknown) occurred in the main dining room because (R1) raised his fist to him saying he was sitting at his spot in the dining room and R2 stated he ended up punching (R1) on the mouth and then (R1) threw him on the floor. After that fight management told him he was no longer allowed in the dining room, but he said he's going to do what he wants to because it's a free world. R2 stated the second fight (date unknown) occurred in the main dining room again and this time he punched (R1) in the mouth again and he made him bleed. R2 stated (R1) grabbed and tore his t shirt and slammed him on the hard floor. R2 stated he will continue to defend himself from (R1) and he told multiple staff about what occurred because no one should ever throw him on the ground. On 8/21/2026 at 9:30 AM V32 (MDS/Care Plan Nurse) and V28 (Care Plan and Restorative Nurse) stated they didn't work at the facility when the resident to resident altercation occurred between (R1) and (R2) on 5/28/2026 and there was no intervention on either residents care plan documented after the 5/28/2026 altercation. V32 and V28 stated after the second altercation on 6/21/2026 interventions were documented on both resident's care plans to prevent them from having further altercations. On 8/21/2026 at 12:01 PM, V27 (Infection Control Preventionist/LPN) stated since the DON (Director of Nursing) and ADON (Assistant Director of Nurses) are not working today she would answer nurse department questions. V27 stated when a resident to resident altercation occurs staff are expected to separate the residents immediately then all staff who witnessed the altercation and responded to the altercation are expected to document a written statement and that should be in the abuse investigation which V1 (Administrator) is responsible for because she is the facility's abuse coordinator. After a resident to resident altercation the residents involved are expected to be assessed by their assigned nurses and that assessment is documented in risk management in the computer and it is copied to the resident's nurse progress notes as well. After a resident to resident altercation the facility staff have an IDT meeting where they put an intervention in place to prevent further altercations between the residents and that intervention should be documented on the resident's care plan within 24 hours of the altercation occurring. On 8/20/2026 at 1:30 PM V1 (Administrator) stated she expects staff to follow the abuse policy to ensure residents are not subject to abuse at the facility. The Facility's Abuse Policy, revised 5/8/2026, documents it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.

Based on observation, interview, and record review, the facility failed to follow their abuse policy to ensure all residents are free from abuse for 2 (R1, R2) of 4 residents reviewed for abuse in a sample of 4.Findings include: 1. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] and diagnoses including dementia, depression, hemiplegia and hemiparesis. R1's admission Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact, wheelchair dependent and no behaviors exhibited. R1's Care Plan dated 5/4/2026 addresses abuse as resident is at risk for abuse related to cohabitating with several others.R1's Care Plan had no documentation of increased supervision or permanent dining room and environmental separation after the resident altercation with (R2) on 5/28/2026.R1's Electronic Medical Record dated 5/28/2026 had no documentation of a resident to resident altercation between R1 and R2 and no skin assessment documented after the altercation. 2. R2's Undated Face Sheet documents R2 was initially admitted to the facility on [DATE] with diagnoses including: dementia and bipolar disorder. R2's Quarterly MDS dated [DATE] documents he was cognitively intact, uses a walker and exhibited no behaviors. R2's Care Plan, dated 3/23/2026 addresses he is at risk for being verbally/physically inappropriate, abusive with staff and other residents r/t (related to) being short tempered and having impaired cognition. R2's Care Plan had no documentation of increased supervision or permanent dining room and environmental separation after the resident altercation with (R1) on 5/28/2026. R2's Electronic Medical Record dated 5/28/2026 had no documentation of a resident to resident altercation between R1 and R2. On 8/21/2026 at 10:20 AM V31 (Dietary Aide) stated she was in the doorway of the kitchen looking into the dining room on 5/28/2026 and she witnessed (R1) yelling at (R2), Stop spitting in our food. V31 stated (R2) yelled, I am so sick of your s***. V31 stated she witnessed (R2) swing his arm at (R1) and missed, (R1) then grabbed (R2's) shirt by the collar and shoved (R1) backwards and (R1) fell on the floor then (R2) fell on the floor as well. V31 stated she yelled to staff down the hall that residents were fighting in the dining room and several staff (names unknown) responded to the fight and separated the residents. R2's Quarterly MDS, dated [DATE] documents he was cognitively intact and exhibited no behaviors. R1's Health Status Note, dated 6/21/2026 at 4:50 PM documented this writer was called to the dining room d/t (due to) residents yelling and causing commotion in in the dining room. Upon arrival resident was sitting in his chair with blood noted around his teeth, yelling at another resident. Resident (R2) was on the ground. The other resident was assessed and assisted to a chair. Residents were separated, skin checks performed, DON (Director of Nurses), Admin (Administrator), POAs (Power of Attorneys) and providers notified. Witnesses stated that the other resident was the aggressor and was upset over a spot in the dining room and that resident defended himself when striking back and landing the other resident on the floor. Police report made. Resident asked if he would like to be seen at the hospital. He respectfully declines and denies pain. R1's Skin Issues Note, dated 6/21/2026 at 4:58 PM V22, LPN documents loose tooth on right side, bloody front teeth. On 8/20/2026 at 12:15 PM V22 LPN stated she recalled the altercation between (R1) and (R2) in June 2026. V22 stated she overheard yelling in the dining room and when she got to the dining room she observed (R1) had a bloody mouth and (R2) was on the floor. V22 stated (R1) reported that (R2) punched him in the mouth and (R2) stated (R1) threw him on the floor. V22 stated she assessed (R1) after the altercation and noted he was bleeding from his mouth. V22 stated she couldn't recall if V22 had a loose tooth but if she documented that then that what her assessment findings were. V22 stated she separated the residents and there were no further altercations that she is aware of. R1's Social Services Progress Note, dated 6/22/2026 at 10:48 AM documents resident was involved in an incident with another resident that resulted in a physical altercation. Resident was redirected. Appropriate safety precautions were implemented to ensure the well-being of all parties involved. situation was addressed, and resident will continue to be monitored and supported as needed. R2's Health Status Note, dated 6/21/2026 at 4:54 PM V19, LPN documented upon arrival to dining room resident was sitting in walker chair. States having a physical altercation with another resident states peer attempted to hit him but was not struck. Stated falling forward out of seated walker landing on both hands and knees. Denies hitting head. Alert and oriented x4. Assisted back to room using seated walker. Torn shirt removed. Skin assessment done at this time. No open or bruises areas noted. Resident complains of pain with PRN (when needed) pain medication given complaints of knee pain. On 8/20/2026 at 9:10 AM R1 was sitting in a wheelchair on the patio smoking a cigarette. R1 stated he was upset because another resident (R2) hit him two times on two different occasions and staff aren't doing anything about it. R1 stated the first fight (date unknown) they were in the main dining room and he went to shake his fist in (R2's) face because he was sitting in his spot at the table and (R2) blocked his fist and punched him in the jaw and then he grabbed (R2's) shirt and (R2) stood up and when he grabbed his shirt (R2) fell on the floor. R1 stated staff yelled and responded and separated them and his understanding was that (R2) wasn't allowed in the main dining room anymore, so they don't fight anymore. R1 stated the second fight (date unknown) (R2) was in the main dining room again and they got into it and (R2) hit him in the right lower jaw and it was bleeding and he had a loose tooth which fell out a few days later. R1 opened his mouth and had missing tooth on the bottom right side. R1 stated he was very upset because the second fight shouldn't have occurred because (R2) wasn't supposed to be in the main dining room after the first fight to keep them apart from one another. On 8/20/2026 at 9:30 AM, R2 stated he had two fights with (R1) at the facility. R2 stated the first fight (date unknown) occurred in the main dining room because (R1) raised his fist to him saying he was sitting at his spot in the dining room and R2 stated he ended up punching (R1) on the mouth and then (R1) threw him on the floor. After that fight management told him he was no longer allowed in the dining room but he said he's going to do what he wants to because it's a free world. R2 stated the second fight (date unknown) occurred in the main dining room again and this time he punched (R1) in the mouth again and he made him bleed. R2 stated (R1) grabbed and tore his t shirt and slammed him on the hard floor. R2 stated he will continue to defend himself from (R1) and he told multiple staff about what occurred because no one should ever throw him on the ground. On 8/20/2026 at 1:30 PM V1 (Administrator) stated she expects staff to follow the abuse policy to ensure residents are not subject to abuse at the facility. The Facility's Abuse Policy, revised 5/8/2026, documents it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.

Based on interview and record review, the facility failed to report allegations of abuse within the regulatory timeframe for 1 (R2) of 4 residents reviewed for abuse in a sample of 4.Findings include: R2's Undated Face Sheet documents R2 was initially admitted to the facility on [DATE] with diagnoses including: dementia and bipolar disorder.R2's Quarterly MDS, dated [DATE] documents he was cognitively intact and exhibited no behaviors. On 8/20/2026 at 9:30 AM, R2 stated a night shift nurse who has 2 pigtails and is light skinned threw water on his face the night of 8/17/2026. R2 stated he reported it to a nurse (name unknown) on day shift on 8/18/2026 and no one has spoke to him about the incident and he felt it was rude and abusive. R2's Health Status Note, dated 8/18/2026 at 11:42 AM V20 (Licensed Practical Nurse/LPN) documented resident told this nurse that someone gave him medication last night and then threw water at him. No acute s/s (signs or symptoms) of distress at this time. Administrator aware. On 8/20/2026 at 11:25 AM V20 (LPN) stated she recalled (R2) reported to her that a night shift nurse [NAME] water on him the night before and he wanted to report abuse. V20 stated she documented the abuse allegation in (R2's) nurse progress notes and notified the Administrator immediately. On 8/20/2026 at 1:30 PM V1 (Administrator) stated she is the abuse coordinator and she is responsible to ensure abuse allegations are reported to the state surveying agency within the reportable timeframe. V1 stated no staff reported to her that (R2) had an allegation of a night shift nurse threw water on his face during night shift on 8/17/2026 and because she wasn't aware of it she hadn't reported the allegation to the state surveying agency nor had she started an abuse investigation. The Facility's Abuse Policy, revised 5/8/2026, documents the facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, and other required agencies (e.g., law enforcement when applicable) within specified timelines. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to document a thorough investigation for allegations of abuse for 2 (R1, R2) of 4 residents reviewed for abuse in a sample of 4. Findings include: 1. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] and diagnoses including dementia, depression, hemiplegia and hemiparesis. R1's admission Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact, wheelchair dependent and no behaviors exhibited. R1's Care Plan dated 5/4/2026 addresses abuse as resident is at risk for abuse related to cohabitating with several others. 2. R2's Undated Face Sheet documents R2 was initially admitted to the facility on [DATE] with diagnoses including: dementia and bipolar disorder. R2's Quarterly MDS dated [DATE] documents he was cognitively intact, uses a walker and exhibited no behaviors. R2's Care Plan, dated 3/23/2026 addresses he is at risk for being verbally/physically inappropriate, abusive with staff and other residents r/t (related to) being short tempered and having impaired cognition.Review of the facility Incident Summary, dated 5/28/2026, documents at approximately 7:50 AM a brief resident to resident interaction in the main dining room involving (R2) and (R1.) Assessment and Investigation: residents were immediately separated and placed in different areas of the facility. Immediate nursing assessment were completed by licensed nursing staff with no signs of injury noted on either resident. (R2) was interviewed and stated that he became upset when (R1) was sitting at a dining room table where (R2) usually sits. He stood from his wheelchair, reached out and touched (R1's) wrist. (R1) then reached out tapped (R2's) chest causing him to lose balance and fall to the floor. (R2) acknowledged that he should not have reached out to touch (R1) and he meant no harm to (R1.) (R1) was interviewed and stated that he asked (R2) to move back from the table because (R2) was spitting as he was talking. (R1) became upset when (R2) tried to touch him. In his reaction, he tapped (R2's) chest. (R1) also acknowledged that he should have not touched (R2) and meant no harm to (R2.) Law enforcement responded, but declined to interview either resident. Social Services met with both residents individually. Neither express any negativity towards each other. Investigation Process: The facility conducted a systematic investigation beginning on 5/28/2026, which included the following: formal interviews conducted with both residents on 5/28/2026, observation of resident interactions and behaviors. The investigation didn't include all staff interviews or written statements that witnessed the resident to resident altercation. Findings/Determination: Upon completion of the investigation, review of all interviews, and consultation with all the interdisciplinary team (IDT), the facility determined: the incident did not meet definition of abuse under CMS (Centers for Medicare and Medicaid) or IDPH (Illinois Department of Public Health) standards, the interaction was non-injurious and isolated, there was no intent, ongoing risk, or pattern of behavior identified. No further incidents occurred after separation. Corrective Actions and Prevention Plan: to prevent recurrence and ensure ongoing protection, the facility implanted the following: permanent dining room and environmental separation of involved residents and care plans updated to reflect increased supervision and environmental management. Conclusion: the facility responded timely and appropriately to the allegation, ensuring immediate resident protection, thorough investigation, and interdisciplinary review. No evidence of abuse was substantiated. Measures have been implemented to reduce risk and monitor for recurrence in accordance with CMS F600. Review of the facility abuse investigation, dated 5/28/2026 documents one staff written statement no other staff statements were documented in the investigation. R1's Electronic Medical Record dated 5/28/2026 had no documentation of a resident to resident altercation between R1 and R2 and no skin assessment documented after the altercation. R2's Electronic Medical Record dated 5/28/2026 had no documentation of a resident to resident altercation between R1 and R2. Handwritten Staff Statement, dated 5/28/2026 documents V31 (Dietary Aide) stated, I was in the doorway (kitchen door.) I yelled fight and CNA (Certified Nurse Assistant) ran in. It was (R2) and (R1.) Signed by V1 (Administrator). On 8/21/2026 at 10:20 AM V31 (Dietary Aide) stated she was in the doorway of the kitchen looking into the dining room on 5/28/2026 and she witnessed (R1) yelling at (R2), Stop spitting in our food. V31 stated (R2) yelled, I am so sick of your s***. V31 stated she witnessed (R2) swing his arm at (R1) and missed, (R1) then grabbed (R2's) shirt by the collar and shoved (R1) backwards and (R1) fell on the floor then (R2) fell on the floor as well. V31 stated she yelled to staff down the hall that residents were fighting in the dining room and several staff (names unknown) responded to the fight and separated the residents. V31 stated no management asked her what she observed and no one asked her to write a statement.R2's Quarterly MDS, dated [DATE] documents he was cognitively intact and exhibited no behaviors. Review of the facility Incident Summary, dated 6/21/2026, documents at approximately 4:45 PM a resident to resident interaction in the main dining room involving (R2) and (R1.) (R1) had a minimal amount of blood to his lip. Assessment and Investigation: residents were immediately separated and placed in different areas of the facility. Immediate nursing assessment were completed by licensed nursing staff, (R2) was interviewed and stated that the was sitting at a table in the main dining room. (R1) approached with his finger pointing at (R2) and (R2) became upset and reached out to tap (R1's) face. He stood from his wheelchair, and lost his balance, and fell as (R1) reach out to grab is shirt. (R2) acknowledged that he should not have reached out to touch (R1) he also acknowledged that he was sitting in his regular dining room. (R1) was interviewed and stated that he saw (R2) sitting at a table that he normally sits to eat meals. He point his finger and asked (R2) to move from the table. (R1) also acknowledged that he should not have pointed his finger at (R2) and meant no harm to (R2.) Social Services met with both residents individually. Neither express any negativity towards each other. Investigation Process: The facility conducted a systematic investigation beginning on 5/28/2026 (wrong date documented, should be 6/21/2026), which included the following: formal interviews conducted with both residents on 6/22/2026, observation of resident interactions and behaviors. The investigation included one staff written statement V6 (Licensed Practical Nurse/LPN). Findings/Determination: Upon completion of the investigation, review of all interviews, and consultation with all the IDT, the facility determined: the incident did not meet definition of abuse under CMS or IDPH standards, the interaction was non-injurious and isolated, there was no intent, ongoing risk, or pattern of behavior identified. No further incidents occurred after separation. Corrective Actions and Prevention Plan: to prevent recurrence and ensure ongoing protection, the facility implanted the following: staff in-serviced on permanent dining room and environmental separation of involved residents and care plans updated to reflect increased supervision and environmental management. Conclusion: the facility responded timely and appropriately to the allegation, ensuring immediate resident protection, thorough investigation, and interdisciplinary review. No evidence of abuse was substantiated. Measures have been implemented to reduce risk and monitor for recurrence in accordance with CMS F600. The abuse investigation dated 6/21/2026 documents one staff written statement, no other staff statements were documented. An Undated Written Statement V6 (LPN) documented, On 6/21/2026 during dinner I heard staff yelling for help. I went to the dining room and observed (R2) on the floor on all fours. I and another staff member assisted (R2) off the floor. I then proceeded to talk with (R1) who stated (R2) came over to him grabbed his face and punched him in the mouth. I assessed (R1) mouth and noticed bleeding coming from his bottom row of teeth. Writer notified Administrator and DON (Director of Nursing) of altercation. R1's Health Status Note, dated 6/21/2026 at 4:50 PM documented this writer was called to the dining room d/t (due to) residents yelling and causing commotion in in the dining room. Upon arrival resident was sitting in his chair with blood noted around his teeth, yelling at another resident. Resident (R2) was on the ground. The other resident was assessed and assisted to a chair. Residents were separated, skin checks performed, DON (Director of Nurses), Admin (Administrator), POAs (Power of Attorneys) and providers notified. Witnesses stated that the other resident was the aggressor and was upset over a spot in the dining room and that resident defended himself when striking back and landing the other resident on the floor. Police report made. Resident asked if he would like to be seen at the hospital. He respectfully declines and denies pain.R1's Skin Issues Note, dated 6/21/2026 at 4:58 PM V22 (LPN) documents loose tooth on right side, bloody front teeth. On 8/20/2026 at 12:15 PM V22 LPN stated she recalled the altercation between (R1) and (R2) in June 2026. V22 stated she overheard yelling in the dining room and when she got to the dining room she observed (R1) had a bloody mouth and (R2) was on the floor. V22 stated (R1) reported that (R2) punched him in the mouth and (R2) stated (R1) threw him on the floor. V22 stated she assessed (R1) after the altercation and noted he was bleeding from his mouth. V22 stated she couldn't recall if V22 had a loose tooth but if she documented that then that what her assessment findings were. V22 stated she didn't witness the altercation, but CNAs (Certified Nurse Assistants) were in the dining room at that time and she instructed all of them to document a written statement of what they observed. V22 stated she separated the residents and there were no further altercations that she is aware of. (R1) told her (R2) punched him in the mouth and that was the second time it had occurred. R1's Social Services Progress Note, dated 6/22/2026 at 10:48 AM documents resident was involved in an incident with another resident that resulted in a physical altercation. Resident was redirected. Appropriate safety precautions were implemented to ensure the well-being of all parties involved. situation was addressed, and resident will continue to be monitored and supported as needed.R2's Health Status Note, dated 6/21/2026 at 4:54 PM V19 (LPN) documented upon arrival to dining room resident was sitting in walker chair. States having a physical altercation with another resident states peer attempted to hit him but was not struck. Stated falling forward out of seated walker landing on both hands and knees. Denies hitting head. Alert and oriented x4. Assisted back to room using seated walker. Torn shirt removed. Skin assessment done at this time. No open or bruises areas noted. Resident complains of pain with PRN (when needed) pain medication given complaints of knee pain. On 8/20/2026 at 9:10 AM R1 was sitting in a wheelchair on the patio smoking a cigarette. R1 stated he was upset because another resident (R2) hit him two times on two different occasions and staff aren't doing anything about it. R1 stated the first fight (date unknown) they were in the main dining room and he went to shake his fist in (R2's) face because he was sitting in his spot at the table and (R2) blocked his fist and punched him in the jaw and then he grabbed (R2's) shirt and (R2) stood up and when he grabbed his shirt (R2) fell on the floor. R1 stated staff yelled and responded and separated them and his understanding was that (R2) wasn't allowed in the main dining room anymore, so they don't fight anymore. R1 stated the second fight (date unknown) (R2) was in the main dining room again and they got into it and (R2) hit him in the right lower jaw and it was bleeding and he had a loose tooth which fell out a few days later. R1 opened his mouth and had missing tooth on the bottom right side. R1 stated he was very upset because the second fight shouldn't have occurred because (R2) wasn't supposed to be in the main dining room after the first fight to keep them apart from one another. On 8/20/2026 at 9:30 AM, R2 stated he had two fights with (R1) at the facility. R2 stated the first fight (date unknown) occurred in the main dining room because (R1) raised his fist to him saying he was sitting at his spot in the dining room and R2 stated he ended up punching (R1) on the mouth and then (R1) threw him on the floor. After that fight management told him he was no longer allowed in the dining room but he said he's going to do what he wants to because it's a free world. R2 stated the second fight (date unknown) occurred in the main dining room again and this time he punched (R1) in the mouth again and he made him bleed. R2 stated (R1) grabbed and tore his t shirt and slammed him on the hard floor. R2 stated he will continue to defend himself from (R1) and he told multiple staff about what occurred because no one should ever throw him on the ground. R2 also stated if I am looking into abuse that I should ask administration why a night shift nurse who has 2 pigtails and is light skinned threw water on my face the night of 8/17/2026. R2 stated he reported it to a nurse on day shift on 8/18/2026 and no one has spoke to him about the incident and he felt it was rude and abusive. R2's Health Status Note, dated 8/18/2026 at 11:42 AM V20 (LPN) documented resident told this nurse that someone gave him medication last night and then threw the water on him. No acute s/s (signs or symptoms) of distress at this time. Administrator aware. On 8/20/2026 at 11:25 AM V20 (LPN) stated she recalled (R2) reporting to her that a night shift employee threw water on him and she documented the allegation in (R2's) nurse progress notes and notified the Administrator immediately. On 8/21/2026 at 9:30 AM V32 (MDS/Care Plan Nurse) and V28 (Care Plan and Restorative Nurse) stated they didn't work at the facility when the resident to resident altercation occurred between (R1) and (R2) on 5/28/2026 and there was no intervention on either residents care plan documented after the 5/28/2026 altercation. V32 and V28 stated after the second altercation on 6/21/2026 interventions were documented on both residents care plans to prevent them from having further altercations. On 8/21/2026 at 12:01 PM, V27 (Infection Control Preventionist/LPN) stated since the DON and ADON (Assistant Director of Nurses) are not working today she would answer nurse department questions. V27 stated when a resident to resident altercation occurs staff are expected to separate the residents immediately then all staff who witnessed the altercation and responded to the altercation are expected to document a written statement and that should be in the abuse investigation which V1 (Administrator) is responsible for because she is the facility's abuse coordinator. After a resident to resident altercation the residents involved are expected to be assessed by their assigned nurses and that assessment is documented in risk management in the computer and it is copied to the resident's nurse progress notes as well. After a resident to resident altercation the facility staff have an IDT meeting where they put an intervention in place to prevent further altercations between the residents and that intervention should be documented on the resident's care plan within 24 hours of the altercation occurring. On 8/20/2026 at 1:30 PM V1 (Administrator) stated she didn't substantiate the resident to resident altercations between (R1) and (R2) that occurred on 5/28/2026 and 6/21/2026 because they didn't meet the definition of abuse guidelines for CMS and IDPH. V1 stated the abuse investigations dated 5/28/2026 and 6/21/2026 regarding (R1) and (R2) were complete and everything was included in the abuse investigations, including all witness statements. V1 stated no staff reported to her that (R2) had an allegation of a night shift nurse throwing water on his face and because she wasn't aware of it she hadn't started an abuse investigation. The Facility's Abuse Policy, revised 5/8/2026, investigation of Alleged Abuse: an immediate investigation is warranted when suspicion of abuse or reports of abuse occur. Written procedures for investigations include: identifying staff responsible for the investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse has occurred, the extent and cause, providing complete and thorough documentation of the investigation.

Based on observation, interview, and record review, the facility failed to do temperature readings on food cooked to maintain safe and appetizing temperatures for residents. This failure has the potential to affect all 84 residents residing in the facility.The findings include: On 2/23/26 at 11:30 AM, an observation was made on the facility's kitchen with V8 (Dietary Manager.)On 2/23/26 at 11:38 AM, V8 stated I did have a lot of complaints of cold food when I started, mostly from the residents who eat in their room. I think most of it came from the staff on the halls not delivering the trays to the rooms in a timely manner. I think we have been working on that. On 2/23/26 at 11:43 AM, V10 (Cook) was seen taking food out of oven and onto the steam table. V10 stated the menu today is meatloaf, sweet potatoes, cauliflower, and pineapple upside down cake. The temperature logbook was reviewed with no temperatures documented since 1/30/26. When asked about it, V10 stated I take the temps, I just forget to write them down.On 2/23/26 at 11:55 AM, V8 was advised that no temperatures were logged in the temp book. V8 stated I was not aware of this, and I would expect them to be documenting the temperatures with each meal.On 2/23/26 at 12:00 PM, V10 was seen checking temperatures of the food coming out of the oven or stove with a digital thermometer, when asked about calibrating the thermometer first, V10 stopped and wiped it off with alcohol pad and then proceeded to check temperatures without calibrating the thermometer. When food was at correct temperatures, V10 placed the food onto the steam table to be served.On 2/23/26 at 12:05 PM, The substitute menu item today was fish. V9 (Cook) was seen placing the fish on the steam table without checking temperature. When asked about the temperature, V10 stated No the fish temp was not checked.On 2/23/26 at 12:26 PM, The first plate of food made with V10 (Cook) plating the food. There was no rechecking of the food temperatures prior to serving. V10 was seen using a utensil to serve food to the plate, then would use his other hand to adjust the food on the plate. On 2/23/26 at 12:42 PM, A second pan of meatloaf was brought out of the oven and placed on steam table. There was no temperature check done prior to V10 plating the food from this pan.On 2/23/26 at 1:15 PM, The last plate/tray was made as the test tray and was walked down the hall with the last resident hall trays. The test plate was taken to the conference room and temperatures checked, and the food tasted. The meatloaf was at 163 degrees F. with a good appearance, good taste, and warm to taste. the corn was at 120 degrees F. with normal appearance, a bland taste with no seasoning, and was cold to the taste. The sweet potatoes were at 102 degrees F. and appeared dry, with a good taste, but was cold to the taste. The fish was at 108 degrees F. with good appearance, good taste, but cold to the taste. The cup of peaches was at 46 degrees F, with good appearance, good taste, and was cold to the taste.The Dietary's Food Temperature Log dated January 2026, documents temps checked each for meal except on 1/7/26, 1/8/26, and 1/31/26.The Dietary's Food Temperature Log dated February 2026, does not have any temperatures logged. From 1/31/26 until 2/23/26, there were no documented temperatures done.On 2/25/26 at 11:55 AM, V1 (Administrator) stated I would expect the dietary staff to check food temperatures for each meal and document the temps in the logbook. I would also expect the dietary staff to always maintain a clean and sanitary environment in the kitchen.The Facility's Dietary Cooking and Cooling Policy, dated 2016, documents in part Foods will be cooked thoroughly, reaching the appropriate internal temperature specific to each item. 2. A properly calibrated thermometer should be inserted into the thickest part of the food, and at least two readings should be taken in different places to ensure the proper temperature has been reached.The Facility's Dietary The Dining Experience Policy, dated 2016, documents in part Residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. 12. Resident meals will be served in a sanitary environment with proper food handling procedures.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices for safe food handling, and failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This failure has the potential to affect all 84 residents residing in the facility.The findings include: On 2/23/26 at 11:30 AM, an observation was made in the facility's kitchen with V8 (Dietary Manager.)On 2/23/26 at 11:43 AM, V10 (Cook), was seen taking food out of oven and onto the steam table. V10 stated the menu today is meatloaf, sweet potatoes, cauliflower, and pineapple upside down cake. The temperature logbook was reviewed with no temperatures documented since 1/30/26. When asked about it, V10 stated I take the temps, I just forget to write them down.On 2/23/26 at 11:45 AM, The stand-up fridge in the kitchen had a temperature reading of 41 degrees Fahrenheit (F.), digital reading from inside. The walk-in fridge did not have a thermometer in the fridge and no external temperature to read. Unable to check temp. There were cups of fruit seen lying on a tray that were uncovered and not labeled. The walk-in freezer did not have a thermometer and had no external temperature to read. There was a plastic bag with a container of crackers that were open to air and a container of dip that was not labeled and appeared to be brought in from an outside facility.On 2/23/26 at 11:55 AM, V8 was advised of no thermometers or temperatures taken. V8 stated They did have thermometers in there, not sure what happened to them. When advised that no temperatures were logged in the temp book, V8 stated I was not aware of this, and I would expect them to be documenting the temperatures with each meal.On 2/23/26 at 12:00 PM, V10 was seen checking temperatures of the food coming out of the oven or stove with a digital thermometer, when asked about calibrating the thermometer first, V10 stopped and wiped it off with alcohol pad and then proceeded to check temperatures without calibrating the thermometer. When food was at correct temperatures, V10 placed the food onto the steam table to be served.On 2/23/26 at 12:05 PM, The substitute menu item today was fish. V9 (Cook) was seen placing the fish on the steam table without checking temperature. When asked about the temperature, V10 stated No the fish temp was not checked.On 2/23/26 at 12:26 PM, The first plate of food made with V10 (Cook) plating the food. There was no rechecking of the food temperatures prior to serving. V10 was seen using a utensil to serve food to the plate, then would use his other hand to adjust the food on the plate. On 2/23/26 at 12:42 PM, A second pan of meatloaf was brought out of the oven and placed on steam table. There was no temperature check done prior to V10 plating the food from this pan.The Dietary's Food Temperature Log dated January 2026, documents temps checked each for meal except on 1/7/26, 1/8/26, and 1/31/26.The Dietary's Food Temperature Log dated February 2026, does not have any temperatures logged. From 1/31/26 until 2/23/26, there were no documented temperatures done.The Dietary Refrigerator Temperature Log does not indicate which refrigerator it is referring to. They have a walk-in fridge and a stand-up fridge. This log documents temps checked in August 2025, September 2025, October 2025, December 2025, and January 2026. There are no checks for November 2025 or for February 2026.The Dietary Freezer Temperature Log documents temperatures were checked August 2025 through January 2026. There are no temperature checks done for February 2026.On 2/25/26 at 11:55 AM, V1 (Administrator) stated I would expect the dietary staff to check food temperatures for each meal and document the temps in the logbook. I would also expect the dietary staff to always maintain a clean and sanitary environment in the kitchen. I would expect staff to label and store foods properly.The Facility's Dietary Cooking and Cooling Policy, dated 2016, documents in part Foods will be cooked thoroughly, reaching the appropriate internal temperature specific to each item. 2. A properly calibrated thermometer should be inserted into the thickest part of the food, and at least two readings should be taken in different places to ensure the proper temperature has been reached.The Facility's Dietary The Dining Experience Policy, dated 2016, documents in part Residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. 12. Resident meals will be served in a sanitary environment with proper food handling procedures.The Facility's Dietary Food Storage Policy, dated 2026, documents in part Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. 1. General storage guidelines to be followed: a. All food items will be labeled. f. leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers. 2. Refrigerated storage guidelines to be followed: a. Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees F. or lower. Place hanging thermometer in the warmest part of the refrigerator. b. Conduct random temperature checks of food items. f. Never leave any food item uncovered and not labeled. 3. Frozen storage guidelines to be followed: b. Check freezer temperature regularly.

Based on interview, and record review, the facility failed to maintain a resident's right to secure and confidential personal and medical records for 2 of 2 residents (R4, R5) reviewed for resident rights in the sample of 9.The findings include: 1. R4's admission Record, dated 2/25/26, documents R4 was admitted to the facility on [DATE] and was discharged on 12/9/25 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Anemia, Obesity, Hyperlipidemia, Hypertension (HTN), and Falls.R4's Care Plan, dated 11/23/25, documents R4 is at risk for falls. R4 has oxygen therapy related to COPD, chronic respiratory failure. R4 has a mood problem. R4 is a smoker.R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively intact and is independent on activities of daily living (ADLs). R4 is always continent of both bowel and bladder.R4's Physician Order, dated 12/4/25, documents May discharge home with PT (physical therapy)/OT (occupational therapy)/HH (home health) services with nursing.R4's Nursing Note, dated 12/9/25 at 12:58 PM, documents Resident discharged home with medication and discharge instructions. Voiced understanding of all teachings. Transported via private vehicle by family. No concerns voiced. Denied pain and discomfort.On 2/25/26 at 9:14 AM, V20 (R4's Daughter) stated My mom gave me the prescriptions, and I took them to (name of pharmacy) and dropped them off. When I returned to get the medications, they didn't say anything to me about having the wrong prescriptions, they just gave me mom's meds. I didn't know anything about the wrong paperwork until the facility called us and told us. While on the phone with V20, R4 got on another phone and joined the conversation and stated I took the envelope home with me, and I gave the prescriptions to my daughter (V20) and she took them to (name of pharmacy). Then I threw the rest of the papers in the trash.2. R5's admission Record, dated 2/25/26, documents R5 was admitted to the facility on [DATE] and was discharged on 12/9/25 with diagnosis of Diverticulitis, Methicillin-Resistant Staphylococcus Aureus (MRSA), Morbid obesity, Respiratory. failure, COPD, Emphysema, Major depressive disorder, Atrial Fibrillation, Stenosis of bilateral carotid arteries, Cardiomegaly, Disc degeneration lumbar, Abdominal Aortic Aneurysm (AAA), Congestive Heart Failure (CHF), Hyperlipidemia, HTN, Cardiac pacemaker, Hernia, and anxiety disorder.R5's Care Plan, dated 11/6/25, documents R5 has no history of falls, and has been free from falls but is at risk for falls. 10/21/25: R5 has oxygen therapy.R5's MDS, dated [DATE], documents R5 is cognitively intact and is independent for her ADLs. R5 is always continent of bowel and bladder.R5's Physician Order, dated 12/2/25, documents May discharge with PT/OT/HH services with nursing.R5's Nursing Note, dated 12/9/25 at 1:23 PM, documents Daughter informed this nurse that her mother would be discharging immediately due to not being able to part with her Medicaid check. Assured this nurse that she has medication coverage and oxygen prepared for at home use. Social services offered home health services. Resident assisted by staff to discharge.R5's Discharge summary, dated [DATE] at 2:06 PM, documents (R5) discharged on the 9th of the month. Daughter said that she will be taking care of her mother in the home and do not want a health care company for PT and nursing. The reason being is that they do not work within her schedule. She prefers not to have one. V17 (R5's Daughter) said that she will be calling Dept (Department) on aging to see if she can get paid for helping her mother. (R5) goes to (name of hospital) to see physician. She will be seeing him within the two weeks of discharge. (V17) discharged her mother within a day. Therefore, SSD (Social Service Director) is still trying to get her a chore worker. SSD spoke with (V17) today and she said that her mother is doing ok. R5's Nursing Note, dated 12/9/25 at 2:11 PM, documents Resident discharged home with medication and discharge instruction. Transported by family via private vehicle. No concerns of pain or discomfort.On 2/23/26 at 9:06 AM, V17 stated My mother (R5) was in the facility for rehab after a lengthy hospital stay. I decided to take her home to care for her and upon her discharge from facility, they gave us a lot of papers, medications, and prescriptions in an envelope. I took the envelope and handed them to the pharmacy to get my mom's meds, and the pharmacist told me those were not my mom's prescriptions and were for someone else (R4). I called and let them know and the nurses then had to e-scribe the prescriptions to the pharmacy to get the correct meds. I was unsure what exactly was in the envelope but was upset because if we have someone else's information, then that other person must have my mom's.On 2/24/26 at 9:28 AM, V13 (Social Service Director) stated On 12/9/25, I had two residents leaving at the same time, (R4 and R5), and I gathered the discharge paperwork in a yellow envelope, unsealed, and accidentally gave each one the wrong envelope. I asked (R5 and her daughter/V17) if they would go over the paperwork with me before they left, and her daughter stated the paperwork was already put in (R5's) bag and she was not going to go get them to go over the paperwork. If she would have, they probably would have discovered the mistake. (R5's) daughter called and cursed me out about the mix up. I then called (R4) to explain to her family what happened, and they were fine and not upset about it.On 2/24/26 at 10:43 AM, V2 (Director of Nursing), stated During a resident's discharge, we normally do not give out paper prescriptions, we always give them a 30-day supply of the medications along with discharge paperwork. (R5's) daughter refused the 30-day supply of medications and insisted on the NP (Nurse Practitioner) to write paper prescriptions instead. The NP agreed to do so, and the paper prescriptions were place in (R5's) discharge paperwork envelope. I received a phone call from (R5's) daughter who began cursing at me from the start about the mix up of prescriptions. I asked them if they would bring the paperwork back, that I would give her the correct ones and (R5's) daughter refused. I had to ask the NP to send (R5's) prescriptions electronically to the pharmacy to get filled, which she did. We had a discharge Care Plan meeting with (R5), her daughter, and other managers and (R5's) discharge was discussed and planned at that time. That is when any discharge teaching is done to (R5) and her daughter, so the nurse doesn't have to take the time to do so upon discharge. The nurses get the paperwork and prescriptions, if on paper, together and gives them to Social Service Director, who will go through it with the resident and family. I never heard back from (R4) or her family, so I reached out to them. (R4) had her own medications and did not have to go to the pharmacy and her family were understanding and not upset about the situation.On 2/25/26 at 8:05 AM, V13 stated The paperwork that I go over with a resident who is getting discharged is any appointments they may have, the discharge instructions, home health and other agencies contact information and appointments that may be set up. I did go through the correct paperwork with (R4) and I remember putting them in a large envelope. I must have given them the wrong envelopes when they left. (R5) and her daughter did not want to go through the paperwork and just wanted their envelope so they could leave.On 2/25/26 at 8:40 AM, V1 (Administrator) stated We do not have copies of the paperwork that was given to (R4 and R5) upon discharge.On 2/25/26 at 11:55 AM, V1 stated I would expect the staff to maintain a resident's confidentiality at all times and to ensure that a resident getting discharged has the correct paperwork to avoid any resident personal information be shared to others.The Facility's Resident Rights/Ombudsman Program Policy, dated 11/2028, documents in part You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Your facility may not give information about you or your care to unauthorized persons without your permission, unless you are being transferred to a hospital or to another health care facility.The Facility's HIPAA Compliance/HIPAA Administrative Requirements Policy, dated 9/2015, documents in part To help ensure that Facility implements and adheres to administrative, technical and physical safeguards in connection with PHI. Facility will implement intentional or unintentional administrative, technical and physical safeguards designated to protect against any use or disclosure of PHI in violation of the HIPAA Privacy Rule or these HIPAA Privacy Policies and Procedures. Facility will reasonably safeguard PHI to limit incidental uses or disclosures made pursuant to an otherwise permitted or required use or disclosure.

Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse for 2 of 6 residents (R2 and R3) reviewed for abuse in a sample of 7. Findings Include: 1. R3's Face Sheet, original admission date of 12/26/22, documented R3 has diagnoses of but not limited to dementia, parkinsonism, bipolar disorder, and hypertension (HTN). R3's MDS (Minimum Data Set), dated 09/24/25, documented R3 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and is independent with most of his activities of daily living (ADLs) and with walking 50 feet. R3's Care Plan, not dated, documented the following: R3 refuses to change rooms or be moved off the hall regarding recent altercation with another resident. Goal: R3 will not engage in an altercation until next review. Intervention: R3 was educated to not engage with the resident he recently had an altercation with. Staff will continue to redirect them and keep them apart in common areas. R3 is at risk for being verbally/physically inappropriate, abusive with staff and other residents' r/t being short tempered and having impaired cognition. R3 makes false accusations of staff during ADL care. R3 has been noted with clippers and attempts to cut other residents' hair. Goal: R3 will fewer behavioral episodes. Interventions include but are not limited to Encourage him to express feelings appropriately, Explain/reinforce why behavior is inappropriate and/or unacceptable to him, and report any claims of abuse/touching/kissing to the Administrator, Director of Nursing (DON), Medical Doctor (MD), Power of Attorney (POA), ensure the safety of those around him, and educate him on the importance of NOT kissing, touching other residents for any reason. R3 was physically aggressive with his peer's related to (r/t) Anger, Dementia, Depression, History of harm to others, Poor impulse control and diagnosis of bipolar disorder. R3 was physically aggressive on 7/6/25. Goal: R3 will seek out staff/caregiver when agitation occurs through the review date. Interventions include but are not limited to Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, both residents separated immediately, full assessment completed by nursing staff, police and proper authorities notified resident sent to hospital for labs urinalysis (UA) and psych evaluation. R3 has potential to experience psychosocial/mental abuse. Goal: R3 will have no indications of psychosocial well-being problem by/through review date. Interventions include but are not limited to Consult with: Pastoral care, social services, Psych services, Other and when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. State surveying agency Final Serious Injury Incident and Communicable Disease Report, incident dated of 11/18/25 at 7:35 AM, documented the following:This is the follow up report to the 11/18/25 reportable for R3 and R2. R3 is a [AGE] year-old long term male resident with diagnosis of dementia, parkinsonism, hypertension, kidney disease, muscle weakness, history of falling, lack of coordination, and atherosclerosis. He has a BIMS of 15. R2 is a [AGE] year-old long term male resident with diagnosis of diabetes, schizophrenia, vascular disease, right below knee amputation, attention and concentration deficit, cognitive communication deficit, and muscle weakness. At approx. (approximately) 7:35 AM staff reported an alleged resident to resident altercation in the dining room. Residents were immediately separated. Both residents were assessed with no injury noted. Police, responsible parties and physician were notified. Investigation initiated per protocol. During the investigation, R3 was interviewed and stated that he was propelling himself through the dining room. R2 was also in the dining room and was in the path that R3 was taking. R3 asked him to move over, but R2 yelled out and pushed R3's wheelchair. R3 reached out to stop his wheelchair from moving when R2 made contact with him causing R3 to fall from his wheelchair.R2 was also interviewed. He stated that R3 was propelling through the dining room and wheeled next to him, into R2's personal space. R2 requested that R3 back up, but he refused. R2 made contact with R3, causing him to fall from his wheelchair. Local police were contacted. Police officer came to the facility but declined to interview the residents. Based on the resident's medical and psych diagnosis, there is no evidence of intentional abuse. Both residents have continued to do their routine with no mental anguish. Both care plans have been updated accordingly. Will continue to monitor for behaviors. Typed Interview from V11 (Former Business Office Manager/BOM), dated 11/18/25, documented the following: To whom it may concern, I V11, was on my way to the dining room this morning around 7:35 AM and as I was walking down the hallway to the dining room, I noticed a lot of staff running into the dining room. As I entered the dining room, I noticed a resident R3 on the floor trying to get up while nurses and CNAs (certified nursing assistants) were present. After entering the dining room, I found out R3 and R2 had gotten into a fist fight. The witnesses were stating that R3 was at the table cleaning it off, where another resident was sitting. R2 was sitting at a table near the kitchen area where he usually sits and went over to the table where he saw R3 wiping off the table and went over and said something to him and R3 hit him, and he hit R3 back and R3 fell on the floor. As I began speaking with R2, he began saying out loud, quote I hit him. I said to R2, we had a talk with you recently regarding trying to stay away from R3, and he began yelling, saying that we always defend R3 and let him do what he wants to do. That statement is not true. R3 and R2 were okay, but I did notice a small bruise under R3's chin. R3's Progress Notes were reviewed and there was no documentation regarding the resident-to-resident altercation with R2 on 11/18/25. R2's Progress Notes, dated 11/18/2025 at 15:49 (3:49 PM) documented the following Note Text: I heard arguing in the dining room and upon entering found this resident and another resident who was in the floor, hitting and kicking each other. They were separated and taken to their rooms. The Administrator and NP (Nurse Practitioner) were notified of occurrence. 2. R2's Face Sheet, original admission date of 07/25/25, documented R2 has diagnoses of but not limited to Schizophrenia, unspecified, Type II Diabetes Mellitus, and acquired absence of right leg below the knee. R2's Minimum Data Set, dated [DATE], documented R2 is cognitively intact with a BIMS of 15 out of 15, needs partial/moderate assistance with most of his ADLs, and with standing. R2's Care Plan, not dated, documented R2 is/has potential to be verbally and physically aggressive r/t Schizophrenia. Goal: R2 will demonstrate effective coping skills through the review date, R2 will not harm self or others through the review date, and the resident will seek out staff/caregiver when agitation occurs through the review date. Interventions include but are not limited to Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, Assess and address for contributing sensory deficits, Monitor/document/report as needed (PRN) any signs and symptoms (s/sx) of resident posing danger to self and others, and Psychiatric/Psychogeriatric consult as indicated. It also documented R2 has potential to experience psychosocial/mental abuse. Goal: R2 will have no indications of psychosocial well-being problem by/through review date. Interventions include but not limited to When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. The state surveying agency Initial Serious Injury Incident and Communicable Disease Report, incident dated of 11/26/25 at 9:57 AM, documented the following: R3 is a [AGE] year-old long term male resident with diagnosis of dementia, parkinsonism, hypertension, kidney disease, muscle weakness, history of falling, lack of coordination, and atherosclerosis. He has a BIMS 15. R2 is a [AGE] year-old long term male resident with diagnosis of diabetes, schizophrenia, vascular disease, right below knee amputation, attention and concentration deficit, cognitive communication deficit, and muscle weakness. On 1/23/25, staff reported R3 was using a box cutter type tool to scrape the dirt from the dining room tables. Administrator and Social Service Director asked R3 to give up the tool as it was unsafe for a resident to have it. R3 refused. Local police were called and R3 gave the tool to the police without incident. On 1/26/25, at approximately 9:57am, R2 told staff that R3 had threatened R2 with the box cutter tool. Investigation was initiated. Follow up report will be sent. R2's Progress Notes were reviewed and have no documentation regarding the incident involving R2 and R3 on 1/23/26. R3's Progress Notes, dated 1/23/2026 15:47 (3:47 PM) documented Behavior Note Text: It was reported that R3 had a razor-sharp item in his possession. SSD (Social Service Director) explained to R3 that the item needed to be turned in so no one will get hurt. R3 refused to give the item to SSD or the Adm (Administrator). Calls were made to his son and his parole officer to see if it would encourage R3 to give the item up. R3 still refused to say no, he was not giving it to anyone. Local Police dept. (department) was called to retrieve the instrument. R3 gave it to one of the policemen. His parole officer will be coming to see him in early Feb. (February). On 01/28/26 at 9:45 AM, R3 is lying in bed in his room that had multiple boxes all over the floor and in his closet and one side of his closet was padlocked shut. He had needles and thread in the top drawer of his bedside table located over by his door, he had nail clippers laying on his bedside table, a disposable razor in a holder on his wheelchair, and a drill bit laying on another table in his room.On 1/26/2026 at 10:30 AM, R3 was asked about what had happened Friday with the box cutter, he stated the R2 was an as****e and he came down to the dining room and was just cussing in front of everyone, while I was scraping the tables with my box cutter because the tables are sticky. R2 continued to state that he told him to stop cussing in front of the children that were visiting. He didn't stop cussing so R3 told him to stop and that he would get him one way or another because (R2) don't think his s**t don't stink. R3 stated that the Social Services Director and the Activity Director came to him and tried to take it away, but they called the police on him, and he gave it to him. On 1/26/2026 at 11:45 AM, R2 stated that R3 threatened him with the box cutter while out in the dining last Friday (1/23/26). R2 stated that he told the staff the R3 had it and the staff attempted to take it away from him, but he wouldn't give it to them. R2 stated that staff asked R3 why he had it and R2 stated that R3 said it was for him (R2). R2 stated that he does not feel safe in the facility. R2 stated, when asked, if he reported it to the staff on Friday of what R3 said to him, he said yes, he did. On 1/26/2026 at 12:30 PM, R1 stated that R3 could have killed them or any of the staff with the box cutter and he does not feel safe living in the facility. R1 stated that R3 lives on the same hall as he does. On 1/26/2026 1:00 PM, R6 stated that she does not feel safe living in this facility because of the resident (R3) that has a box cutter, and he has threatened another resident. R6 also stated that she feels that V1 (Administrator) ignores their complaints and sweeps everything under the rug. On 01/27/26 at 11:35 AM, Follow up interview with R2. R2 said R3 threatened him with a box cutter on Friday and administration knew about it but they didn't do anything about it. He said he didn't see any police come to the facility and remove the box cutter from R3 and he (R3) has a lot more stuff in his room. R2 said he doesn't feel safe at the facility because of the incident with R3. R2 said he couldn't get up and walk and R3 could so he wouldn't be able to get away from R3. R2 said V8 (Social Services Director/SSD) asked R3 what the box cutter was for and R3 pointed to him (R2) and said it was for him. On 01/27/26 at 11:50 AM, V8 (SSD) said she can't remember who came and got her, but someone did. She said they told her R3 had something like a box-cutter/razor blade. V8 said she went down to the dining room area where R3 was at and asked him for the sharp object. She said she even begged, and he showed it to her, but he wouldn't give it to her. V8 said her and V1 (Administrator) both went down to R3 room with him trying to get the box-cutter from him, but he wasn't going to give it to them. V8 said V1 stayed with R3 while V8 went down to her office and called the police. She said the police came and retrieved the item from R3 with no issues. She said he wouldn't tell them where he got the box-cutter, but he did tell them he used it for his crafts and wanted to know how he was going to be able to use it now. She said she told him when he wanted to use sharp objects, he would have to use them with activities, and they would keep it locked up for him. V8 said a few days before this they had to take scissors away from R3 and lock them up. She said R3 shouldn't be allowed to have sharp objects due to his temperament is kind of bad. On 01/27/26 at 12:45 PM, V1 (Administrator) said yes, she stayed with R3 while V8 (SSD) went down and called the police. She said she stayed in the room with him because R3 had secured it (box-cutter) in his room, and he wouldn't give it over to them, so they didn't want him to get it out with no one being in the room. She said R3 told her he's had the box-cutter for years and she said you could tell it was old. V1 said the police came and R3 handed it right over to them. V1 said V8 had also taken scissors away from R3 and put them up. V1 said she visually looked around his room and didn't see anything but when his parole officer comes, they are going to do a sweep of his room to make sure he doesn't have anything else. V1 said R3 told her he would let her (V1) look around with his parole officer here. On 01/27/26 at 2:10 PM, R7 who is cognitively intact with a BIMS of 15 out of 15 stated he was in the dining room when the incident happened between R2 and R3. He said R3 had brought some type of razor knife to the dining room and was cleaning stuff off the tables with it. R7 said when R3 was asked why he had it (box-cutter) he said R3 stated it's for him and pointed to R2. R7 said R3 refused to give it to V1 (Administrator). R7 said he didn't see any police in the building that day after the incident. R7 stated today was the first day in a long time they had butter knifes given to them at mealtime. He said he saw R3 out in the dining room using the butter knife to cut some fabric off one of the bibs. On 01/28/26 at 9:45 AM, Follow up interview with R3. R3 said he had a tool that had a razor blade like object on the end of it and he was using it to scrap off the tables in the dining room. He said R2 can't say a sentence without having cuss words in it and he doesn't like that kind of language being use exceptionally around little kids. R3 said R2 came in the dining room wanting to start something with him and he told him he wished he could put R2 back in the sewer, close the lid, flush it, and make sure he doesn't come back up. R3 said he has a wrench and other tools in his room, but the facility isn't aware he has them. On 01/28/26 at 10:25 AM, V3 (Licensed Practical Nurse/LPN) said she didn't see the incident between R2 and R3 and she didn't hear R3 threaten R2. She said R2 and R3 just don't get along. She said they will wheel past each other and both will mumble stuff under their breath, and it just goes from there and both will just get louder and louder. R3 only seems to argue with R2. On 01/28/26 at 10:35 AM, V6 (Certified Nursing Assistant/CNA) stated R3 had a box-cutter or something like it and he took it out in the dining room. He said he didn't see it, but he did have it. He said they had to call the police to come out and get it from R3. R6 said R2 and R3 just don't mix well, and they will say things to each other. He said you never know who really starts it. The facility's Abuse Prevention Program, last revision dated of 2/2023, documented Purpose: This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriations of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. The facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. It further documented Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. It also documented Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. It also documented Willful as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to ensure residents were free from abuse in 2 of 3 residents (R2, R3) reviewed for sexual abuse in the sample of 6. This failure resulted in R2 crying, was emotional and shaken up. For a reasonable, rational person this would result in psychosocial distress.Top of FormFindings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.R1's Care Plan dated 8/5/25 documents R1 has a behavior problem of being sexually inappropriate. On 10/10/25 at 1:35 PM, V8 (Certified Nursing Assistant/CNA Supervisor) stated R1 has been on 15-minute checks since 8/22/25 for inappropriate behavior.On 10/14/25 at 9:10 AM, V14 (Nurse Practitioner) stated R1 has a history of sexual aggression and is monitored every shift.On 10/14/25 at 9:15 AM, V4 (Licensed Practical Nurse/LPN), stated R1 has inappropriately touched staff in the past and is on 15-minute checks for monitoring.On 10/14/25 at 9:53 AM, V16 (CNA) stated R1 has a history of inappropriately touching both staff and residents and requires redirection. 2.) R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities.R2's MDS dated [DATE] documented R2 was moderately cognitively impaired and ambulated by wheelchair.R2's Care Plan dated 6/5/25 documents R2 is at risk of abuse due to impaired cognition.On 10/10/25 at 12:35 PM, R2 stated, (R1) touched me down there (pointed to genital area). That's not good for me. I don't like him touching me.The Facility's Initial Report sent to the state surveying agency on 10/5/25 documents R1 attempted to touch R2 on her private area at the nurse's station. R2's Progress Note by V7 (LPN) on 10/5/25 at 5:41 PM documents, Resident stated she was touched on her private area by a male resident in the hallway by nurse station.On 10/10/25 at 12:30 PM, V5 (Social Services Director/SSD) stated, I know it happened. We believe her when she tells us it happened and took it (the allegation) seriously. This is not the first time (R1) has had inappropriate behaviors. On 10/14/25 at 9:56 AM, V7 stated she was R2's nurse when R2 reported the allegation to her. V7 saw R2 next to the nurse's station while R1 was self-propelling his wheelchair down the hallway. V7 went to her medication cart, and a few minutes later R2 came and said R1 touched her. R1 was rolling himself back down the hallway at that time, and R2 was pretty shaken up. R2 was crying and pretty emotional. On 10/14/25 at 9:50 AM, V15 (Activities Director) stated she was about to take residents on an outing and R2 motioned for her to come over to her. R2 told V15 that R1 had touched her in the private area.The Facility's Final Report and Conclusion of Incident also documents R2 reported R1 touched her private area while she was sitting at the nurse's station. When interviewed by V1, R2 asked what the Facility was doing about it. R1 was interviewed about the incident and replied, What is wrong with that? 3.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two and muscle weakness.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was cognitively intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted here, she was at the nurse's station when R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for R1 and R3. On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between R1 and R3 could be considered sexual abuse, because there was no physical touching. R1 was just asking R3 if she would be interested and does not feel that would be upsetting to people.On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Bottom of Form

Based on interview and record review, the Facility failed to implement its abuse policy through prevention, reporting and investigating abuse allegations in 2 of 3 residents (R2, R3) reviewed for abuse in the sample of 6. Top of FormFindings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.R1's Care Plan dated 8/5/25 documents R1 has a behavior problem of being sexually inappropriate. On 10/10/25 at 1:35 PM, V8 (Certified Nursing Assistant/CNA Supervisor) stated R1 has been on 15-minute checks since 8/22/25 for inappropriate behavior.On 10/14/25 at 9:10 AM, V14 (Nurse Practitioner) stated R1 has a history of sexual aggression and is monitored every shift.On 10/14/25 at 9:15 AM, V4 (Licensed Practical Nurse/LPN), stated R1 has inappropriately touched staff in the past and is on 15-minute checks for monitoring.On 10/14/25 at 9:53 AM, V16 (CNA) stated R1 has a history of inappropriately touching both staff and residents and requires redirection.2.) R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities.R2's MDS dated [DATE] documented R2 was moderately cognitively impaired and ambulated by wheelchair.R2's Care Plan dated 6/5/25 documents R2 is at risk of abuse due to impaired cognition. On 10/10/25 at 12:35 PM, R2 stated, (R1) touched me down there (pointed to genital area). That's not good for me. I don't like him touching me.The Facility's Initial Report sent to the state surveying agency on 10/5/25 documents R1 attempted to touch R2 on her private area at the nurse's station. R2's Progress Note by V7 (Licensed Practical Nurse/LPN), on 10/5/25 at 5:41 PM documents, Resident stated she was touched on her private area by a male resident in the hallway by nurse station.On 10/14/25 at 9:56 AM, V7 stated she was R2's nurse when R2 reported the allegation to her. V7 saw R2 next to the nurse's station while R1 was self-propelling his wheelchair down the hallway. V7 went to her medication cart, and a few minutes later R2 came and said R1 touched her. R1 was rolling himself back down the hallway at that time, and R2 was pretty shaken up. R2 was crying and pretty emotional. On 10/10/25 at 12:30 PM, V5 (Social Services Director/SSD), stated, I know it happened. We believe her when she tells us it happened and took it (the allegation) seriously. This is not the first time (R1) has had inappropriate behaviors.On 10/14/25 at 9:50 AM, V15 (Activities Director) stated she was about to take residents on an outing and R2 motioned for her to come over to her. R2 told V15 that R1 had touched her in the private area.The Facility's Investigation was provided on 10/10/25 at 12:36 PM. The investigation did not include any staff or resident interviews.On 10/10/25 at 1:37 PM, V1 (Administrator) provided an additional document that listed names of residents interviewed by V5 (Social Services Director) on 10/9/25. Residents listed included R3, R5, and R6. On 10/10/25 at 1:43 PM, R3 stated V5 just interviewed her about the incident between R1 and R2 earlier today.R3's MDS dated [DATE] documented R3 was cognitively intact.On 10/10/25 at 3:10 PM, R5 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility. R5's MDS dated [DATE] documented R5 was cognitively intact.On 10/10/25 at 3:11 PM, R6 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility.R6's MDS dated [DATE] documented R6 was cognitively intact.On 10/14/25 at 4:00 PM, V1 stated it is a problem if residents are saying they were not interviewed for this investigation.The Facility's Final Report and Conclusion of Incident documents V4 (LPN), reported R2's abuse allegation to V1. On 10/14/25 at 9:15 AM, V4 stated she was unaware of R2's allegation against R1 and did not report this to V1 because she had no knowledge of it.The Facility's Final Report and Conclusion of Incident also documents R2 reported R1 touched her private area while she was sitting at the nurse's station. When interviewed by V1, R2 asked what the Facility was doing about it. R1 was interviewed about the incident and replied, What is wrong with that?3.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two and muscle weakness.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was cognitively intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted here, she was at the nurse's station when R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for R1 and R3. V1 was notified that R3 alleged R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to the Facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by R3 about R1 that was reported to her on 10/10/25. On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between R1 and R3 could be considered sexual abuse, because there was no physical touching. R1 was just asking R3 if she would be interested and does not feel that would be upsetting.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. documents Facility staff will report and investigate any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse. Bottom of Form

Based on interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 6.Findings include:1.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two and muscle weakness.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was cognitively intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted to the facility, she was at the nurse's station and R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she reported this incident to staff working at the time but could not remember their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the facility did not have any abuse investigations for R1 and R3. V1 was notified that R3 alleged R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to the facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by R3 regarding R1. On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy. On 10/14/25 at 4:00 PM, V1 stated she did not understand how the incident with R1 and R3 could be considered abuse since there was no physical touching. R1 was just asking R3 if she would be interested.The Facility's Abuse Prevention Program Policy revised 2/2023 documents abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Facility staff will report any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse.

Based on interview and record review, the Facility failed to thoroughly investigate abuse allegations from 1 of 3 residents (R2) reviewed for abuse in the sample of 6.Findings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.2.) R2's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities.R2's MDS dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.On 10/10/25 at 12:35 PM, R2 stated, (R1) touched me down there (pointed to genital area). The Facility's Initial Report sent to state surveying agency on 10/5/25 at 5:41 PM documents R1 attempted to touch female resident R2 on her private area at the nurse's station. The Facility's Investigation was provided on 10/10/25 at 12:36 PM. The investigation did not include any staff or resident interviews.On 10/10/25 at 1:37 PM, V1 (Administrator) provided an additional document that listed residents interviewed by V5 (Social Services Director)on 10/9/25. Residents listed included R3, R5, and R6.On 10/10/25 at 1:43 PM, R3 stated V5 just interviewed her about the incident between R1 and R2 earlier today.R3's MDS dated [DATE] documented R3 was cognitively intact.On 10/10/25 at 3:10 PM, R5 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility. R5's MDS dated [DATE] documented R5 was cognitively intact.On 10/10/25 at 3:11 PM, R6 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility.R6's MDS dated [DATE] documented R6 was cognitively intact.On 10/14/25 at 4:00 PM, V1 stated it is a problem if residents are saying they were not interviewed as part of the investigation.The Facility's Final Report documented V4 (Licensed Practical Nurse) reported the incident to V1 (Administrator).On 10/14/25 at 9:14 AM, V4 stated she had no knowledge of R2's allegation toward R1 and did not report this to V1 because she knew nothing about it.On 10/14 25 at 12:52 PM, V1 stated the investigation she provided was complete.On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/2023 documents Facility staff will investigate any allegations of abuse within timeframes required by Federal law.

Based on observation, interview, and record review the facility failed to 1) develop and implement a person-centered plan of care for fall prevention; 2) ensure proper working order of R2's bed for 1 of 3 residents reviewed for falls in the sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer, R2's bed rolled away from him due to a malfunctioning locking mechanism, and with R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include:R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Morse Fall Scale, dated 07/25/25 at 2:29 PM, documented R2 was a high risk for falling with a score of 50. Morse Fall Scoring is as follows: High Risk 45 and higher, moderate risk 25-44, and low risk 0-24. R2's Care Plan, date initiated for falls 08/19/25, documented R2 is at risk for falls. Gait/balance problems d/t (due to) a recent BKA (below the knee amputation). 08/17/25 Unwitnessed fall, reopened surgical BKA. Goal: The resident will be free of injury (r/t related to) falls. Interventions include but not limited to anticipate and meet the residents needs as needed, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol. R2's Progress Notes, dated 8/9/2025 at 10:13 PM, Administration Note: documented R2 had his staples removed from his right BKA. R2's Progress Notes, dated 8/16/2025 at 11:21 AM, Administration Note: documented R2's areas to his right BKA had healed over. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN) R2' Progress Notes, dated 8/18/2025 at 5:16 AM, documented *Transfer to Hospital Summary Resident admitted to Local Hospital Admitting diagnosis (Dx): wound Dehiscence. R2's Operative Note, dated 08/20/25 at 10:18 AM, documented R2 had depleted (used up) venous (vein) access and a suitable IV (Intravenous) could not be started. Instead, they had to place a triple lumen-catheter (a type of central venous catheter in his right femoral vein (in his right groin area) to be able to administer the general anesthesia. Under general anesthesia the right leg was prepped and draped. The patient had a complete dehiscence (is a surgical complication where a closed incision reopens, exposing internal tissues and potentially organs) of the right BKA closure site. There was a hematoma present. The incision was made along the previous closure site and the entire below-knee flap was taken down. There was evidence of some nonviable (incapable of life or living) muscle and traumatized muscle from the fall as well as a hematoma (localized collection of blood that pools outside of blood vessels) which was evacuated (removed). There was a large amount of fibrous tissue in the posterior flap. An excisional debridement was preformed of these fibrous tissues. A portion of the tibial bone was exposed in the wound. Proximally a cm of tibial bone was then excised using a power saw. All the posterior flap was viable with no evidence of necrosis or ischemia. The wound was irrigated with an antibiotic solution, the posterior flap was brought anteriorly, and the previous skin incision was reapproximated using interrupted vertical sutures. The leg was dressed with Adaptic gaze, fluff gauze, kerlix wraps and an ace wrap. R2's Progress Notes, dated 08/22/2025 at 4:00 PM, documented R2 returned to the facility at this time.R2's Illinois Department of Public Health (IDPH) Final Report, dated 08/25/25, documented Diagnosis: Attention and concentration deficit, moderate protein-calorie malnutrition, peripheral vascular disease, unspecified, cognitive communication deficit, complete traumatic amputation at knee level, right lower leg, subsequent encounter, muscle weakness (generalized), need for assistance with personal care, acquired absence of right leg below knee. Nursing reported a fall with injury. The fall took place on 8/17 at 22:30. Resident was sent out to the hospital for further evaluation. Resident was a new admission that came to the facility on 7/25/25, brand new amputee on right lower leg. Resident was found lying on the floor that resulted from a fall. Resident was trying to complete a self-transfer. Resident is a brand-new amputee and has a diagnosis deficit. Resident lack safety awareness and has not come to terms with his most recent amputation. Resident has difficulty with asking for assistance or using his call light because he is in denial about losing his independence. Resident was interviewed and stated he had to poop. Resident didn't want to ask for help, so he initiated a self-transfer and fell. The resident had a laceration, but he also caused his surgical wound to reopen resulting in a hematoma. Resident was sent out for further evaluation. Resident returned on 8/22 after the hospital completed a revision of his right BKA closure site. The hospital didn't come back with any new wound treatments. Our wound nurse was able to assess and obtain orders from out Nurse Practitioner to do the following: resident returned with sutures, apply wet to dry dressing with ABD pad and Kerlix/ace wraps daily. Resident care plan has been updated with new interventions regarding his recent fall and will continue therapy to build his upper body strength to conduct safe transfers. Will continue to monitor resident at this time. On 09/11/25 at 1:25 PM, R2 said his bed was broke and his wheels on the bed wouldn't lock. He said he had his wheelchair beside the bed and when he was trying to get out of bed and into his wheelchair the bed rolled away from him, and he fell on the floor and busted his stump open. R2 said he put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help. R2 said two certified nursing assistants (CNAs) finally came down and helped him up off the floor, they put him in his wheelchair and wheeled him up to the nurse's station (NS) so the nurse could check him out. R2 said they sent him out to the hospital, and they put the sutures back in his leg and then sent him home on Sunday. On 09/16/25 at 11:57 AM, V14, Maintenance Director said he isn't sure if R2 got a new bed or not and he would have to look it up. He then asked V15, Maintenance who was standing next to V14 if he remembered if R2 had gotten a new bed and V15 said yes, he did. This surveyor asked V14 and V15 if they could tell me why R2 received a new bed. V15 said because R2 complained his bed wouldn't lock. V14 then stated the locking mechanism on the bed wasn't working and when it doesn't work it will cause the bed to slide. On 09/17/25 at 2:41 PM, Follow up interview with R2. R2 said the incident happened around eight or nine in the evening. He said he went to get up on his own and the bed slid, he fell, and he put his call light after he fell. R2 said he waited for a long time, and no one came to assist him, so he crawled out into the hallway and yelled for help, and it still took the CNAs a while to come and help him. R2 stated the CNAs finally came and got him in his wheelchair and took him to the nurse's station for the nurse to assess. R2 said he was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out R2's bed was broken from a work order then he stated, no he made a note in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of R2's bed not working properly. She said R2 came in and then he had the fall, and it was sometime during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem R2 a fall risk and there should be a fall plan of care in place for him. V19 stated the fall R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks the facility failed in preventing R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death. He said it's unacceptable and he absolutely agrees the facility failed. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well being. It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I. Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever the resident has a fall that is not consistent with previously identified risk factors. This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.

Based on interview and record review the facility failed to ensure essential resident equipment was in good working condition for 1 of 1 resident reviewed for physical environment in a sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer, R2's bed rolled away from him due to a malfunctioning locking mechanism, and with R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include: R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN). The facility's Work Order/Maintenance request form, dated 08/18/25, documented V14, Maintenance Director per: Morning meeting that R2 needed his bed replaced due to bed/lock on old bed defective. On 09/11/25 at 1:25 PM, R2 said his bed was broke and his wheels on the bed wouldn't lock. He said he had his wheelchair beside the bed and when he was trying to get out of bed and into his wheelchair the bed rolled away from him, and he fell on the floor and busted his stump open. R2 said he put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help. R2 said two certified nursing assistants (CNAs) finally came down and helped him up off the floor, they put him in his wheelchair and wheeled him up to the nurse's station (NS) so the nurse could check him out. R2 said they sent him out to the hospital, and they put the sutures back in his leg and then sent him home on Sunday. On 09/16/25 at 11:52 AM, V16, Housekeeping said R2 did complain that his bed slides and he fell because of it. On 09/16/25 at 11:57 AM, V14, Maintenance Director said he isn't sure if R2 got a new bed or not and he would have to look it up. He then asked V15, Maintenance who was standing next to V14 if he remembered if R2 had gotten a new bed and V15 said yes, he did. This surveyor asked V14 and V15 if they could tell me why R2 received a new bed. V15 said because R2 complained his bed wouldn't lock. V14 then stated the locking mechanism on the bed wasn't working and when it doesn't work it will cause the bed to slide. On 09/17/25 at 2:41 PM, Follow up interview with R2. R2 said the incident happened around eight or nine in the evening. He said he went to get up on his own and the bed slid, he fell, and he put his call light after he fell. R2 said he waited for a long time, and no one came to assist him, so he crawled out into the hallway and yelled for help, and it still took the CNAs a while to come and help him. R2 stated the CNAs finally came and got him in his wheelchair and took him to the nurse's station for the nurse to assess. R2 said he was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out R2's bed was broken from a work order then he stated no he made a note in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of R2's bed not working properly. She said R2 came in and then he had the fall, and it was sometime during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed.V25, Regional Director stated the facility doesn't have an updated policy for maintenance as they are transitioning to a new system.

Based on interview and record review the facility failed to develop and implement a person-centered plan of care for fall prevention for 1 of 3 residents reviewed for falls in a sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer and R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include: R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Morse Fall Scale, dated 07/25/25 at 2:29 PM, documented R2 was a high risk for falling with a score of 50. Morse Fall Scoring is as follows: High Risk 45 and higher, moderate risk 25-44, and low risk 0-24. R2's Care Plan, date initiated for falls 08/19/25, documented R2 is at risk for falls. Gait/balance problems d/t (due to) a recent BKA (below the knee amputation). 08/17/25 Unwitnessed fall, reopened surgical BKA. Goal: The resident will be free of injury (r/t related to) falls. Interventions include but not limited to anticipate and meet the residents needs as needed, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN). R2's Operative Note, dated 08/20/25 at 10:18 AM, documented R2 had depleted (used up) venous (vein) access and a suitable IV (Intravenous) could not be started. Instead, they had to place a triple lumen-catheter (a type of central venous catheter in his right femoral vein (in his right groin area) to be able to administer the general anesthesia. Under general anesthesia the right leg was prepped and draped. The patient had a complete dehiscence (is a surgical complication where a closed incision reopens, exposing internal tissues and potentially organs) of the right BKA closure site. There was a hematoma present. The incision was made along the previous closure site and the entire below-knee flap was taken down. There was evidence of some nonviable (incapable of life or living) muscle and traumatized muscle from the fall as well as a hematoma (localized collection of blood that pools outside of blood vessels) which was evacuated (removed). There was a large amount of fibrous tissue in the posterior flap. An excisional debridement was preformed of these fibrous tissues. A portion of the tibial bone was exposed in the wound. Proximally a cm of tibial bone was then excised using a power saw. All the posterior flap was viable with no evidence of necrosis or ischemia. The wound was irrigated with an antibiotic solution, the posterior flap was brought anteriorly, and the previous skin incision was reapproximated using interrupted vertical sutures. The leg was dressed with Adaptic gaze, fluff gauze, kerlix wraps and an ace wrap. R2's Progress Notes, dated 08/22/2025 at 4:00 PM, documented R2 returned to the facility at this time. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem R2 a fall risk and there should be a fall plan of care in place for him. V19 stated the fall R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks the facility failed in preventing R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death. He said it's unacceptable and he absolutely agrees the facility failed. The facility's Care Planning policy, effective date of 05/02/07, documented Comprehensive Care Plans The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS/RAI). Each care plan will be dated indicating the date in which it was implemented. Each resident's comprehensive care plan should be designed to: o Incorporate identified problem areas; o Incorporate risk factors associated with identified problems; o Reflect goals and objectives in measurable outcomes; o Identify the professional services that are responsible for each element of care; o Aid in preventing or reducing declines in the resident's functional status and/or functional levels;o Enhance the optimal functioning of the resident and;o Build upon the strengths of the resident. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well-being. It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I. Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever the resident has a fall that is not consistent with previously identified risk factors. This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.

Based on observation, interview and record review, the facility failed to provide monitoring of a resident requiring continues oxygen with a known history of having smoking materials in the room and failed to implement interventions to ensure a safe environment for 1 of 3 residents (R3) reviewed for smoking. This failure resulted in (R3) continuing to smoke inside room while wearing oxygen placing self and others at risk for safety concerns. Findings include:This failure resulted in an Immediate Jeopardy began on 8/5/2025 when R3 who requires continuous oxygen and suffers from Chronic Obstructive Pulmonary Disease and Dyspnea was found to have odors of smoke of mind altering substances in his room. The survey team validated the abatement on 8/26/25 at 3:27pm. The facility remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.R3's Care Plan, dated 8/10/2025, documents that (R3) at for safety concerns r/t (related to) possession of smoking substance and using it in his room. The resident will not suffer injury from unsafe smoking practices. (R3) is instructed to get up every 2 hours to sit in his chair to have his room searched for drugs hidden. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. It also documents (R3) is at risk for safety concerns r/t having possession of smoking substances in his room while in use of O2 and not being supervised. The resident will not smoke without supervision. The resident will not suffer injury from unsafe smoking practices. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns.R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact.R3's Physician Order Sheet (POS), dated 5/20/2025, documents Oxygen 2LPM (liter per minute) per NC (nasal canula) continuous every shift.R3's progress Notes, dated 8/5/2025 at 3:24 AM, documents that Nursing Note (HC), Note Text: Writer has noted that resident was noted to have mind altering substance in his room. The smell of THC. Resident states he is aware of facility policy and will not do it again. Attendee to see resident today on rounds.R3's Progress Notes, dated 8/10/2025 at 10:34 AM, documents that Nursing Note (HC), Note Text: Day shift aide stated resident was in his room with door closed, when they opened resident door very strong smoke smell released from the room. Nurse educated resident on safety concerns while on oxygen and while in building as well facility smoking policies.On 8/11/2025 15:57 Nursing Note (HC) Note Text: room searched, sweep complete on room for smoking supplies. resident given copy of smoking policy, verbalized understanding of policy and verbalized understanding of education given by nurse V5 at time of smoking incident. will continue to f/u.On 8/20/2025 a review of R3's electronic health record documents no smoking assessment or contract. R3's Behavior Monitoring & Interventions, dated 8/5/2025 to 8/25/2025, and MONITOR - Behavior Symptoms documents, dated 8/5/2025 to 8/25/2025, documents no refusals of care.On 8/21/2025 at 11:00 AM R3's Electronic Health Record (EHR) reviewed. R3's EHR documents no smoking assessment and no contract. At that time R3's smoking assessments and contracts requested. R3's EHR documents no monitoring of R3 for smoking in room from 8/5/2025 to 8/10/2025. R3's EHR documents no refusal to transfer from bed to chair from 8/12/2025 to 8/19/2025, 8/21/25 to 8/24/2025. As of 8/25/2025 at 3:00 PM the facility hadn't provided R3's smoking assessments or smoking contract.On 8/20/2025 at 10:01 AM V2, Director of Nurses, stated that the midnight CNA upon entering R3's room, noticed the smell. V2 stated that they asked if he was smoking and R3 denied. V2 stated that they did not complete an incident report or complete an investigation. V2 stated that they put in place to get R3 up during the day. V2 stated that R3 has behaviors of yelling and cursing the staff out. V2 stated that when this occurs the staff leaves the room and then he goes down to the room and talk with R3. V2 stated that they completed a room search of R3's drawers and did not find anything. V2 stated that they were not able to search R3's bed or person because R3 would not get out of the bed.On 8/20/2025 at 11:32 AM V5, LPN, stated that she was notified of the strong smoke smell coming from room by V16, CNA, and that R3 had offered to sell V16 some marijuana. V5 stated that V16 identified the smell as marijuana. V5 stated that she entered R3's room. V5 stated that she did not see R3 smoking but was able to smell the aroma. V5 stated that she spoke with R3 about smoking in his room and he said he wouldn't do it anymore.On 8/20/2025 at approximately 11:00 AM V1, Administrator, stated that she was aware of R3 smoking and the care plan had been updated to reflect interventions put in place. V1 stated that this is not a new problem for R3. V1 stated that this has been going on prior to V1 date of hire in March. V1 stated that she inherited this problem.On 8/20/2025 at 2:15 PM V13, MDS Coordinator, stated that she was made aware of R3's smoking in his room on a Sunday. V13 stated that the facility addressed, provided education, and put interventions in place. V13 stated that the interventions are not working due to R3 refusing to get up. V13 stated that they continue to educate R3, and interventions are in place.On 8/20/2025 at 2:30 PM V10, Wound Nurse, stated that she was present on August 10 when R3 was noted to have smoked. V10 stated that she was alerted by staff that there was an odor coming from R3's room. V10 stated that upon entering V10 smelled the smoke. V10 stated that R3 was lying in bed with oxygen on and in place. V10 stated that she informed R3 that he could not smoke in his room because it was dangerous. V10 stated that she educated him on the risk of smoking with his oxygen. V10 stated that R3's oxygen was on and in place. V10 stated that she was able to get the lighter from R3. V10 stated that she didn't find any smoking supplies. V10 stated that she asked R3 where it was? R3 stated that he didn't have any more he smoked it all. V10 stated that she educated R3 on not smoking and R3 stated that he would not do it anymore. V10 stated that she was concerned because R3 has oxygen, and it could ignite. V10 stated that she started working at the facility in April. V10 stated that she was told that this was a problem prior to her employment.On 8/21/2025 at 2:04 PM V17, Nurse Practitioner (NP), stated that it is a big concern of any resident to smoke when using oxygen. V17 stated that the concern would be causing fire, harm to the resident and others. V17 stated that she would expect herself or the rounding physician to be notified. V17 stated that it is dangerous, and she would expect the resident to be assessed, interventions put in place, an investigation to be conducted, and ongoing monitoring.On 8/21/2025 at 3:00 PM V15, NP, stated that it was a fire hazard for R3 to be smoking in his room. V15 stated that it is dangerous for R3 to smoke in his room. V15 stated that R3 is on continuous oxygen and that could ignite causing harm and injury to R3 and his roommate if he has one. V15 stated that she would expect to be notified of the incident. V15 stated that she was not aware and not been notified of these incidents prior to this conversation. V15 stated that she would expect an investigation to be performed to find out how is R3 getting the items as he does not get out of the bed or leave his room. V15 stated that R3 health concerns could be a problem as well due to his COPD.On 8/25/2025 at 12:40 PM V16, CNA, stated that R3 showed her a small amount of substance in a bag. V16 stated that R3 identified it as marijuana and offered to sell it to her. V16 stated that she declined and reported it to her supervisor. V16 stated that she is unsure of the date. V16 stated that on a Sunday she came onto the hall and smelled a strong odor. V16 stated that she noticed that R3's door was closed. V16 stated that when she entered R3's room a cloud of smoke came out of the room. V16 stated that R3 was lying in bed with his oxygen on and in place. V16 stated that she asked R3 what was going on and R3 became upset and started cursing at V16. V16 stated that she explained to R3 that he can't smoke in his room because it is dangerous. V16 stated that she explained that he is putting her and all the residents on oxygen at risk for blowing up and catching on fire. V16 stated that R3 told her that he would not do it again. V16 stated that she texted V1 and informed her of what she found. V16 stated that V1 notified V10, and a room search was performed. V16 stated that interventions were put in place at that time. V16 stated that they were notified to get R3 out of the bed. V16 stated that R3 does not want to get out of bed and curses her and threatens to hit her in the head if she tries.On 8/25/2025 at 4:10 PM V1 stated that she was only aware of 1 incident of R3 smoking.On 8/26/2025 at 3:23 PM V18, Primary Physician, stated that it is a big concern with R3 smoking in his room with oxygen. V18 stated that R3 could blow the place up. V18 stated that he would expect that the facility would monitor this behavior.The facility Smoker's List 2025 documents All Cigarettes and Lighters must be returned into activity staff. All Smoking activities must be done in the designated area and with supervision. All residents that smoke must have a signed contract on file. No exceptions.The facility's Smoking Policy, dated 5/22/2017, This is a smoke free facility for staff. This facility allows direct supervised smoking by resident outside on patio in rear of facility. All resident cigarettes and smoking paraphernalia will be maintained in a locked box. No resident shall have possession of these materials. Smoking is prohibited in front of the facility in resident rooms or compartment where flammable liquids, combustible gases or oxygen is in use or stored. It continues Oxygen containers are not allowed in smoking areas at any time.The facility's Drug and Alcohol Behavioral Contract, not dated, documents for any resident who appears to be under the influence of any illegal substance or alcohol, the physician will be notified and the resident will be tested immediately. 1. First offense: responsible party/guardian will be notified of the offense. Staff will discuss behavior with the resident and attempt to define why the action occurred. Care plan will be updated as indicated. Nursing will check room daily, at random times, for illegal substances or alcohol for an unspecified amount of time. 2. Second offense: responsible party/guardian will be notified of the offense. Staff will discuss behavior with the resident and attempt to define why the action occurred. Care plan will be updated as indicated. Nursing will check room daily, at random times, for illegal substances or alcohol for an unspecified amount of time. The resident will be sent to a chemical dependency/alcohol abuse program within or outside of the facility.The Immediate Jeopardy that began on 8/5/25 was removed on 8/26/25, when the facility took the following actions to remove the immediacy: All smoking materials and paraphernalia were removed from R3's room on 8/10/25. This action was completed by nurse (V19).Resident room audit every 2 hours initiated 8/10/2025. Will be changed to Nursing to complete room audit with resident consent every shift due to R3 refusal of every 2 hours 8/25/2025.Smoking assessment completed for R3 on 8/25/2025 by MDS nurse.Installed smoke alarm in R3's room; placed oxygen safety signage 8/25/2025 by Maintenance Director.Initiated a every 15-minute safety check on R3 by nursing staff on 8/25/2025.Director of Nursing or designee completed re- education on smoking policy and safety on 8/5/25, 8/10/2025 and 8/25/25.Admin, DON/ADON, and CNA Supervisor educated all staff on smoking policy, oxygen/fire safety, monitoring procedures, and procedures for reporting noncompliance. Initiated on 8/25/2025 to all staff present and remaining staff will be educated prior to next shift.Smoking policy will be reviewed for implementation of additional interventions for safety of residents with oxygen. Completed by Regional Nurse on 8/25/25.Actions to prevent re-occurrence:On 8/25/2025, smoke detectors to be placed in resident rooms who smoke and are on oxygen. This will be completed by the maintenance Director.All residents with oxygen orders will receive a smoking risk assessment within 24 hours on all re-admissions starting on 8/25/2025 by charge nurse. All care plans will be updated by the MDS nurse to include individualized interventions by 8/25/2025.All residents who smoke and/or are on oxygen will be educated on facility smoking policy, fire hazards, and oxygen safety by 8/25/25.Education will be documented in resident records and completed by the maintenance director.Ongoing quality assurance:DON/designee will complete daily audits for 14 days to ensure 15-minute checks and compliance with interventions for R3 starting on 8/25/25.Admin or Activity director will conduct weekly audits for 8 weeks, then monthly audits for 6 months starting 8/25/2025.Results reviewed in monthly QAPI meetings by IDT with corrective actions implemented as needed starting on 8/25/2025.On 8/20/2025 V4, Social Service Director, provided the facility resident roster identifying 89 residents residing in the facility.

Based on interview and record review the facility failed to assess and monitor admission weights for 1 of 3 (R3) residents in a sample of 5 reviewed for weight loss.Findings include:R3's admission Record document that R3 was admitted [DATE].R3's Care Plan, dated 7/7/2025, documents that (R3) requires tube feeding r/t (related to) impaired cognition, difficulty chewing/swallowing. Chronic history of emesis with aspiration. 04/11/2025, G-Tube changed to J-Tube in hospital. 6/25/25: J-tube has been removed and replaced with a G-tube.R3's Registered Dietician (RD) Note, dated 3/21/2025, Current weight is unknown, but (R3) looks very thin with muscle & subQ (subcutaneous) fat loss. Based on (R3's) ideal body weight from his height of 141 lbs (pounds), his estimated energy needs are 2243 kcals (35kcal/kg), 77g protein (1.2g/kg), 2243 ml H20 (1 ml/kcal) Resistant is currently NPO & on TF order Jevity 1.5 45cc/hr x 23 hours providing 1552 kcals (69% kcal needs) and 83g protein (100% protein needs). RD to evaluate per facility policy and PRN. Intervention: Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed.R3's Minimum Data Set, dated [DATE], documents that R3 is severely cognitively impaired. Weight 111. R3 has had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on prescribed weight-loss regimen.R3's Post Acute Care Transfer Report, dated 3/12/2025, document that R3's weight 3/11/2025 was 70.9 kg. On 7/31/2025 The facility provided R3's first obtained weights 3/25/2025 at 4:20 PM 115.0 lbs. On 8/4/2025 at 8:15AM V5, MDS Coordinator, stated that she oversees the restorative and weight program. V5 stated that she is new to the facility. V5 stated that she is not familiar with R3. V5 stated that the normal process is that the facility obtains weights upon admission/readmission then the resident is weekly x4 weeks unless needs more. V5 stated that the dietician and physician are notified.On 8/4/2025 at 8:20 AM V6, Restorative Aide, stated that she completes weekly weights on Tuesday and Wednesday if not completed on previous day. Those residents are the tube feeders and dietary orders. V6 stated that this consists of New and Re admits. Monthly weighs are completed on the 1st to 6th. V6 stated that she is familiar with R3 and has weighed him several times. V6 stated that R3 has had multiple hospitalization and has had a weight loss when returned. V6 stated that R3 was in the hospital for about a month and came back with weight loss. V6 stated that he was placed on weekly weights and R3 started to gain the weight back and then went back out to the hospital.V5 provided a form title Weights July 2025, signed, and dated 8/3/2025, that documents that the Restorative aides performs all the weights or the facility. Weekly weights are completed every week on Tuesday/Wednesday's. Monthly weights are completed for the whole facility by the 6th of every month. New admit: are weighed at admission then once weekly x4 weeks unless there is a current doctor order in place that states for weekly weights to continue or if the resident has diagnosis respiratory issues, trach and or G tubes.On 8/4/2025 at 1:38 PM V2, Director of Nursing, stated that they do not use the hospital weight because of difference in instrument used. V2 stated that he would expect R3's weight to be obtained within the first 72 hours of admission. The facility's Nutrition and Unplanned Weight Loss/Gain policy, dated 6/28/2019, documents that the facility will assess and monitor the nutrition status of residents to assist the resident in maintaining adequate nutritional status to the extent possible. Guidelines all residents shall be weighed upon admission, monthly, and as required by their clinical condition, and/or as ordered by nursing and/or physician orders.

Based on observation, interview, and record review, the facility failed to prevent mental abuse by denying access to visitors who abuse, exploits and harasses the residents residing in the facility. This failure has the potential to affect all 91 residents residing in the facility. This failure resulted in a Immediate Jeopardy when on 6/18/25, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video which included two residents (R1, R4), without their permission, that was posted on social media, now showing over 67,000 viewers. This failure has caused mental and psychosocial harm, leading to residents feeling unsafe in the facility, which is their home. Due to the unknown reason of the men's intrusion into the facility, this could have caused physical, mental, and psychosocial harm to all residents, due to the incident that occurred and not knowing if the men had deadly weapons or what their intentions were. This failure has caused residents to feel unsafe in the facility. The Immediate Jeopardy began on 6/18/25 at 6:00 PM, when the group of men entered the facility. On 7/7/25, at 1:43 PM, V1, Administrator, V2, Director of Nurses (DON), and V27, Assistant Director of Nursing (ADON), were notified of the Immediate Jeopardy. On 7/9/25, the surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 7/8/25 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training. Findings include: On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and included two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers. On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident. R4's Face Sheet, undated, documents R4 has the following diagnoses: Type 1 Diabetes, Neuropathy, Chronic Kidney Disease, Heart Disease, Traumatic Amputation of the Right Foot, Need for Assistance with Personal Care, and Traction Detachment of the Left Eye Retina. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact. R4's Care Plan, dated 7/14/25, documents R4 has Activities of Daily Living (ADL) self-care performance deficit and requires assistance with daily care needs. On 7/3/25 at 2:35 PM, R1 stated he did not give permission to be videotaped or have the video posted on social media. R1's Face Sheet, undated, documents R1 has the following diagnoses: Altered Mental Status, Schizophrenia, Type 2 DM, Pulmonary Hypertension, and Heart Disease. R1's MDS, dated [DATE], documents R1 has a BIMS score of 10, indicating R1 has moderate cognitive impairment. R1's Care Plan, dated 4/12/24, documents R1 has an ADL self-care performance deficit and requires assistance with daily care needs. R1's Care Plan, dated 6/25/25, documents on 6/25/25, it was brought to staff's attention that R1 was in a video going around on social media that illegally recorded on the premises, violating R1's privacy. R1 will be removed from the common areas if door lock system fails. The facility doors will be locked 24/7 and will require either a code or staff permission to enter the facility, approved visitors only. R1's Progress Note, dated 6/25/25 at 4:32 PM, documents the following: About 12:00 PM, writer received notification from staff that a video was circulating on social media posted by a civilian. Apparently, the video had a glimpse of the resident in it. The facility was unaware of the video being recorded. Police were notified and took a report. Writer spoke with R1's POA (Power of Attorney) and made her aware of the video and advised the preventative measures that would be put into place moving forward. R1's Progress Note, dated 6/27/25 at 11:16 AM, documents the following: Resident is alert with periods of confusion. Resident has a diagnosis of Schizophrenia, Wandering, and Insomnia. Resident likes to hang out in the common areas. Resident witnessed an incident regarding some men running in the building. R1 stated he saw the event take place. He stated they were just young and confused. The facility's Final Investigation Report, dated 6/27/25, documents the following: On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100 halls. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish. The QAPI (Quality Assurance Performance Improvement) Action Plan, dated 6/27/25, documents the concern was video recording and invasion. The root cause analysis was unlocked doors, possible people hanging around parking lot, and ensure proper screening. Goals/Objectives are to keep the doors locked 24/7. Action items are to lock the doors 24/7, pending new cameras with a possible buzz in option, and spot checks of the parking lot. On 7/2/25 at 8:30 AM, V4, CNA (Certified Nursing Assistant), stated she saw a video that was circulating, some guys came in rapping, unsure of the date, the video was inappropriate, the men in the video kept saying sit your old a** down. On 7/2/25 at 8:32 AM, V5, LPN (Licensed Practical Nurse), stated she saw the video on social media, it was inappropriate, there were young men rapping, she was unable to watch it fully and she is unsure of who's social media site it came from. On 7/2/25 at 8:35 AM, V6, CNA, stated she wasn't here when the video was made but it was all over social media, the video was inappropriate, there were young men running around singing sit you old ass down. On 7/2/25 at 8:37 AM, V7, CNA, stated there was a video shot in the facility and that was inappropriate. V7 stated she isn't sure of who's social media page it was shared from. V7 stated it was from a gentleman that made the video, they were in the parking lot and facility, there were residents in the video. On 7/2/25 at 8:40 AM, V9, RN (Registered Nurse), stated there was a video on social media, it was inappropriate, the individuals in the video don't work at the facility, it was disrespectful and not safe. V9 stated she didn't think there were any residents or staff that were affiliated with or knew the men in the video, it could be local people, but she isn't sure of who they were or any of their names. V9 stated she only saw it because someone else posted it, but she was unable to tell the surveyor who posted it. On 7/2/25 at 8:50 AM, V10, Dietary Manager, stated she was gone for the day when the incident with the video occurred on 6/18/25, but her evening dietary staff were here and wrote statements. V10 stated the video crossed the line and violated HIPAA (Health Insurance Portability and Accountability Act), the men were walking through the facility, she thinks there was one resident in the video. On 7/2/25 at 9:00 AM, V2, Director of Nurses (DON), there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had came in, gave the receptionist a phony name to distract her, while the other men snuck in the front door. On 7/2/25 at 10:15 AM, V12, R3's Family, stated R3 was in the hospital but has been transferred to another nursing home. V12 stated R3 didn't want to return because she didn't feel safe in the building because of the video that was made in the facility. On 7/2/25 at 10:37 AM, R7 stated he doesn't feel safe in the facility with those men coming through the door like that, smoking marijuana. On 7/2/25 at 10:40 AM, R8 stated he doesn't feel safe in the facility since the incident occurred. On 7/2/25 at 3:35 PM, V18, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there. On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff. On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few. On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened. On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated R1 was the main resident in the video, he and his POA (Power of Attorney) were not concerned for him or his safety. V1 stated she isn't sure who the men were, but the word is that the one singing could be a rapper with local connections. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 stated since the incident, they are keeping the front door locked at all times and anyone entering through that door has to be let in by the receptionist or staff. On 7/8/25 at 10:25 AM, V29, Paramedic/Clinical Team Member for V28, FNP (Family Nurse Practitioner), stated an incident like this could cause mental and psychosocial harm. V28 stated staff needed to observe R4 for any signs of increased anxiety, acting out towards stimulation like what had occurred with the incident that could resemble PTSD (Post Traumatic Stress Disorder). The Abuse Prevention Program policy, dated 6/2008, documents the facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. It is the policy of this facility to develop a mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Examples include abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings of any manner that would demean or humiliate residents. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility. The Immediate Jeopardy that began on 6/18/25 was removed on 7/8/25, when the facility took the following actions to remove the immediacy: On 6/18/2025, Dietary staff demanded for the group of men to exit the facility. Then men exited to the parking lot. On 6/18/2025, local authorities were called, and they took report and immediately made the group of men exit the premises. On 6/18/2025, the doors were programmed to lock at 6:00 PM which requires a code upon entry, or the receptionist has to manually open the door for all visitors. When the facility was notified, an unauthorized video surfaced the internet, the Administrator, V1, immediately reported the recording and called the local authorities on 6/25/2025. On 6/25/2025, Maintenance Director reprogrammed the door to lock 24/7. On 6/27/2025, Activity Director, V40, conducted a resident council and ensured the residents they safety is our first priority. All residents were invited, the ones who desired to come, attended the meeting. On 6/27/2025, Human Resources (HR), V38, sent out a voice alert to residents' families and staff advising the new safety measures that were implemented. On 6/27/2025, V1, conducted a QAPI meeting with all department heads analyzing the following: receptionist must spot check front premises to ensure no civilians are lingering around, if so call 911, lock doors 24/7 and don't pass out code, ensure proper screening for visitors. a. The screening process requires the following: the receptionist or designee is required to ask the purpose of their visit. Vendors must identify themselves and the purpose of their visit. All families and friends that are here for residents must identify the residents name and the purpose of their visit. b. b. The receptionist or designee will be required to fill out the spot check form daily, and the checks are ongoing between 8:00 AM-9:00 PM. Spot checks are completed every two hours. A CNA or a Nurse will check the lobby every two hours between 9:00 PM-8:00 PM. No other doors are accessible to the public from the outside; you must use a code. By locking the doors, it does not interfere or override our fire alarm system. In the case of an emergency, the doors are still programmed to open, and residents and staff will still have an exit to egress. On 6/27/2025 an in-service was conducted by the Business Office Manager, V43. a. Front doors will be locked 24/7. b. Must conduct proper screening, ensure they have purpose for their visit. On 6/27/2025, the Administrator, V1, called the local authorities and made a second report to (V25, Local Police Officer), case number 2025-05942. He advised he will now escalate this matter to (V26, Local Police Detective) for charges of disorderly conduct and property invasion. On 7/7/2025, Maintenance Director, V37, reached out to the (local) police department for a consult regarding a plan or a preventative measure for unwanted visitors. (V41, Local Police Officer) advised he will check with the sheriff and give us an update. On 7/7/2025, QAPI team created a code for possible weapon/invasion. DON, V2, ADON, V27, initiated an in-service regarding the following: a. All unwanted visitors, immediately call 911 and demand them to exit the premises. b. If intruders bypass front doors/ force entry call 911 and yell code Silver c. Once the Silver code is activated, all available staff will move residents to a safe zone, or behind a barrier such as a locked door. If possible, they can evacuate to an alternate door if there is no potential harm. d. Any suspicion of weapons, foreign objects, violence, disorderly conduct, unauthorized recordings, suspicious activity, drug utilization, yell the code Silver and call 911 e. Any concealed clothing, face coverings, disguises, yell code Silver. f. After a code Silver has been activated, any designated person that can go into a locked room will initial the 911 call. Locked rooms are utility closets, storage rooms, manager offices, and the medication room. g. After a code Silver is activated, all staff will have residents go in their room and hide or move them to a safe zone. h. Staff will help our residents exit, they will proceed to evacuate if safe. i. In-serviced staff to create a barrier between themselves/residents and the perpetrators. Starting 7/7/2025, and continuing until further addressed in a plan of correction, the IDT team will have a monthly QAPI to review any concerns and make necessary changes and review the following: a. Going forward, receptionist will have a form to complete daily, indicating they completed a spot check of the front premises. b. Implementing name tags, ensuring everyone can be identified. Vendors must have a visitor pass/badge indicated they were allowed in the building. c. On 7/8/2025, All CNAs completed a Safety questionnaire with all the residents. The CNAs will be directed by Social Services to ask questions for a screening and any resident who responds affirmatively will be referred to Social Services for further assessment, physician/psychiatrist notification and recommendation as to further services and supports. The questionnaire focused on, fears of their surroundings, safety concerns, mood state, and providing education with the new interventions that were implemented for their safety. d. On 7/8/2028, Social Services, V39, initiated a whole house in-service regarding the abuse policy and will be completed by night shift. e. On 7/8/2028, our abuse policy is being reviewed and modified to focus on key components such as Psychosocial and mental abuse. The policy was updated by (V42, Regional Operational Support). Date of Removal/Abatement Completion: 7/8/2025

Based on observation, interview and record review, the facility failed to recognize potential abuse and immediately report an allegation of abuse to the Department. This has the potential to affect all 91 residents in the facility. Findings include: On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and including two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers. On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident. R4's Minimum Data Set, MDS, dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact. The facility's Final Investigation Report, dated 6/27/25, documents the following: The initial report was submitted on 6/25/25 which was 7 days after the incident occurred. On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100-hall. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish. On 7/2/25 at 9:00 AM, V2, Director of Nurses, DON, there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had come in, gave the receptionist a phony name to distract her, while the other men snuck in the front door. On 7/2/25 at 3:35 PM, V18, Certified Nurse's Aide, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there. On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff. On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few. On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened. On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 stated since the incident, they are keeping the front door locked at all times and anyone entering through that door has to be let in by the receptionist or staff. V1 stated she reported the incident after she became aware of the video. The Abuse Prevention Program policy, dated 6/2008, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends and patterns that may constitute abuse or that may require further investigation. Facility staff will investigate and report any allegations of abuse within timeframe required by Federal Law. Any allegation of abuse will be reported to the facility Administrator or his/her designee, who will follow Federal requirements for reporting to the following entities: State licensing agency responsible for licensure of the facility, law enforcement officials, the resident's representative, and the resident's primary physician. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. This has the potential to affect all 91 residents in the facility. Findings include: On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and including two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers. On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact. On 7/2/25 at 9:00 AM, V2, Director of Nurses, DON, stated there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had come in, gave the receptionist a phony name to distract her, while the other men snuck in the front door. On 7/2/25 at 3:35 PM, V18, Certified Nurse's Aide, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there. On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff. On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few. On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened. On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated R1 was the main resident in the video, he and his POA (Power of Attorney) were not concerned for him or his safety. V1 stated she isn't sure who the men were, but the word is that the one singing could be a rapper with local connections. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 state she reported the incident after the video surfaced. The facility's Final Investigation Report, dated 6/27/25, documents the following: The initial report was submitted on 6/25/25. The report documented On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100-halls. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish. The abuse investigation for this incident was reviewed. V1 interviewed all alert and oriented residents on 100-hall but did not interview any other residents in the facility regarding this incident. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility. The Abuse Prevention Program policy, dated 6/2008, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends and patterns that may constitute abuse or that may require further investigation. The Policy documents Facility staff will investigate and report any allegations of abuse within timeframe required by Federal Law.

Based on interview and record review, the facility failed to follow advanced directives for 1 of 4 (R89) residents reviewed for advanced directives in the sample of 67. This failure resulted in an Immediate Jeopardy on [DATE] when R89 was transferred to the hospital with lifesaving measures, against the documented DNR (do not resuscitate) advanced directive status. R89 ultimately expired at the hospital after being subjected to CPR, Mechanical Ventilation and the use of an AED (automated external defibrillator) which subsequently re-started his heart for a period of time. On [DATE] at 2:28 PM V1, Administrator, V2 DON and V3 ADON were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on [DATE], after abatement reviews dated [DATE] at 3:05 PM and 3:17 PM, [DATE] at 12:11 PM and [DATE] at 10:57 AM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings include: R89's Undated Face Sheet, documents R89 was initially admitted to the facility on [DATE]. R89's admission Minimum Data Set (MDS) dated [DATE] documents he was cognitively intact. R89's Social Services Note, dated [DATE] at 4:18 PM documents R89 was admitted from a local hospital on [DATE]. He signed the POLST to be DNR. POLST will need to be signed by NP or Doctor. Order needs to be entered in PCC (Point Click Care). On [DATE] at 11:53 AM V7, Director of Social Services stated she documented the wrong year on the social service note dated [DATE] should be documented [DATE]. V7 confirmed (R89's) code status was DNR because she spoke to him herself about it and he definitely didn't want anyone pounding on his chest or being electrically shocked to restart his heart, he'd rather die peacefully. R89's POLST Form, dated [DATE] documents do not resuscitate, comfort-focused treatment. Primary goal is maximizing comfort through symptom management. Allow natural death. Do not use treatments listed in full and selective treatment. Full treatment: mechanical ventilation and cardioversion (use of an AED shocking the heart.) Selective treatment: do not use invasive mechanical ventilation. R89's Care Plan dated [DATE], documents resident chose to be a DNR per POLST. No CPR in the event that patient has no pulse, do not attempt resuscitation/DNR. Comfort focused treatment if patient is not in cardiac arrest. Follow if patient has a pulse. On [DATE] at 2:59 PM, V27, Medical Records stated she uploaded (R89's) POLST form on [DATE] and although she stated it wasn't a good and clear copy to scan into the resident's medical record, she could still read the form after it was uploaded to (R89's) medical record. R89's Nursing Note, dated [DATE] at 8:00 AM documents nurse alerted by staff that resident showing a change in condition. Resident observed with a thready, faint pulse. Patient assessed and treated until EMS arrived. R89's Nursing Note, dated [DATE] at 8:50 AM documents hospital notified facility patient expired at 8:48 AM. Arrangements made from hospital to be transported to funeral home. R89's Health Status Note, dated [DATE] at 10:37 AM documents EMS arrived at 8:09 AM and departed at 8:21 AM. On [DATE] at 2:00 PM V11, CNA stated she recalled (R89) he was alert and oriented and was able to make his needs know. On [DATE] V14, CNA was assigned to (R89) and she recalled they both reported to V15, RN that (R89) was out of it that morning and the resident was really spacy. A while later she entered (R89's) room and observed V14 transferring (R89) with a gait belt from his bed to wheelchair and (R89) stated, I can't stand, I'm dizzy! and V14 lowered (R89) to the floor. V11 stated she ran down the hall and yelled for a nurse and grabbed the crash cart. V11 stated staff (names unknown) laid (R89) on the floor and started CPR and continued CPR until EMS arrived to the facility. V11 stated she was really concerned for (R89) because he was slow to respond earlier that morning but when she reported it to V15 she was receiving nurse report from the night shift nurse and she waived her away. On [DATE] at 2:15 PM V12, LPN stated she recalled (R89) and the day he was transferred to the hospital on [DATE]. V12 stated she wasn't assigned to the resident that day but at around 6:30 AM, at the beginning of the shift she overheard V11, CNA report to V15 that (R89) wasn't acting himself, she didn't know if V15 assessed (R89) or not because she was assigned to another hall. A while later, V12 heard staff yelling down the hall they need a nurse. She entered (R89's) room and observed V17, LPN and V16, LPN was on the floor administering CPR compressions to (R89) she relieved V16 from doing CPR compressions and checked (R89's) pulse and she didn't feel a pulse at that time. She didn't know (R89's) code status was but she did CPR because the other nurses were doing it. V12 stated after the code was over and (R89) was transferred to the hospital V15 told her that she was very upset because (R89) was a DNR and they did CPR on him and shouldn't have. She was concerned for her nursing license at that time and V12 didn't know what V15 documented as to what occurred when (R89) coded. V12 stated she didn't see V15 in the room during this time, V15 may have been outside at that time. R89's Medical Record dated [DATE] documents no vital signs documented. On [DATE] at 3:45 PM V17, LPN stated on [DATE] she was assigned to the 500 hall and during nurse report she overheard V11, CNA and V14, CNA report to V15, RN that (R89) was not himself and something was wrong with him. V17 didn't know if V15 went to assess (R89) or anything because she was assigned to the 500 hall and (R89) resided on 300 hall. Sometime in the morning (time unknown) V15 asked her, We don't do CPR on a resident that's still breathing, right? V17 responded, No, we only do CPR if the resident's not breathing. V17 didn't know what was going on or if V15 assessed (R89) at that time. A while later (time unknown) V17 heard staff yelling, CODE and she ran to (R89's) room and noted (R89) was sitting on the edge of the bed as V14 was holding him up and she assisted V14 to placed (R89) on the floor. V16, LPN arrived to (R89's) room and they started doing CPR at that time. V17 stated she didn't know (R89's) code status if he was a DNR or a full code but she went with performing CPR because that was her nurse intuition. After the EMS left the facility V17 stated V15 looked at (R89's) medical record she told her (R89) was supposed to be a DNR not a full code so staff shouldn't have done CPR on (R89) and they were nervous about it and didn't want to get in trouble. V17 stated she doesn't know what V15 documented in (R89's) medical record but she told her she wasn't going to document that staff did CPR because she didn't want to get in trouble or lose her nursing license. On [DATE] at 10:45 AM V14, CNA was assigned to (R89) on [DATE] and he recalled what occurred. V14 stated this was the first day he was assigned to (R89) and didn't know him at all. V14 stated he asked V11 if she could help him and she went into (R89's) and told V14 that (R89) wasn't acting himself and she left the room and reported to a nurse (name unknown) that (R89) wasn't right and V11 came back to (R89's) room and said she told the nurse about it. Over an hour later V14 stated (R89) was laying in bed and was yelling, Get me up! I want to get up! No nurse came to (R89's) room V14 and V11 transferred (R89) to his wheelchair and as they did (R89) fainted/passed out and wasn't responsive. V14 and V11 got (R89) back to bed and he wasn't talking and his eyes were closed. V11 left (R89's) room and yelled down the hall that they need a nurse and V12, V16, V17 responded to (R89's) room immediately. They told them to put (R89) on the floor and the nurses started CPR. V14 stated he's a CNA and didn't know (R89's) code status. V14 recalled when EMS arrived to the facility he saw they used a mechanical ventilator to pump (R89's) chest and used an AED to shock (R89's) heart. EMS stated they got a heartbeat back on (R89) and he was transported to the hospital. V15 entered (R89's) and finally assessed him, 911 was called and he was transported to the hospital. On [DATE] at 11:14 AM V15, RN stated she was assigned to (R89) on [DATE] and she was familiar with him and was assigned to him often. V15 stated (R89's) baseline was he was alert and able to make his needs known and was a 1-2 person transfer. On [DATE] she recalled she got to work around 6:30 AM and got report from the night shift nurses (names unknown) and no issues or concerns was expressed for (R89.) No staff reported that he wasn't acting right during nurse report. It wasn't until around 8:00 AM that V11 reported that (R89) was not acting himself and she immediately went to his room and laid eyes on him. At that time (R89) was in bed and he stated he didn't want to get up out of bed. V15 stated (R89) was lethargic at that time and was very slow to respond to her and while she was assessing his vital signs including blood pressure, heart rate, pulse oxygenation and respirations and he was rapidly declining right in front of her. V15 recalled (R89's) pulse was faint and the oxygen saturation machine didn't register on his finger and she tried different fingers but it still would register a reading. She instructed V11 and V14 to put (R89) on the floor and she ran and got the crash cart and yelled, Code blue! She looked up (R89's) code status in the computer but she stated it was grayed out and she couldn't read it so she errored on the side of caution and instructed staff to start CPR. V12, V16 and V17 helped with CPR compressions and bagged (R89) until EMS arrived to the facility. V15 reported to EMS that (R89) was a full code and they continued CPR using a mechanical ventilator and also shocked (R89's) heart with an AED. (R89) heartbeat came back and EMS transferred him to the hospital. Hospital staff called back a few minutes later and stated (R89) was deceased . V15 stated she didn't ask other staff if a resident was breathing if you should start CPR because she is an RN and knows if the resident is breathing you don't start CPR. V15 stated she documented the entire change in condition regarding (R89) in the nurse progress notes in the computer including his vital signs and how staff provided CPR that day, she didn't know why the assessment wasn't documented in (R89's) medical record because she knows if you don't document it it wasn't done and she definitely wanted to protect her nursing license. After (R89) was transferred to the hospital the medical records staff showed her a code status book at the nurse's station and she read (R89's) code status and it showed he was a DNR. She was really upset because of everything staff did to save his life including mechanical ventilation and using the AED to shock his heart when they weren't supposed to do any of that. On [DATE] at 12:25 PM V15 called back and stated she recalled when she got the crash cart to (R89's) room staff (name unknown) was on the phone with V2 and he told staff to start CPR on (R89) immediately and that's why staff did CPR. On [DATE] at 9:45 AM V34, Former Therapy Program Manger stated she worked with (R89) and provided occupational therapy, she noted (R89) was alert and able to make his needs known. V34 stated she got to the facility at 5:00 AM on [DATE] and noted (R89) was in bed around 6:30 AM and observed V11 and V14 were transferring (R89) from his bed to wheelchair and he was yelling out that he didn't want to get up. V34 entered (R89's) room and told the CNAs to sit him back on the bed and they did. V15, RN entered (R89's) room and asked what he's yelling about and at that time V34 noted (R89) took a gasp for breath which she thought was odd. V15 instructed the CNAs to lay him in bed and raise the head of the bed and that he'd be fine V15 then left (R89's) room. V34 stated she was gravely concerned about (R89) but that V15 was an RN and she trusted her nurse judgement. Around 8:00 AM she went to (R89's) room to check on him and V11, CNA was in his room and told V34 that she reported to V15, RN that (R89) was not responsive but that no one was doing anything about it. V34 stated she went to get a blood pressure cuff and a pulse ox and put it on (R89), neither the blood pressure or pulse ox would register a reading at that time and from what she could tell (R89) wasn't breathing. V34 stated she called V2, DON at that time on her cell phone and V2 stated he wasn't at the facility but if (R89) wasn't breathing that she needed to call a code blue and start doing CPR. V11, CNA yelled code blue down the hall and V12, LPN and V17, LPN entered (R89's) room and started doing CPR on him. V34 stated (R89) was transferred to the hospital after EMS got a heartbeat and she was informed he passed away shortly after arriving to the emergency room. V34 stated she found out from staff on [DATE] that (R89) was supposed to be a DNR, not a full code. On [DATE] at 3:00 PM V16, LPN stated she worked night shift and arrived to the facility at 10:30 on [DATE] and also worked day shift on [DATE] as well. V16 stated she was assigned to (R89) night shift and administered a medication, (medication name and dose unknown) to him at 6:00 AM on [DATE], V16 stated he was sleeping and she woke him up and he was at baseline at that time he took the medication and went back to sleep. He didn't complain of shortness of breath or pain at that time. V16 gave nurse report to the day shift nurses V12, V15 and V17 and V15 was (R89's) day shift assigned nurse. V16 didn't recall any staff reporting (R89) was having any changes during nurse report. A while later she was at the nurse's station and V11 came to the nurse's station and reported to V15 several times that (R89) wasn't acting right and was slow to respond to them. V16 stated V11 is assigned to (R89's) hall and knows him well so she knew something must be wrong if she kept saying something was wrong with (R89.) A few minutes went by and V15 was still on the computer at the nurse's station at that time and wasn't going to assess (R89) so her and V12 went to assess (R89.) V16 stated she was halfway down the hall when a therapy employee (name unknown) came out of (R89's) and stated he's no longer responsive. V16 stated when she entered (R89's) he was in bed and eyes were closed. Her and V12 assessed (R89) by doing a sternal rub which he had no response to and the pulse oximetry machine wasn't displaying a reading at that time. We called for a crash cart at that time and an unknown staff told them he is a full code. She instructed staff to put (R89) on the floor and she, R12 and V17 started CPR. When EMS arrived they used a mechanical ventilator and an AED to shock his heart a few times. After (R89) was transferred to the hospital she recalled a staff said (R89) was supposed to be a DNR and she didn't know that and she knew if a resident is a DNR they aren't supposed to do CPR on them. On [DATE] at 2:20 PM V27, Medical Records stated she recalled on [DATE] when (R89) was transferred to the hospital. V27 stated she told the nurse (name unknown) that was on the phone with EMS that she has a binder with resident information in it and that they could use the binder information if needed and she would replace whatever documents they use from the binder after (R89) was transferred to the hospital. V27 stated she didn't recall telling a nurse that the resident's code status was in the binder. R89's Hospital Medical Record, dated [DATE] documents History of Present Illness patient presents to the ER by EMS in cardiac arrest. Per EMS 10 minutes of downtime with bystander CPR. When EMS arrived 3 shocks were advised. EMS was a BLS crew, no medications give. No other history obtained. ACLS was continued on arrival to the ER. Pt airway was intubated on arrival, ACLS was continued. On arrival was initially given epinephrine, calcium bicarb. On pulse check, was in V Fib was shocked and provided with 300 mg of amiodarone. On next pulse, was V-Tach was provided with 150 of amiodarone and shock. Next pulse check was also V-Tach was provided with 100 of lidocaine and shock. At next pulse check, PE, AA was given epinephrine next couple pulse checks 2, still PE with cardiac standstill. Eventually time of death was called at 8:48 AM. On [DATE] at 12:45 PM V2, DON stated when a resident has a change in condition he expects staff to obtain vital signs including blood pressure, heart rate, oxygen saturation and respirations. He also expects the nurse to assess the resident from head to toe noting any abnormalities. The nurse should talk to the resident and see what their orientation status is to see if there is a change in baseline. The nurse should also assess the resident for pain and dizziness. and to notify the physician of what the assessment was and to obtain orders from the physician. V2 stated the full change in medical condition assessment including vital signs is expected to be documented in the resident's nurse progress notes. V2 recalled R89 and stated he was sent to the emergency room for his catheter at one point but he was readmitted to the facility the same day and he didn't recall any specifics of what occurred on [DATE]. On [DATE] on 12:12 PM V2, DON stated if staff call him and notify him of a resident having a change in condition he would tell staff to get the resident's vital signs and have a nurse assess the resident and to notify the resident's physician of the change in condition to get physician's orders but he would never tell staff to initiate or start CPR because he doesn't know residents' code status and denied telling staff to initiate or start CPR on (R89) when he coded on [DATE]. He doesn't know why staff would say that he said that. On [DATE] at 11:25 AM V2, DON stated when a resident is initially admitted to the facility he expects staff to assess the resident's code status and document it on the POLST form. He expects the POLST form to be scanned into the computer in the resident's medical record and expects staff to upload a readable POLST form so staff can view it in an emergency situation. V2 stated he noted (R89's) POLST appeared [NAME] and it was poor quality and he couldn't read what (R89's) code preference was on the form. V2 stated (R89) was a DNR and staff should have provided comfort measures only and shouldn't have done CPR or had an AED used on him to restart his heart. A DNR comfort measures only means staff should still assess the resident, obtain vital signs, apply oxygen to the resident and ensure the resident is pain free and stabilize the resident to the best of the nurse's ability. V2 expected staff to honor the resident's POLST form wishes. On [DATE] at 11:40 AM V1, Administrator stated the facility doesn't have an advanced directive policy and they probably should so staff would know what it is and to follow it. V1 expects the POLST form in resident's medical records to be readable to ensure in an emergency the licensed nurse can read the POLST form and abide by the resident's documented POLST form code decision. On [DATE] at 9:50 AM, V21 Nurse Practitioner stated staff including the assigned nurse should know the resident's code status and should most definitely follow it because that is the resident's wishes which are usually documented upon admission to the facility. V21 stated if (R89's) comfort measures only then staff shouldn't have done CPR including mechanical ventilation or using an AED to shock his heart. The only thing staff should have offered (R89) should be oxygen if his signed POLST form documents comfort measures only. Identified opportunity for improvement/deficient practice: Improving nursing skill sets for conducting a code blue status and executing physician orders timely and efficiently. Immediate Corrective Action for those affected by the deficient practice: -V22, Wound Nurse from hospital held a CPR class that was completed for nurses on [DATE]. -Code Blue status in-service completed on [DATE]. The in-service outlines reviewing the POLST before performing CPR or when a Code Blue is active. Completed by DON and ADON. -Physician Orders for Life sustaining treatments inservice and Change in Medical Condition policy inservice completed on [DATE]. Completed by DON and ADON. -Medical order that outlines patients specifics wishes for end of life-sustaining procedures in-service completed on 4/25. Completed by DON and ADON and LNHA. -Night shift charge nurse currently audits Crash Carts daily. Inservice completed by DON and ADON on [DATE]. -Performing CPR on a resident with no pulse return demonstration, initiated [DATE] and will be ongoing. Completed on [DATE] by DON and ADON. -Immediate DNR and Full Code Status Audit completed on [DATE]. Completed by SSD. -Ordered AED Machine, pending delivery Date, Order placed on [DATE] by Medical Records on [DATE]. Pending tracking number. -Inserviced Medical Record [NAME] and [NAME] SSD to ensure all POLST forms are readable. Completed by LNHA on [DATE]. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: -All residents have the potential to be affected. R89 expired on [DATE]. 3. Measures put into place/systematic changes to ensure the deficient practice does not reoccur. -DON/ADON or designee will review physician's orders (e.g., code status) daily for the next 4 weeks. -DON/ADON or designee will review Review laboratory or radiology results pertinent to the resident's death when a death occurs for the next 4 weeks. DON/ADON will pull three random charts twice a week for the next 4 weeks and do the following:Review progress notes to determine what interventions were put into place to address the change or decline in condition (e.g., first aid measures, glucose monitoring, cardiopulmonary resuscitation [CPR], and immediate transfer)? 4. Plan to monitor performance to ensure solutions are sustained. Beginning [DATE] and continuing until further addressed in the plan of correction, the DON or Designee will conduct a chart review, 3 random charts twice a week for 4 weeks to ensure chart is the following: -Evaluate interventions to determine was intervention appropriate, monitored and modified as needed -Was pain assessed and treatment measures documented. -Ensure care was consistent with the resident advance directive or goals for care -If concerns are identified, review facility policies and procedures with regard to factors that led to the resident's death. -Review resident sig change and compare it to their baseline. -Ensure resident decisions were honored and executed. -Communicate changes with family/POA. -Do a complete audit on chart, after death. -Medical Records or SSD is responsible for auditing the POLST form in PCC, Emergency Response book on Wednesday weekly for the next 4 weeks. Surveyors validated the removal of abatement by reviewing medical records for change in medical condition. R89 was deceased and therefor his medical record was not further reviewed. Surveyors reviewed additional sampled residents medical records to ensure the facility's following notification changes in condition policy. The facility documented inservices of staff which the surveyors reviewed. Employees including (V1, V2, V3, V19, V29 and V29) were interviewed regarding the inservices. R48's does not have a POLST but does have a state guardianship paperwork that documents he is a DNR. V1 stated all staff have been inserviced on the facility's advanced directive policy and if they haven't been they will be inserviced on the policy prior to working on the floor with residents.

3. R240's Electronic Medical Record (EMR) Medical Diagnoses Sheet, documented his code status was Do Not Resuscitate (DNR) with comfort focused measures. The Sheet documented R240 had the following diagnoses: Acute Kidney Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Chronic Kidney Disease stage 2, Congestive Heart Failure, muscle weakness, sepsis, severe sepsis with septic shock, vascular dementia. R240's Physician's Orders (PO), dated 5/13/25, documented R240 was receiving Bactrim DS Oral, tablet 800-160 mg (milligram), Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days. R240's Progress Note, dated 5/13/25, at 17:17 PM, documented Resident on antibiotic therapy due to UTI. Resident remains afebrile, vital signs WNL (within normal limits), no adverse reactions noted. Will continue to monitor. R240's Vital Summary, dated 5/15/25, at 9:38 PM, documented his blood pressure was 114/70 mmHg (millimeters of mercury); oxygen (O2) saturation level (sats) was at 98% at room air; temperature was 97.8 degrees Fahrenheit (F), and respirations 18 breaths/minute. There were no vital signs documented on 5/16/25 in R240's medical record. R240's Vital Summary, dated 5/17/25, at 12:24 PM, documented R240's temperature was 97.2 degrees F; at 12:26 PM respirations of 18 breaths/minute; and blood pressure of 135/72 mmHg ; and no O2 sats documented. No further vital signs were documented in R240's medical record. R240's Nursing Note, dated 5/18/25, at 1:37 PM, documented Resident has had a change in condition. Resident is refusing to eat, drink, or take noon meds. Resident is non-compliant with care. Writer reached out to resident POA (Power of Attorney), (V81) to make aware of changes and was sent to voicemail. There is no documentation R240's medical practitioner, V50 (Nurse Practitioner) was notified. R240's Nursing Note, dated 5/18/25, at 9:28 PM, documented Residents POA (V81) came up to facility to see resident. Writer informed POA of residents decrease in appetite and fluid intake. Writer also made POA aware of resident's resistance when it came to allowing staff to provide peri care, showers, and assistance with feeding. POA stated she noticed a change in resident as well. Writer suggested hospice POA stated she would talk with residents' sons, and will the facility know when they make their decision. There was no documentation R240's medical provider, including V50, Nurse Practitioner, was notified. R240's Nursing Note, dated 5/19/25, at 6:46 AM, documented Resident observed to be declining. No food or drinks consumed during a 24-hour period due to resident consistent refusal. Resident appears to be less responsive than baseline. Appropriate staff have been notified. There was no documentation R240's medical provider, including V50 was notified. On 5/27/25 2:44 PM V80, LPN stated she was the night shift nurse that had come in on 5/18/25. Stated that she recalls being notified by the off going nurse that day that R240 hadn't been himself that day and wasn't wanting to eat/drink/take meds. Stated they told her to keep an eye on him and they had talked to his family about initiating hospice. Stated that night she can't recall if she took any vital signs, stated the electronic medical record system prompts the nurses if vital signs are needed are needed per a schedule or with meds. V80 stated that night he slept well and displayed no emergent needs. Stated she had given report to the oncoming shift of the previous day expressed concerns and that he had no occurrences over the night. R240's Nursing Note, dated 5/19/25, at 7:25 AM, documented Residents conts (continues)to decline in condition. Resident is having shallow breathing, only responds to physical stimuli. Writer notified residents POA (V81) and stated she would be up today to visit resident. There was no documentation R240's medical provider, including V50, was notified. R240's Nursing Note, dated 5/19/25, at 9:00 AM, documented Writer got report resident health is declining. Writer got vitals, O2 (oxygen) was low, O2 was administered at 2L (Liters). Resident son is present, POA notified of changes in condition. POA and son requested resident be sent out to (out of state hospital) per POA. (Ambulance Service) EMS (Emergency Medical Service) called, ambulance arrived resident transported to (out of state hospital). R240s's Nursing Note, dated 5/19/25, at 2:07 PM, documented Writer called (out of state) ED (Emergency Department) to get report on resident, nurse stated resident was changed to full code and was intubated and sent to ICU (Intensive Care Unit). R240's Nursing Note, dated 5/19/25, at 5:23 PM, documented This nurse called (out of state hospital) ED for report on (R24). I spoke with charge nurse (name of charge nurse) who states that resident expired at 3:35 PM this afternoon. R240's Hospital Emergency Department (ED) Records, dated 5/19/25, documented R240 arrived at the hospital at 9:54 AM. The Hospital Records documented EMS (Emergency Medical Service) states that when they arrived pt (patient) was very lethargic and cool to touch, blood sugar read low. EMS gave Glucagon. Upon arrival pt still only responsive to pain and blood sugar read low. R240's Emergency Medicine Resident Note, in the hospital record dated 5/19/25, documented Patient was brought in by EMS from nursing home after he was found to be unresponsive. Patient had low blood sugars to below 40s per EMS. EMS was unable to establish any venous access, patient was given glucagon instead. Per EMS, patient has not been eating for the past several days, and patient was recently hospitalized (at out of state hospital) for an unknown sickness. Initial vital signs for normal on presentation aside from hypothermia to 88.9 Degree F. Patient was responsive to pain but was not alert to self or place. R240's Attending Physician Supervisory Note, dated, 5/19/25, documented The patient is a [AGE] year-old male that comes from a nursing home initially for hypoglycemia. The patient is paperwork demonstrated that is patient status was DNR DNI with more so an emphasis on comfort measures. An ultrasound IV was placed by myself and during this time the patient continued to decline. We started the patient on pressors since the patient did not have any paperwork stating that he would not want this. Also, during this time, we attempted to contact the family after several attempts we finally were able to get a hold of the patient's son. At this point they completely changed the patient 's code status and made him a full code. The note continued We had multiple discussions with the family. Therefore, at this point the patient was CPR. The patient subsequently declared dead at 1525 by myself. On 5/23/25, at 11:36 AM, V24, LPN stated she took care of R240 on Monday, 5/19/25. She stated she was given report that he had a change of condition. V24 stated R240 had stopped eating and was being non-compliant with care. V24 stated R240's breathing was shallow, and his O2 sats were low. V24 stated she put oxygen on R240 for comfort. V24 stated R240's son, V82, was at the bedside while she took R240's vitals and was asking if there was something they could do. V24 stated that there was a conversation between V82 and V81 on the phone. V24 stated V81 and V82 decided to send him out. V24 stated V83 was R240's physician but the facility was notifying V50, as she was in the facility Monday through Friday. When questioned where this notification would be documented, V24 responded it would be documented the Progress Notes. V24 stated that on the weekend, the facility did have an on-call doctor that they could notify, but they were calling V50, as they had her direct number and could call her. V24 stated that the on-call service would be notified from 1:00 PM on Friday until 7:00 AM the following Monday. When asked what V50 directed them to do regarding R240, she stated nothing. V24 stated she notified V50 when the family requested R240 be sent to hospital as she needed V50's permission to send R240 out. On 5/23/25, at 11:50 PM, V10, LPN, stated that V50 was in the facility routinely and followed R240's care. V10 stated R240 wasn't eating or drinking. She said it all started on Tuesday of the previous week. V10 stated V50 was at the facility on Tuesday, and she notified V50 at that time. V10 stated it wasn't like R240 to not eat or drink. V10 said that he was not letting them care for him. She said that she came in on Saturday or Sunday and it was the same thing, he was not eating or drinking. She said that she called V81 and discussed possible Hospice. She said that was the family's choice. She encouraged V81 and the family come in as she thought they may be able to help or get him to eat. V10 stated said they notified V81 that needed to get in and see him. She said the son, V82, came in and was at the bedside. V10 stated she attempted to R240's blood pressure using the wrist cuff, and it was reading low, she thought 96/52. V10 stated it was up to the family as to what they wanted to. V24 stated V82 was at the bedside and V81 was talking to him, and they decided to send him out to the hospital. When asked if V50 was notified of his blood pressure and changes of condition, she said that she initially told V50 of the change but after that, he didn't have a big change it just continued. V10 stated she did not notify V50 because she was already aware of R240's change. On 5/23/25, at 10:28 AM, V50 stated that she was R240's medical practitioner and she was the one who saw him in the facility. V50 stated that she had not been notified on 5/18/25 of R240's change of condition as she does not take weekend call. She stated that the on-call service takes over at 1:00 PM on Friday and extends until 7:00 AM on Monday. V50 stated that she was not aware R240 had been sent to the hospital until Tuesday (5/20/25), at which time she was told he expired. She stated that notification of medical practitioner would have been documented in the Progress Notes. V50 stated that per standards of practice, vital signs would be taken if the initial vitals were abnormal. V50 stated that for example if a O2 sat was below 90%, the nurses should contact the medical practitioner and the medical practitioner would make the decision as if they wanted to send the resident to the hospital, continue to monitor vitals or get laboratory work. On 5/23/25, at 12:00 PM, during a follow-up call with V50, she stated that V10 did notify her of R240's change of condition on Tuesday, 5/13/25. She stated she was not notified on 5/18/25, that there was a change in R240's baseline. V50 stated she was not called regarding R240 being sent to the hospital, and she did not give that order. V50 stated she did not become aware of R240's change of condition until after he passed away. She stated that she was not sure if the outcome would have changed if she had been notified, but she said it would have allowed her to have a conversation with the family regarding how they wanted to proceed. She said they would have discussed possible medications to stimulate appetite, tube feeding and possible Hospice. She again stated that R240 had chosen Do Not Resuscitate with Comfort Measures. The facility took the following actions to remove the Immediacy: Identification of Residents Affected or Likely to be Affected: Improving nursing skill sets for conducting a complete assessment on residents who has acute change in condition and non-urgent change in condition. 1.Immediate Corrective Action for those affected by the deficient practice: DON, V2 and V3, ADON completed an in-service on 4/29/2025 on our Notification Changes in Condition policy. The policy includes the following: Upon identification of any change in condition licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change. All notifications should be documented and should include; The date and time of the notification; a) The name of the individual contacted; b) The specific reason for the notification; c) And any specific responses that were given by the person contacted. All changes of condition require an immediate assessment and documentation of resident condition which should include, at a minimum: a) Pain b) Orientation c) Any change from baseline status d) Status of any pending labs/diagnostics e) Vital signs All changes of condition require a follow up assessment with proper documentation that will include the following: pain, orientation, baseline status and current status, updates on results from labs/diagnostics and vital signs. Nursing will continue to update MD/NP on the status of the resident. 2. Process/Steps to identity others having the potential to be impacted by the same deficient practice: -All resident have the potential to be affected. R89 expired on 2/25/2025. 3. Beginning April 29, 2025, measures were put into place/systematic changes to ensure the deficient practice does not recur. -DON/ADON or designee will review physician's orders (e.g., code status) daily for the next 4 weeks. -DON/ADON or designee will review laboratory or radiology results pertinent to the resident's change in condition for the next 4 weeks. -DON/ADON will pull three random charts twice a week for the next 4 weeks and do the following: Review progress notes to determine what interventions were put into place to address the change or decline in condition (e.g., first aid measures, glucose monitoring, cardiopulmonary resuscitation [CPR], and immediate transfer)? 4. Plan to monitor performance to ensure solutions are sustained. -Beginning April 29, 2025 and continuing until further addressed in the plan of correction, the DON or Designee will conduct a chart review, 3 random charts twice a week for 4 weeks to ensure chart is the following: -Evaluate interventions to determine was intervention appropriate, monitored and modified as needed -Was pain assessed and treatment measures documented. -Ensure care was consistent with the resident advance directive or goals for care -If concerns are identified, review facility policies and procedures with regard to factors that led to the resident's change in condition. -Review resident significant change and compare it to their baseline. -Communicate changes with family/POA. Surveyors validated the removal of abatement by reviewing medical records to ensure residents had readable POLST forms uploaded and a physician's order for code status, verification of code status documented in medical. R89 was deceased and therefor his medical record was not further reviewed. Surveyors reviewed POLST forms and physician's orders for code status. R48 didn't have an updated POLST form and this was brought to the attention of V7, Social Services Director. The facility submitted an advanced directive policy dated 4/30/2025 and they inserviced staff that day on the policy. V1, Administrator stated all staff will be inserviced before they start working, including agency staff. Employees including (V1, V2, V3, V7, V19, V27, V29 and V49.) Surveyors conducted a review of all facility inservices. Were interviewed to ensure they were aware of current policies and procedures and had been inserviced. The completion date was changed from 4/29/2025 to 4/30/2025 due to V1, DON and V2 ADON inservicing staff on the new advanced directive policy. V1 stated all staff have been inserviced on the facility's notification changes in condition policy and if they haven't been they will be inserviced on the policy prior to working on the floor with residents. Based on interview and record review, the facility failed to properly assess, monitor residents experiencing a change in condition for 3 of 5 residents (R89, R193, R240) reviewed for change in medical condition in the sample of 67. This failure resulted in R89's delay in medical treatment for a change in condition and R89 was pronounced deceased at the hospital on 2/25/2025. This failure resulted in Immediate Jeopardy on 2/25/202 when R89, he had a change in condition and the facility failed to timely assess R89 which resulted in R89 being transferred to the hospital with lifesaving measures. R89 ultimately expired at the hospital. On 4/29/2025 at 9:15 AM V1, Administrator, V2 DON and V3 ADON were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 4/30/2025, after abatement reviews dated 4/29/2025 at 1:18 PM, 2:00 PM and 2:29 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings include: 1.R89's Undated Face Sheet, documents R89 was initially admitted to the facility on [DATE]. R89's admission Minimum Data Set (MDS) dated [DATE] documents he was cognitively intact. R89's Nursing Note, dated 2/25/2025 at 8:00 AM documents nurse alerted by staff that resident showing a change in condition. Resident observed with a thready faint pulse. Patient assessed and treated until EMS arrived. R89's Nursing Note, dated 2/25/2025 at 8:50 documents hospital notified facility patient expired @ 8:48 AM. Arrangements made from hospital to be transported to funeral home. R89's Health Status Note, dated 2/25/2025 at 10:37 AM documents EMS arrived at 8:09 AM and departed at 8:21 AM. On 4/23/2025 at 2:00 PM V11, CNA stated she recalled (R89) he was alert and oriented and was able to make his needs know. On 2/25/2025 V14, CNA was assigned to (R89) and she recalled they both reported to V15, RN that (R89) was out of it that morning and the resident was really spacy. A while later she entered (R89's) room and observed V14 transferring (R89) with a gait belt from his bed to wheelchair and (R89) stated, I can't stand, I'm dizzy! V14 lowered (R89) to the floor. V11 stated she ran down the hall and yelled for a nurse. V11 stated she was really concerned for (R89) because he was slow to respond earlier that morning but when she reported it to V15 she was receiving nurse report from the night shift nurse, and she waived her away. On 4/23/2025 at 2:15 PM V12, LPN stated she recalled (R89) the day he had a change in medical condition and was transferred to the hospital on 2/25/2025. V12 stated she wasn't assigned to (R89) that day but at around 6:30 AM, at the beginning of the shift she overheard V11, CNA report to V15 that (R89) wasn't acting himself, she didn't know if V15 assessed (R89) or not because she was assigned to another hall. A while later V12 heard staff yelling down the hall they need a nurse that (R89) had a change in medical condition. R89's Medical Record dated 2/25/2025 documents no vital signs documented. On 4/23/2025 at 3:45 PM V17, LPN stated on 2/25/2025 she was assigned to the 500 hall and during nurse report she overheard V11, CNA and V14, CNA report to V15, RN that (R89) was not himself and something was wrong with him. V17 didn't know if V15 went to assess (R89) or anything because she was assigned to the 500 hall and (R89) resided on 300 hall. Sometime later that morning (time unknown) staff announced (R89) wasn't responsive and 911 was called and he was transferred to the hospital. On 4/24/2025 at 10:45 AM V14, CNA was assigned to (R89) on 2/25/2025 and he recalled what occurred. V14 stated this was the first day he was assigned to (R89) and didn't know him at all. V14 stated he asked V11 if she could help him and she went into (R89's) and told V14 that (R89) wasn't acting himself and she left the room and reported to a nurse (name unknown) that (R89) wasn't right and V11 came back to (R89's) room and said she told the nurse about it. Over an hour later, V14 stated (R89) was laying in bed and was yelling, Get me up! I want to get up! No nurse came to (R89's) room V14 and V11 transferred (R89) to his wheelchair and as they did (R89) fainted/passed out and wasn't responsive. V14 and V11 got (R89) back to bed and he wasn't talking and his eyes were closed. V11 left (R89's) room and yelled down the hall that they need a nurse and V12, V16, V17 responded to (R89's) room immediately. V15 entered (R89's) and finally assessed him, 911 was called and he was transported to the hospital. On 4/23/2025 at 11:14 AM V15, RN stated she was assigned to (R89) on 2/25/2025 and she was familiar with him and was assigned to him often. V15 stated (R89's) baseline was he was alert and able to make his needs known. On 2/25/2025 she recalled she got to work around 6:30 AM and got report from the night shift nurses (names unknown) and no issues or concerns was expressed for (R89.) No staff reported that (R89) wasn't acting right during nurse report. It wasn't until around 8:00 AM that V11 reported that (R89) was not acting himself and she immediately went to his room and laid eyes on him. At that time (R89) was in bed and he stated he didn't want to get up out of bed. V15 stated (R89) was lethargic at that time and was very slow to respond to her and while she was assessing his vital signs including blood pressure, heart rate, pulse oxygenation and respirations and he was rapidly declining right in front of her. V15 recalled (R89's) pulse was faint and the oxygen saturation machine didn't register on his finger and she tried different fingers but it still wouldn't register a reading. V15 also reiterated that no staff reported to her that (R89) was having an issues or any concerns prior to after nurse report and she started administering medications to residents. V15 stated she documented the entire change in condition regarding (R89) in the nurse progress notes in the computer including his vital signs, she didn't know why the assessment wasn't documented in (R89's) medical record because she knows if you don't document it it wasn't done and she definitely wanted to protect her nursing license. V15 stated (R89) was transferred to the hospital via EMS and he died shortly after arriving to the hospital. On 4/25/2025 at 9:45 AM V34, Former Therapy Program Manger stated she worked with (R89) and provided occupational therapy, she noted (R89) was alert and able to make his needs known. V34 stated she got to the facility at 5:00 AM on 2/25/2025 and noted (R89) was in bed around 6:30 AM and observed V11 and V14 were transferring (R89) from his bed to wheel chair and he was yelling out that he didn't want to get up. V34 entered (R89's) room and told the CNAs to sit him back on the bed and they did. V15, RN entered (R89's) room and asked what he's yelling about and at that time V34 noted (R89) took a gasp for breath which she thought was odd. V15 instructed the CNAs to lay him in bed and raise the head of the bed and that he'd be fine V15 then left (R89's) room. V34 stated she was gravely concerned about (R89) but that V15 was an RN and she trusted her nurse judgement. Around 8:00 AM she went to (R89's) room to check on him and V11, CNA was in his room and told V34 that she reported to V15, RN that (R89) was not responsive but that no one was doing anything about it. V34 stated she went to get a blood pressure cuff and a pulse ox and put it on (R89), neither the blood pressure or pulse ox would register a reading at that time and from she could tell (R89) wasn't breathing. V34 stated (R89) was transferred to the hospital and she was informed he passed away shortly after arriving to the emergency room. On 4/23/2025 at 3:00 PM V16, LPN stated she worked night shift and arrived to the facility at 10:30 PM on 2/24/2025 and also worked day shift on 2/25/2025 as well. V16 stated she was assigned to (R89) night shift and administered a medication, (medication name and dose unknown) to him at 6:00 AM on 2/25/2025, V16 stated he was sleeping and she woke him up and he was at baseline at that time he took the medication and went back to sleep. He didn't complain of shortness of breath or pain at that time. V16 gave nurse report to the day shift nurse V15 was (R89's) day shift assigned nurse. V16 didn't recall any staff reporting (R89) was having any changes during nurse report. A while later she was at the nurse's station and V11 came to the nurse's station and reported to V15 several times that (R89) wasn't acting right and was slow to respond to them. V16 stated V11 is assigned to (R89's) hall and knows him well so she knew something must be wrong if she kept saying something was wrong with (R89.) A few minutes went by and V15 was still on the computer at the nurse's station at that time and wasn't going to assess (R89) so her and V12 went to assess (R89.) V16 stated she was halfway down the hall when a therapy employee (name unknown) came out of (R89's) and stated he's no longer responsive. V16 stated when she entered (R89's) he was in bed and eyes were closed. Her and V12 assessed (R89) by doing a sternal rub which he had no response to and the pulse oximetry machine wasn't displaying a reading at that time. R89's POS and MAR dated 2/2025, documents no 6:00 AM medication was ordered for that time. No medications were signed out by staffing including V16. On 4/25/2025 at 8:35 AM V2 stated he looked into (R89's) POS and MAR dated 2/2025 he didn't see any physician ordered medications due at 6:00 AM and wasn't sure what medication V16 would have administered to (R89.) On 4/23/2025 at 12:45 PM V2, DON stated when a resident has a change in condition he expects staff to obtain vital signs including blood pressure, heart rate, oxygen saturation and respirations. He also expects the nurse to assess the resident from head to toe noting any abnormalities. The nurse should talk to the resident and see what their orientation status is to see if there is a change in baseline. The nurse should also assess the resident for pain and dizziness and to notify the physician of what the assessment was and to obtain orders from the physician. V2 stated the full change in medical condition assessment including vital signs is expected to be documented in the resident's nurse progress notes. V2 recalled (R89) and stated he was sent to the emergency room for his catheter at one point but he was readmitted to the facility the same day and he didn't recall any specifics of what occurred on 2/25/2025. On 4/23/2025 on 12:12 PM V2, DON stated if staff call him and notify him of a resident having a change in condition he would tell staff to get the resident's vital signs and have a nurse assess the resident and to notify the resident's physician of the change in condition to get physician's orders. On 4/25/2025 at 11:40 AM V1, Administrator stated she expects staff to follow facility policies and procedures for when a resident experiences a change in medical condition. On 4/23/2025 at 9:50 AM, V21 Nurse Practitioner stated she assessed (R89) on 2/21/2025 at the facility and he was sitting up in bed and was alert and oriented to person, time, place and situation and he told her he was struggling to walk but should be getting therapy soon so he hoped he gets better so he can go home. V21 assessed (R89's) and noted his lower extremities and left arm were swollen at that time. She ordered the following labs: CBC, CMP, BMP and a doppler to his left arm at that time and doesn't know if the facility got the order completed or not, she hasn't seen the blood work or the doppler results in (R89's) medical record. V21 stated although she didn't order the labs and doppler STAT (immediately) she expected staff to order the blood work and doppler the same day and to get the results as soon as possible. When staff report to a nurse that a resident isn't acting himself or is out of it she expects the assigned nurse to assess the resident immediately and to obtain vital signs including blood pressure, heart rate, respirations and pulse oxygenation and to check on the orientation of the resident at that time to see if he's had a change in medical condition. After the nurse assesses the resident they should call the physician and report the findings to see what if any interventions or new physician's orders are applicable. After the nurse completes the assessment on the resident if she thinks the resident should be 911 be transported to the emergency room then she can do that without a physician's order but after the resident is transferred to the hospital the nurse should call the physician's office and give them an update on the resident's medical status. V21 stated there is no documentation in the physician's medical record that (R89's) nurse notified the physician's office of the resident's change in medical condition. 2. R193's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses included Stage 3 pressure ulcer of left hip. R193's POLST form, signed 2/16/2024 documents R193 was a full code. R193's Significant Change MDS, dated [DATE] documents R193 was severely cognitively impaired. R193'2 Nursing Note, dated 6/15/2025 at 11:20 AM, documents writer went into resident's room to perform wound care and found resident unresponsive. Writer called for assistance from staff. CPR administered 911 called CPR performed until ambulance arrived. Paramedics arrived and took over CPR. Writer notified Hospice along with POA and physician and DON. Paramedics continued to work on patient while they escorted him out the building to local hospital. No vitals signs or thorough assessment documented. The Facility's Notification Changes in Condition Policy, revised 2/20/2023 documents it is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status. Upon identification of any changes in condition licensed nursing personnel will contact the resident's physician/on call-physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition. All notifications should be preceded by an appropriate physical assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions. For acute changes in condition this should occur immediately when practicable and after addressing the resident's immediate needs. All notifications should be documented and should include the date and time of the notification, the name of the individual contacted, the specific reason for the notification and any specific responses that were given by the person contacted. All changes of condition require follow-up assessment and documentation of resident condition which include at a minimum, vital signs, pain, orientation any change from baseline status.

3. R66's Face Sheet, print date of 5/21/25, documented diagnoses of Alzheimer's Disease with late onset, muscle weakness, difficulty walking, R66's Care Plan, revision dated of 3/6/25, documented left heel 'mushy'. R66's Care Plan intervention, initiated on 3/7/25, documented Left multipodus boot to be worn at all times. R66's MDS, dated [DATE], documented she was not at risk for pressure ulcer and did not have any pressure ulcers at that time. On 5/21/25, at 10:06 AM, R66 was seated in a wheelchair (w/c) at the nurse's station near the bird cage. R66 was wearing blue colored crocs with fur-type lining and pink socks. She was not wearing a pressure relieving boot on her left foot. On 5/21/25, from 10:07 AM until 12:06 PM, R66 remained in the small dining room for activities and then for lunch. She continued to wear crocs on both feet and was not wearing a pressure relieving boot on her left foot. At 1:05 PM, V41, CNA, was coming out of R66's room. R66 was sitting in her room in her w/c wearing crocs and socks. After asking R66 if I could see her heels, and she agreed, V41 assisted by removing R66's shoes off the left and right feet and removed R66's socks. R66's left heel was darkened, and she said it was sore. V41 placed R66's socks on both her feet and then placed a blue pressure relieving boot onto R66's left foot. V41 stated to R66, That will make it feel better. On 5/27/25, V22, Wound Nurse, stated that R66 should have skin prep to her left heel and the use of the boot for pressure relieving measure. V22 stated that the goal of the interventions is to prevent breakdown. V22 stated that R66's boot should be worn while out of bed and while also in bed if the heels are not being floated. Based on observation, interview, and record review, the facility failed to assess, timely treat pressure ulcer infection, and provide pressure relief, to prevent pressure ulcer development and worsening of pressure ulcers for 3 of 6 residents (R6, R29, R66) reviewed for pressure ulcers in the sample of 67. On 12/27/2024, R6 acquired a deep tissue injury from pressure to his left shoulder which opened to a Stage IV, exposing tendon. On 1/10/2025, (R6) acquired another deep tissue injury, unstageable, from pressure to right hip which opened to Stage IV pressure ulcer exposing hardware on his right hip. Subsequently, (R6's) pressure ulcers worsened and (R6) was admitted to the hospital with pressure ulcer infection from 2/28/2025 - 3/14/2025 with osteomyelitis. This failure resulted in Immediate Jeopardy on 12/13/2024 when R6, who is severely contracted and in fetal position, has a history of pressure ulcers and is at high risk for pressure injuries. (R6's) low air loss mattress malfunctioned on 12/13/2024, which caused him to lay on the metal frame with no pressure reducing device for the prevention of bedsore. On 12/27/2024, (R6) acquired a deep tissue injury which Wound Nurse Practitioner, V13, stated was from the facility not providing adequate pressure relief and from the low air loss mattress malfunctioning. From 12/27/2025 until 1/17/25, the facility did not follow the order from wound consultant for the left shoulder pressure ulcer. On 1/10/2025, (R6's) acquired an additional deep tissue injury, unstageable, to his right hip from pressure. (R6) was seen by Wound Nurse with pressure ulcers worsening and opening to Stage IV pressure ulcers, exposing tendon on his left shoulder and hip hardware on his right hip. On 2/28/2025, due to the decline in (R6's) pressure ulcer and possible infection in (R6's) left shoulder, V13 ordered (R6) be sent to hospital. (R6) remained in the hospital from [DATE] through 3/14/2025 and diagnosed with osteomyelitis. (R6) returned to the facility on 3/14/25 and had an order for IV antibiotic to be administered for 7 days. The MAR documented R6 did not receive the antibiotic for 3 of the 7 days prescribed. On 4/9/25, V50, Nurse Practitioner, concerned with possible infection in (R6's) pressure ulcer, ordered a culture. This culture was not obtained until 4/17 and not reported to V50 until 4/24/25 at which time, the lab indicated infection. V50 ordered PICC line placement for (R6) to administer antibiotics. The facility failed to gain venous access until 4/29/25, at which time antibiotic was started. V50, NP, stated the delay in treatment of the wound infection could cause R6 sepsis which could result in organ shutdown resulting in death. On 5/9/2025 at 10:44 AM V1, Administrator, V2 Director of Nursing DON and V3 Assistant Director of Nursing ADON were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 5/20/25, after the team attempted to validate abatement on 5/13 and 5/14/25, and 5/20/25, and observed that residents (R6, R51, and R59) at high risk for skin breakdown were lying on low air loss mattresses that were not set to the appropriate weight setting of each resident. On 5/20/25, at 12:10 PM, the survey team validated the facility's abatement but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's in-service training, ongoing assessment, monitoring of pressure relieving equipment and pressure ulcer monitoring. Findings include: 1. R6's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses including osteomyelitis, stage IV pressure ulcer to sacrum, stage IV left upper back pressure ulcer, stage IV right hip pressure ulcer, pressure induced deep tissue damage, paraplegia, hyperglycemia and contractures of both knees. R6's Physician's Order Sheet (POS) dated 10/10/2024 documents pressure relieving low air loss mattress to bed and pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin. R6's Annual MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, at risk for developing pressure ulcers, one stage III pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet. R6's POS, dated 12/1/2024 documents the following active physician's orders: 10/12/2023 document weekly skin assessment every Monday day shift and 7/9/2024 waffle boots on when in bed every shift pressure release. 6/11/2024 apply pillows between left and right legs and thighs every shift for positioning. 10/10/2024 pressure relieving low air loss mattress to bed and pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin. Notify MD/DON/Wound Nurse if he has or c/o (complaint of) any excoriated and/or open areas. R6's Undated Care Plan, documents resident is at risk for decline in wound impairment to skin integrity r/t (related to) poor PO (by mouth) intake, incontinence and decreased mobility. 12/31/2023 left shoulder stage IV pressure ulcer -nosocomial (acquired in house) and right hip pressure ulcer stage IV pressure ulcer. Goal: resident will have a decline in wound status through next review date. Interventions: pressure relief techniques, left to right side to side t/p (turn and reposition) every hour and PRN (when needed), use positioning devices as indicated. Multipodus boots on when in bed. Use positioning devices when in bed to maintain positioning when in bed. Use pillows between legs when in bed. Educate staff on the importance of maintaining left to right t/p schedule to promote healing and reduce the risk for skin breakdown. Apply padding to bony areas (such as pillows, boots, heel protectors etc.) as indicated. Low air loss, pressure relieving mattress to bed. He uses a pressure relieving cushion to protect the skin while up in chair. Notify nurse of any redness areas, s/s (signs or symptoms) of infection, excoriation or skin breakdown immediately, treatments as ordered (see physician's order sheet/TAR), notify PCP (primary care provider) DON (Director of Nursing) if decline noticed in wound status, monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal. s/s of infection, maceration etc. to MD (physician.) R6's POS dated 12/13/2024, documents late entry: d/c (discontinue) low air loss mattress until replaced, due to it not functioning properly, per wound consultation company CNAs moved resident from broken low air loss mattress today and put on regular mattress until replacement mattress is available. R6's Wound Nurse Practitioner Progress Note, dated 12/13/2025 stage 3 coccyx pressure ulcer measured 2.3 cm x 2.3 cm x 0.6 cm, 50% slough, granulation tissue 30%, skin intact 20%, exposed structure: blank. Pressure ulcer length, width, depth and tissue status deteriorated as compared to previous visits conclusion. Visit specific information: patient now has a regular mattress and appears to be able to turn and reposition much better. This was the only pressure ulcer R6 had as of 12/13/2024. R6's Nursing Progress Note, dated 12/18/2024 at 3:14 PM documents, Upon doing daily treatment to coccyx, this nurse noticed an area to the right hip which appears to be consistent with an abrasion. Area measures 5.5 x 4.5 x 0.1 cm. (whole reddened area.) with a small open area to the middle measuring 2 x 2 x 0.1 cm. Area bright red in color, small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet bright (whole reddened area.) with a small open area to the middle measuring 2 x 2 x 0.1 cm. Area bright red in color, small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet bright red. Facial grimacing noted when area cleansed. This nurse also noted an area to the Right shoulder/deltoid measures; 8 x 3.5 x 0.1 cm (whole reddened area) with a small open area to the middle measuring; 2 x 0.5 x0.1 cm small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet, bright red in color. Facial grimacing noted when area cleansed. Area consistent with an abrasion as well. This nurse reported findings to the Administrator as well as DON and ADON. Message left with POA to return call. MD made aware as well as well as V13- new orders redc'd to Cleanse areas with soap and water, pat dry. Apply skin prep to periwound apply TAO and cover with dry protective dressing daily and PRN. Education provided to staff regarding turning and repositions q2. Resident also provided with more offloading devices such as pillows and wedges. Spoke with maintenance regarding status of the replacement low air loss mattress, maintenance states that one came in today he was going to check and see if it belonged to him or not. On 5/2/2025 at 2:55 PM, V63, LPN stated she was assigned to R6 on 12/18/2025 and stated she observed (R6) laying on the air loss mattress but all the air was in the foot of the mattress, no air was at the head of the bed and the (R6) lay directly on the bedframe. V63 stated she spoke to the maintenance man regarding (R6's) air loss mattress malfunctioning but he said it was working just fine and he wouldn't switch the bed out or change (R6's) bed. V63 stated there were numerous times that she observed (R6) laying on the air loss mattress with no air in the head of the bed and she spoke to V13, Wound Consultant about her concerns but (R6) continue to lay in the broken air mattress bed. R6's Wound Nurse Practitioner Progress Note, dated 12/19/2024, documents (R6) was removed off the low air loss mattress last week due to his wound continuing to decline. Patient is contracted and lies on fetal position and on the low air loss mattress this potentially place him on the frame depending on the level of inflation that the bed is set to. We placed them on a regular mattress so he would stop sinking into the bed however this week he now has two new wounds. I did discuss with V2, DON that maybe we could place a thinner foam on the bed frame and then a low air loss mattress which would help reduce pressure to the area if the mattress deflated enough to where he's putting pressure on the frame. Also discuss with V2 the need for frequent turning and repositioning. Stage 3 pressure ulcer to right trochanter wound 3 initial assessment measured 3.5 cm x 2.1 cm x 0.2 cm wound bed 60% granulation and 40% slough. Stage 3 pressure ulcer to right shoulder wound 4 initial assessment measured 1.5 cm x 5.5 cm x 0.2 cm wound bed 30% granulation and 70% skin intact. 5/1/2025 at 3:25 PM V32, Maintenance Director stated there was a situation with R6's low air loss mattress and he wasn't here at that time but he recalled it was in December 2024 that maintenance staff reported to him that the resident's air loss mattress was found to be faulty, all the air was out of the mattress and the resident lay in a concave hole in the middle of the bed and the resident was laying on bedframe. Staff told him the mattress needs to be replaced and it was replaced the same day. He replaced several low air loss mattresses for the resident due to staff not pushing the static mode button to the off position when the resident is in the prone position. Observation showed at that time that the static mode button was in the on position, and it should have been off, V32 turned it to the off position. V32 stated when the resident's head of bed is elevated the static mode should be in the ON position because if not it doesn't distribute the air in the air loss mattress properly. V32 stated he has replaced R6's low air loss mattress at least 4 times in the last 2 years because it just wears out after time. On 5/8/2025 at 9:30 AM V32, Maintenance Director stated they don't document work orders when they change out resident's bed even if they are faulty. V32 didn't know what dates (R6's) air loss mattress was malfunctioning or when (R6) had a regular pressure relieving mattress. On 5/8/2025 at 9:45 AM V22, Wound Nurse stated she doesn't know what dates (R6's) air loss mattress wasn't working properly or when he lay on a regular mattress. R6's Wound Nurse Practitioner Progress Note, dated 12/27/2024 documents a new Unstageable pressure ulcer on left shoulder measured 0.9 cm x 1.5 cm x 0.1 cm. Treatment: skin prep, paint wound edges and surrounding skin. Visit specific information: Patient is still on a regular mattress and his wounds are improving this week. This was the suspicion that patient just needed better off flowing and not necessarily the low air loss mattress which was sinking him into the frame of the bed. Due to patient's falling (means balling) up in the fetal position it is highly likely that he needs offloading more frequently. R6's POS dated 12/27/24 through 12/31/20242024 documents no physician's order for skin prep. R6's TAR, dated 12/27/2025 through 12/31/2025 no documentation staff administered skin prep to (R6's) unstageable left shoulder pressure ulcer. R6's Wound Nurse Practitioner Progress Note, dated 1/3/2025 documents a initial/new assessment an unstageable pressure ulcer on left shoulder/wound 5 measured 3.0 cm x 2.5 cm x 0.1 cm. Wound assessment documents the pressure ulcer was facility acquired. Treatment: skin prep, paint wound edges and surrounding skin. Right trochanter wound 3 and right shoulder wound 4 documented healed. R6's POS, dated 1/1/2025 through 1/9/2025 physician's order for skin prep to (R6's) unstageable left shoulder pressure ulcer. R6's TAR, dated 1/3/2025 through 1/9/2025 no documentation staff administered skin prep to (R6's) unstageable left shoulder pressure ulcer. R6's Wound Nurse Practitioner Progress Note, dated 1/10/2025 documents left shoulder unstageable pressure ulcer/wound 5 treatment: cleanse with soap and water, skin prep to periwound, apply calcium alginate to wound base and cover with bordered gauze. New pressure ulcer assessed unstageable right trochanter wound 6 measured 2.0 cm x 2.5 cm x 0.1 cm, 100% skin intact treatment: skin prep. R6's Wound Nurse Practitioner Progress Note, dated 1/10/2025 documents wound 5 unstageable left shoulder pressure ulcer/wound 5 measured 3.1 cm x 3.8 cm x 0.2 with 30% slough and documents pressure ulcer deteriorated compared to previous visit. New unstageable pressure ulcer right trochanter (hip) wound 6 measured 2.0 cm x 2.5 cm x 0.1 cm wound bed 100% intact. Treatment: paint surround skin with skin prep. R6's POS dated 1/10/2025 no physician's order for (R6's) unstageable left shoulder pressure ulcer/wound 5 treatment of calcium alginate to wound base and cover with bordered gauze per wound nurse practitioner documentation dated 1/10/2025 and no physician's order for skin prep to right trochanter wound 6 unstageable pressure ulcer per the wound nurse practitioner's documentation dated 1/10/2025. R6's Braden, dated 1/16/2025 at 1:08 PM documents moderate risk for skin breakdown. R6's Annual MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, at risk for developing pressure ulcers, two stage III pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet. R6's Wound Nurse Practitioner Progress Note, dated 1/17/2025 documents left shoulder unstageable pressure ulcer/wound 5 and unstageable right trochanter pressure ulcer/wound 6 treatment changed to cleanse with soap and water, skin prep to periwound, calcium alginate to wound bed and cover with bordered gauze. It was documented both pressure ulcers had deteriorated compared to the conclusion of the previous visit. R6's TAR dated 1/1/2025 through 1/16/2025 no documentation staff administered skin prep to (R6's) left shoulder of right trochanter. R6's POS dated 1/17/2025 and discontinued on 1/21/2025 documents a new physician's order for skin prep to both shoulders and right hip daily. (The wound nurse practitioner initially ordered skin prep to left shoulder daily on 12/27/2024 and right hip on 1/10/2025 this is the first physician's order for skin prep.) No new physician's order from the wound nurse practitioner progress note, dated 1/17/2025 documented both left shoulder and right trochanter pressure ulcer treatments to soap and water, skin prep to periwound, calcium alginate to wound bed and cover with bordered gauze. R6's POS dated 1/21/2025, documents a new physician's order left shoulder and right trochanter pressure ulcer cleanse with soap and water, pat dry, apply skin prep periwound, apply Santyl to wound bed, calcium alginate to wound bed and cover with bordered gauze. R6's POS dated 1/17/2025 documents pressure relieving mattress to bed and a pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin. R6's TAR dated 1/2025 documents blank boxes dated 1/22/2025, 1/29/2025 and 1/30/2025 for the left shoulder and right trochanter pressure ulcer treatment. R6's Braden, dated 2/10/2025 at 4:18 PM documents high risk for skin breakdown. R6's Quarterly MDS, dated [DATE], documents R6 was severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, two stage III pressure ulcers, two unstageable pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet. R6's Wound Nurse Practitioner Progress Note, dated 2/12/2025 documents visit specific information: patient now has a low air loss mattress. R6's Wound Nurse Practitioner Progress Note, dated 2/21/2025 documents wound 5 left shoulder pressure ulcer is now documented as a Stage IV measured 10.0 cm x 6.0 cm x 0.8 cm with tunneling and wound bed was covered with 80% slough, with exposed tendon, serosanguineous drainage. Wound 6 right trochanter pressure ulcer is now documented a stage IV measured 5.8 cm x 6.3 cm x 0.6 cm with tunneling no exposed structure documented. Both pressure ulcers per wound nurse practitioner documentation had deteriorated compared to the conclusion of the previous visit. R6's TAR dated 2/2025 blank boxes for left shoulder and right trochanter pressure ulcer treatments on 2/3/2025, 2/4/2025, 2/10/2025, 2/12/2025, 2/18/2025, 2/20/2025 and 2/26/2025. R6's Wound Nurse Practitioner Progress Note, dated 2/28/2025 documents wound 5 left shoulder pressure ulcer stage IV measured 8.5 cm x 6.2 cm x 0.8 cm, wound bed 80% slough, 10% granulation and 10% exposed structures, exposed structure: tendon and serosanguineious exudate. Wound 6 right trochanter pressure ulcer stage IV measured 6.5 cm x 6.5 cm x 0.7 cm with tunneling tissue type: 10% granulation and 10% exposed structures (no specific exposed structures documented) with purulent exudate. Both pressure ulcers per wound nurse practitioner documentation had deteriorated compared to the conclusion of the previous visit. Visit specific information: recommend culture to left shoulder and right trochanter today and if it is not completed today patient needs to go to the hospital. R6's POS, dated 3/2/2025 discontinue pillows between left and right legs and thighs every shift for positioning. Physician's order discontinued: pressure relieving mattress to bed and a pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin. R6's Nursing Note, date 3/3/2025 at 9:27 AM documents R6 was admitted to the hospital for osteomyelitis. R6's POS dated 3/12/2025 a new physician's order pillows between left and right legs and thighs every shift for positioning related to contracture, left and right knee. A new physician's order pressure relieving low air loss mattress to bed and wheelchair every shift for pressure relieving devices to protect skin. A new physician's order weekly skin assessment on day shift every Monday and pressure relieving mattress to bed and chair. R6's Braden, dated 3/14/2025 at 7:11 PM documents moderate risk for skin breakdown. R6's Hospital After Summary dated 3/14/2025, documents Ertapenem 1 gram into a venous catheter daily last given on 3/14/2025 at 10:14 AM. Pressure ulcer treatment documented Santyl apply topically daily to left shoulder and right trochanter. R6's readmission assessment dated [DATE] at 6:54 PM no documentation of a readmission skin assessment. R6's Nurse Progress Note, dated 3/14/2025 no documentation of skin upon readmission to the facility. R6's Weekly Observation Note, dated 3/17/2025 at 12:44 PM documents (R6) was admitted on [DATE]. Skin color is pale. Skin temperature is warm. Skin turgor shows tenting due to a delay in return of skin. Skin issues present. Refer to assessment for more information. Recent readmit with wound vac in place. Refer to full assessment for more information. R6's Medical Record, dated 3/17/2025 no documentation of (R6's) skin or wounds. R6's POS dated 3/14/2025 documents Ertapenem 1 gram IV every 24 hours for infection for 7 days until finished. End date 3/19/2025. On 3/19/2025 new physician's order Ertapenem 1 gram IV every 24 hours for infection until 3/21/2025. No pressure ulcer treatment to coccyx on POS. R6's MAR dated 3/2025 documents new physician's order on 3/14/2025 documents Ertapenem 1 gram IV every 24 hours for 7 days for infection. No documentation Ertapenem was administered on the following days: 3/15/205, 3/17/2025, 3/19/2025 was blank on the MAR and 3/21/2025 had an X on the MAR. R6's Medical Record no documentation of reason why staff didn't administer Ertapenem IV antibiotic medication per physician's orders. R6's Weekly Skin Observation Note, dated 3/17/2025 at 12:44 PM documents (R6) was admitted on [DATE], skin color is pale, skin temperature is warm, skin turgor shows tenting due to delay in return of skin, skin issues present refer to assessment for more information. No additional skin/wound assessment was documented in (R6's) medical record. R6's Significant change MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel, indwelling urinary catheter, at risk for developing pressure ulcers, three stage IV pressure ulcers, 2 unstageable pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet. R6's Wound Nurse Practitioner Progress Note, dated 3/19/2025 documents wound 5 left shoulder stage IV pressure ulcer measured 7.6 cm x 6.5 cm x 0.9 cm with tunneling, wound bed 70% covered with slough with tendon exposed. Right trochanter wound 6 stage IV pressure ulcer measured 8.5 cm x 6.5 cm x 0.7 cm with tunneling. Wound bed was covered with 50% slough, with exposed hardware, purulent drainage. Both pressure ulcers documented to have deteriorated compared to the conclusion of the previous visit. R6's Braden, dated 3/21/2025 at 8:36 AM documents moderate risk for skin breakdown. R6's Weekly Skin Observation Note, dated 3/21/2025 at 9:05 AM documents skin color is normal, skin temperature is dry, skin turgor is normal as skin returns promptly, skin issues present refer to assessment for more information. R6's POS, dated 3/25/2025 a new physician's order prevalon boots on at all times every shift for pressure relieving device. R6's Wound Nurse Practitioner Progress Note, dated 3/26/2025 documents a new treatment order for (R6's) stage IV right trochanter pressure ulcer was cleanse with soap and water, skin prep to periwound, calcium alginate to wound base, santyl to wound bed and cover with bordered gauze daily. R6's Braden, dated 3/28/2025 at 8:38 AM documents moderate risk for skin breakdown. R6's Skin/Wound Note dated 4/4/2025 at 11:23 AM documents wound care provided. Treatment applied per treatment orders. Resident's wound is red a bright red beefy color with white slough present on wound bed. Resident tolerated wound care well with no s/s (signs or symptoms) of pain or discomfort noted during treatment. R6's Medical Record no documentation of wound nurse practitioner weekly wound assessment dated [DATE] through 4/8/2025. R6's Wound Nurse Practitioner Progress Note, dated 4/9/2025 documents stage IV left shoulder pressure ulcer wound 5 treatment: wash with soap and water, skin prep, calcium alginate, Bactroban and bordered gauze dressing change twice a day (BID.) Wound nurse practitioner documented pressure ulcer deteriorated compared to the conclusion of the previous visit. R6's POS dated 4/15/2025 documents Bactroban apply to left shoulder topically everyday shift for wound healing, cleanse wound with w/s apply Bactroban and calcium alginate and dry dressing every day and PRN. There was no physician's order to change the dressing BID per the wound nurse consultant's recommendation, dated 4/9/2025. R6's TAR, dated 4/2025 Bactroban apply to left shoulder topically everyday shift for wound healing, cleanse with w/s apply Bactroban and calcium alginate and dry dressing every day and PRN. Blank boxes on the TAR for the following dates that R6 did not recieve treatments: 4/15/2025, 4/16/2025, 4/25/2025, 4/28/2025 and 4/29/2025. R6's POS, dated 4/9/2025 documents a new physician's order obtain wound culture from (R6's) left shoulder related to possible infection. R6's Wound/Skin Note, dated 4/9/2025 at 2:39 PM, documents NP stated to obtain cultures form area due to discoloration of wound related to possible infection. R6's Lab Result, documents specimen collected 4/22/2025 documents organisms present. Moderate growth organism growth for two and rare growth for one organism. (No documentation of which pressure ulcer/wound was cultured.) On 5/6/2025 at 3:07 PM V64, Lab Client Solutions Representative stated a specimen was collected from the facility on 4/14/2025 but it was tossed out by the lab due to missing resident identification information. A second specimen was collected from the facility on 4/22/2025 and arrived to the out of state lab on 4/23/2025. R6's POS, dated 4/24/2025 documents a new physician's order for Meropenem 1 gram IV every 12 hours for 7 days for wound infection, wound location not documented. R6's MAR, dated 4/2025 documents evening dose on 4/24/2025, both morning and evening doses on 4/25/2025 and 4/26/2025, morning dose on 4/27/2025, evening dose on 4/27/2025 staff documented administered, morning dose on 4/28/2025 staff documented 9/other, then physician's order was discontinued. On 5/1/2025 at 3:34 PM V58, LPN stated he did not give (R6) the IV dose of Meropenem 1 GM on the morning of 4/28/2025. V58, LPN, stated if his initials are on (R6's) MAR it is by accident and he is not allowed to give IV medication because he is an LPN. R6's POS dated 4/28/2025 documents a new physician to discontinue the IV antibiotic Meropenem 1 gram and reordered it on 4/29/2025. On 5/7/2025 at 11:40 AM V3, ADON stated she was aware the V50, NP ordered a wound culture (wound location unknown) at the beginning of 4/2025 and the first wound culture was sent to the lab (date unknown) and it was thrown out from the lab due to not have appropriate resident labeling/identification on it. The second wound culture was obtained at the facility a few days later and sent to the lab. V22, Wound Nurse reported the wound culture results to V50, NP on 4/24/2025 and she spoke to V50 on 4/25/2025 regarding (R6's) wound culture report results showing there was an infection. V50 ordered 7 days of IV antibiotics at that time and ordered (R6) to have a PICC line placed or to have a mobile PICC line company come to the facility and insert a PICC line. V3 stated she discussed PICC line placement with V22, wound nurse and she was told (R6) needed an appointment to have the PICC line placed and the facility doesn't have a mobile PICC line company service. V3 stated on 4/28/2025 she attempt multiple times to insert an IV peripherally and (R6's) veins were not cooperating so she was not able to get IV access. She notified V50 of no IV access and V50 put the IV antibiotics on hold and (R6) got an appointment and had the PICC line placed on 4/30/2025 and since then the IV antibiotics were reordered and (R6) has received the IV antibiotics were administered per physician's orders. When staff administer medications, including IV antibiotics they are expected to sign off the medication was administered as soon as they administer it. On 5/7/2025 at 3:22 PM V22, Wound Nurse stated she looked up the wound culture results from the lab in the computer on 4/24/2025 and notified (V50), NP of the lab results. (V50) called her back on 4/25/2025 and gave a physician's order for (R6) to get a PICC line inserted and to have IV antibiotics for 7 days for a wound infection. V22 stated she couldn't just send (R6) to the hospital for PICC line placement and the facility didn't have a mobile company to come place the PICC line in the facility. V22 stated V3, ADON attempted multiple times to place a peripheral IV in (R6) but it was unsuccessful. An appointment was made for (R6) on 4/29/2025 and the PICC was placed at an outside office on 4/30/2025. V22 stated (R6) has received the IV antibiotics since they had PICC line access on 4/30/2025. V22 stated IV antibiotics were put on hold by (V50) because (R6) didn't have [TRUNCATED]

6. R31's Diagnoses Report, print date of 5/27/25, documents he has diagnoses of need for assistance with personal care, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, and cerebral infarction. R31's Care Plan, with revisions dated 12/21/21, documented (R31) has an ADL (Activities of Daily Living) self-care deficiency r/t (related to) CVA (stroke with left sided weakness, activity intolerance, confusion and fatigue. The Care Plan, interventions with revision on 8/16/23 documented Toilet Use: x2 extensive assist with toileting. Assist with dressing change and peri care after all toileting and incontinent episodes. The interventions documented Transfer x2 extensive assist with transfers. R31's MDS, dated [DATE], documented he has impairment on one side of lower extremities (hip, knee, ankle, foot). The MDS documents that R31 is dependent for toilet transfer as helper does ALL of the effort, Resident does none of the effort to complete the activity. On 5/14/25, at 12:50 PM, V6, CNA, stated that she was going to assist R31 to the toilet. V6 entered R31's room. R31 was seated in his wheelchair. V6 pushed R31 into the bathroom. She placed a gait belt around R31's waist. V6 directed R31 to stand up and he did so independently without assistance. She told him to grab both handicap rails on the wall to each side of the toilet. He did this. At this time, his right leg began to shake, as he faced the toilet. She cued him to grab the handicap bar to the right of the toilet, which he did. R31 was having difficulty moving his right and left legs to pivot to the right to sit on the toilet. V6 verbally cued him multiple times. He finally pivoted enough and then he fell heavy onto the toilet seat and sighed. On 5/27/25, at 12:57 PM, V2, DON, stated that he was unsure of R31's transfer status. Based on interview and record review the facility failed to properly supervise, develop and implement progressive intervention to prevent falls and provide safe transfers for 6 of 6 residents (R22, R31, R43, R46, R69, R72) reviewed for accidents in a sample of 67. This failure led to R69 having multiple visits to the emergency room and receiving a closed non-displaced fracture of right ilium, 0.5 cm laceration to right eyebrow, a laceration to the forehead, and bruising to face on 3 separate occasions. Findings include: 1. R69's EMR (Electronic Medical Records) undated documents that resident was admitted to the facility on [DATE]. R69's EMR dated 11/22/23 documents a diagnosis of epilepsy, history of falling, and unspecified convulsions. R69's MDS (Minimum Data Set) dated 1/30/25 documents a BIMS score of 11 out of 15. The MDS documents that the resident is independent with roll left and right. The MDS documents that the resident requires supervision or touching assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. R69's Care Plan dated 11/23/23 documents (R69) is at risk for falls and/or injury r/t weakness, impaired gait, unsteadiness on feet and poor safety awareness. He will get self-up off the floor without notifying staff. The resident had 8 interventions for 24 falls from 4/19/24 until 4/19/25. R69's Nursing Note dated 4/19/24 at 8:07 PM documents This nurse was notified by staff members that resident fell out of his wc (wheelchair) while smoking and then started to have a seizure. This nurse and second nurse went to patio area. Resident noted to be on the ground on his back having tonic clonic seizure. This nurse came back into building called 911 and began printing paperwork for resident to be sent to (local hospital). Second nurse stayed outside with resident for assistance. Resident noted to be combative when staff tried to assist resident to his chair. Resident finally let staff assist him into wc. This nurse informed resident once inside building that he would be taking to the hospital for eval. Resident stated I don't agree with that. I don't take medicine. Resident then wheeled himself to his room. No intervention documented on the care plan for this fall. R69's Health Status Note dated 5/25/24 at 5:40 PM documents Summoned to room. Resident lying on floor, face down next to bed. Resident non-verbal. Blowing respiration noted. Eyes open and fixed. Upper and lower extremities jerking. Head moving in an up and down motion Resident not responding to verbal stimuli. Staff at side to prevent injury. V/S (vital signs) 97.8 108 22 O2 sat (oxygen saturation) 96. No intervention documented on the care plan for this fall. R69's Nursing Note dated 6/26/24 at 7:18 AM documents CNA (Certified Nursing Assistant) notified writer that resident was in his room on the floor. Writer went into residents' room and found resident lying on his rt side on the floor. ROM (Range of Motion) performed resident is able to move all limbs without any pain or discomfort. Limbs are equal in length no injuries or bruising present at this time Neuro Check performed. Staff assisted resident up into his wheelchair. MD (Medical Director) notified of fall along with POA (Power of Attorney). No intervention documented on the care plan for this fall. R69's Nursing Note dated 7/19/24 at 9:28 AM documents the aid answered the resident call light and noticed he was on the floor asked was he ok and after he stated yes the aid alerted the nurse. this nurse went into the resident ' s room to assess the resident while on the floor. he is alert and oriented x4. the resident stated he was on the floor because he tried to get in his wheelchair and did not make it so he got on the floor to keep from falling. the resident stated he did not hit his head nor hurt himself he just needed help getting back up into his wheelchair. no new s/s no c/o pain or discomfort. this nurse and the aid assisted him back into his wheelchair and will check on him throughout the day and f/u. No intervention documented on the care plan for this fall. R69's Nursing Note dated 7/26/24 at 8:21 PM documents Resident noted on the floor in his room. Resident stated he wants to go to the hospital so he can get out of here. But needs help getting up. Resident states he is cold. Resident is spitting on the floor. Resident VS WNL (within normal limits). (Local Ambulance Service) called to transport Res to hospital. Psych MD Notified and a message was left. R69's Nursing Note dated 8/2/24 at 4:14 PM documents res was transported back to facility after x-rays r/t (related to) to large abd (abdomen) bruise on R side patients was diagnosed at ED (Emergency Department) w/ a closed nondisplaced fracture of R ilium resident has no recollection of fall or incident that would have caused fracture will cont to f/u (follow up) res is in bed resting quietly no outward c/o pain or discomfort at this time. No intervention documented on the care plan for this fall. R69's Nursing Note dated 8/11/24 at 9:15 AM documents Resident noted on the floor in his room next to AC (air conditioning) unit. Resident states he does not know what he was doing before or during time he was noted on floor. Resident is conscious and breathing. Resident's wheelchair was Parallel to his body and clothes were Neatley folded on the seat of the wheelchair. Resident refused to let staff check vital signs, Resident offered pain medication and declined it. Resident asked staff if he could smoke a cigarette. No apparent injuries noted, (local ambulance service) called to transport Resident to ER (Emergency Room) for further assessment. MD Notified and Aware. Resident's Guardian (V36) Notified via phone call he did not answer, A voicemail message was left with call back number. No intervention documented on the care plan for this fall. R69's Health Status Note dated 10/6/24 at 8:49 AM documents Resident was found on the floor this morning covered in wet having a hard time breathing lying on his left side. Resident asked what happened and how did he get on the floor? he stated he didn't know. he was assisted into chair and immediately started leaning to the left unable to stay conscious, when asked if he was in pain, he stated he was having pain to back. He was very lethargic, hard to keep eyes open. sent to (metro hospital) for evaluation via ems (Emergency Medical System). vitals 147/70 72 95 98.0 18. pupils slow to react. No intervention documented on the care plan for this fall. R69's Nursing Note dated 10/10/24 at 1:30 PM documents Resident had a fall in the dining room he was found bottom down, and wheelchair flipped over on the left side of him. Resident had no injuries, and he could not explain what he was doing. He refused vitals to be taken. No neuro initiated. Left voicemail for (V36). Md was notified. No intervention documented on the care plan for this fall. R69's Nursing Note dated 11/21/24 at 4:19 PM documents (R69) had possible seizure, unwitnessed fall with AMS (Altered Mental Status) and difficulty breathing. He is lying on the floor, wheelchair alongside him, tipped onto its side. (R69) is struggling to inhale through his trach stoma. He is refusing supplemental O2/Nursing care and being combative with care. Guardian notified that he will most likely be sent to the closest ER, (local hospital) and that bed hold policy is being sent with him. MD notified he is being sent out to the ER via *911. Face sheet, POS (Physician Orders), Code Status, Guardianship papers and Bed hold policy in folder to be sent with him. No intervention documented on the care plan for this fall. R69's Nursing Note dated 11/26/24 at 8:04 AM documents Resident had a seizure in the dining room. Resident was sitting up in his chair in dining room when he fell to the floor and began seizing. Seizure began at 753am and ended at 758am resident is alert per his usual baseline. Staff assisted resident up off floor and back into chair after seizing end no injuries noted at this time. MD notified. No intervention documented on the care plan for this fall. R69's Nursing Note dated 12/11/24 at 7:46 AM documents the halls CNA alerted the writer that the resident was on the floor so the writer went into the residents room and the resident was also covered in blood across his face, as the writer assessed the resident she noticed a gash across the residents right eye and scratches on his right leg that had an open wound where the blood was flowing from but was dried up. there is blood on the resident ' s pillow on his bed and blood on numerous items and the floor of the resident ' s room. the writer asked the resident was he experiencing any pain and the resident stated he was not in any pain, and he could not pull his WC close enough or push his self-back on the bed, so he eased his self to the floor. the resident was assisted back into his WC by two CNAS the writer attempted to wash his face, but he refused and stated he would do it his self the writer alerted the administrator and called the ambulance, and the writer will f/u. R69's Nursing Note dated 12/12/24 at 8:13 AM documents Per ER notes: (R69) has 0.5 cm (centimeter) laceration to right eyebrow, with bruising. (x2) absorbable sutures to right eyebrow. He received his Tdap (BOOSTRIX) while in ER. Intervention: 12/11/24 - educate on importance of medication compliance and possible consequences of not taking. Encourage him to taking medication to prevent consequences more frequent checks throughout the night. R69's Nursing Note dated 12/25/24 at 10:40 PM documents Resident had a seizure in the dining room and had an unwitnessed fall. Ambulance was called and resident refused to be transported. His vital were 98.1, 76, 18 149/88 patient is back at his current baseline. He refused all vital thereafter stating that he didn't fall. Intervention: 12/25/24 - fall due to seizure activity. Educate on need for and importance of taking all medications as prescribed. Notify MD of continued refusal of medications and seizure activity with fall. R69's Nursing Note dated 1/14/25 at 9:43 AM documents Writer observed a laceration to residents' forehead he also had a bruise on his nose that was reddish in color, he was also noted to have a discoloration on his right inner eye. Resident stated that he fell and didn't notify anyone. Resident will be sent out to (local hospital) for an evaluation. Md, DON (Director of Nursing) and there was a message left for (V36) to contact the facility at their earliest convenient. No intervention documented on the care plan for this fall. R69's Nursing Note dated 1/20/25 at 9:55 PM documents Writer was notified by staff that resident was on the floor in his room. Upon evaluation of resident, he was lying on the floor on side trying to get to the door. His isn't complaining of any pain or discomfort. He couldn't stat what happened. His vitals are 98.1,76,18,163/94, 96 % room air. Neuro checks where initiated, but the resident denied any further vitals. Md, (V36) where notified. No intervention noted on the care plan for this fall. R69's Nursing Note dated 1/29/25 at 4:45 AM documents 4:30am (R69) was found sitting on the floor. He says he rolled out of bed face first, no pain, redness in his face, ROM wnl, no other bumps or bruises, he says he feels fine, vitals wnl. Physician and DON notified. Will notify POA and continue to monitor. R69's Nursing Note dated 1/30/25 at 2:27 PM documents Resident noted to have an area protruding from right above the right eye. It is black and purple. Resident stated he has no pain. There is an open tiger text awaiting an answer from the MD. Intervention: 1/29/25 - increase nighttime checks, assist with getting out of bed as indicated. R69's Nursing Note dated 2/17/25 at 12:34 PM documents Writer was alerted to the dining room where patient had fallen out of the chair during a seizure. He denied falling or having a seizure and denied vitals. He agreed to go to the hospital and when the ambulance arrived, he declined to go. His family member was notified, and she knows he denied being assessed at the hospital. Resident is back at his current baseline. Intervention: 2/17/25 - Notify MD of continued refusal of medications and seizure activity with fall. educate on importance of medication compliance and possible consequences of not taking. Encourage him in taking medication to prevent consequences. more frequent checks throughout the night. R69's Health Status Note dated 2/27/25 at 5:05 AM documents Alerted to the resident's room, (R69) noted on floor near bedside laying on his left side in fetal position. Upon assessment for pain resident complaint of lower back and buttock pain. No c/o hitting head, resident noted with redness to left hip. Will transport to E.R. for exam related to lower back and buttock pain. Intervention: 2/27/25 - ask if he has to toilet of if he wants to get out of bed if noted to be awake. R69's Nursing Note dated 3/7/25 at 8:54 PM documents Resident found lying on ground in smoking area actively seizing and vomiting. Placed on left side, head protection provided by staff hand. 02 85% on room air. Seizure activity continued x5 minutes. Resident sat upright in wheelchair. Alert and oriented x2able to make needs known. Refusing vital signs and care at this time. CNA unable to clean vomit from resident. Remains non-compliant with all medication. On call Np contacted and notified of condition. Skin intact, no injuries noted related to fall. No intervention documented on the care plan for this fall. R69's Health Status Note dated 3/27/25 at 5:01 AM documents call placed to this pt's (V36) his p.o.a. to notify him of this pt having fallen, no answer, brief message left. Intervention: 3/27/25 - Educate (R69) to ask for assistance prior to attempting to stand up. staff to increase rounding on (R69). R69's Nursing Note dated 4/01/25 at 3:05 AM documents Resident noted to be on the floor during rounds. resident noted to have seizure like activities. pupils fixed. extremities rigid. Resident legs lowered to the floor. resident not responding to verbal or painful stimuli. loss of bodily fluid. blue tinged lips. 911 initiated approx 0150. Resident monitored until ems arrival. resident began to respond back to stimuli approx 0212. EMS arrival 0220. Attempted to change resident clothing and assist to stretcher. resident required 3x assist. No intervention documented on the care plan for this fall. R69's Nursing Note dated 4/09/25 at 11:51 AM documents Resident was found in his room on the floor between the doorway and hallway. When asked if resident fell, he stated no and then when asked if he placed himself on the door he stated, he didn't know. Resident was placed on neuro checks as protocol. Resident A&Ox2, VS: 134/82, 98.0, 91, 18 with pupils equal and reactive to light. Will cont. to monitor. Intervention: 4/09/25 - Psych to eval. R69's Nursing Note dated 4/19/25 at 2:01 PM document Writer was notified by several staff members that resident was on the floor in the dining room having a seizure. Seizure lasted about 3 mins while resident was lying on his left side with head elevated by writer. When asked any of the witnesses if he hit his head, other alert and oriented residents gave full account of resident falling and hitting his head om another resident's chair. Neuro checks have been implemented. Assessment at baseline. Intervention: 4/19/25 - staff to assist (R69) to the floor if seizure activity is present. 2. R43's EMR undated documents that the resident was admitted to the facility on [DATE]. R43's EMR dated 5/6/22 documents a diagnosis of Dementia. R43's EMR dated 10/14/24 documents a diagnosis of history of Falling. R43's EMR dated 1/1/25 documents a diagnosis of muscle weakness (generalized) and difficulty in walking. R43's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is independent with roll left and right. The MDS documents that the resident requires supervision or touching assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident requires partial/moderate assistance for sit to stand, chair/bed to chair transfer, and toilet transfer. R43's Care Plan dated 10/15/24 documents (R43) is at risk for falls r/t impaired Gait/balance, Psychoactive drug use, weakness, Poor safety awareness. R43's Nursing Note dated 10/15/24 at 5:43 PM documents Resident had a fall at 5:05pm. I was a couple doors down at my cart when I heard him fall. I walked into the room to find him laying on his right side. Resident was assesed and neuro vitals started. Resident denied any pain or discomfort. Resident did receive a skin tear to the back of his left arm. He stated that he was trying to get to the bathroom. Resident teaching provided on call light use. No intervention noted on the care plan for this fall. The intervention was noted in the nursing note that the resident was educated on call light use. R43's Nursing Note dated 10/19/24 at 8:46 AM documents CNA notified writer that resident was in his room on the floor. Writer went into residents' room and found resident was in his room on floor on fall mat on his hands and knees. Staff assisted resident up off floor and onto bed range of motion performed. Resident has no c/o of pain limbs equal in length. Writer asked resident what caused him to fall resident stated he was attempting to get into wheelchair unassisted. Writer educated resident on the importance of using call light to ask for assistance when attempting to get into wheelchair. Resident sister notified along with MD. No intervention documented on the care plan for this fall. Intervention noted in the nursing note that the resident was educated on call light to ask for assistance when attempting to get into wheelchair. R43's Nursing Note dated 11/14/24 at 1:34 PM documents Resident was found in room on his knees in staff assisted resident up off his knees and into his wheelchair. Rom (Range of Motion) performed no c/o pain or discomfort noted. MD notified along with family. No intervention documented on the care plan for this fall. R43's Nursing Note dated 11/25/24 at 9:36 AM documents Staff notified writer that resident was on the floor in the bathroom. Writer went into bathroom saw resident lying face first on floor. Staff assisted resident up off floor into wheelchair resident denied pain during transfer. Rom performed resident denied pain limbs are equal in length. Writer asked resident how fall occurred. Resident stated he was attempting to transfer himself on to toilet and lost his balance. Writer educated resident on the importance of using call light when needing to use restroom to get assistance from staff. No intervention documented on the care plan for this fall. Intervention noted in the nursing note that resident was again educated on call light use. This intervention was previously used twice and not progressive. R43's Nursing Note dated 11/30/24 at 6:45 PM documents Staff notified writer that resident was in dining area lying on floor. Writer went into dining room and found resident lying face first on floor. Staff assisted resident up off floor and into chair. Rom performed no c/o of pain noted all limbs equal in length. No injuries or bruising noted at this time. MD notified along with sister. No intervention documented on the care plan for this fall. R43's Nursing Note dated 12/05/24 at 11:49 AM documents Resident was attempting to get out of his wheelchair and into a regular chair at nurses station. Resident lost his footing and fell on to the floor. Resident denies hitting his head. Writer and another nurse assisted resident up off floor. No injuries noted no c/o of pain Rom performed all limbs equal in length no c/o pain. Residents' sister (V40) notified along with MD. Resident was educated to ask for assistance when attempting to ambulate. No intervention documented on the care plan for this fall. Intervention noted in the nursing note that resident was educated to ask for assistance when attempting to ambulate. R43's Nursing Note dated 12/07/24 at 11:36 AM documents CNA alerted this nurse that resident was on the ground this nurse upon assessment noted resident lying on floor in room, face up with head sticking out of doorway with legs towards bed. VS immediately taken, noted WNL limits. Resident is noted to be pleasantly confused and alert. ROM WNL. [NAME] without difficulty. Noted floor is dry, lighting is adequate and resident had on regular socks with shoes noted to be on floor at end of bed. Resident states that he was in his bed and wanted to get up so he got up and tried to get in my wheelchair but doesn't remember falling. No injury noted. Denies pain or discomfort. Noted call light on bedding. Resident assisted to wheelchair from floor with 2 staff assist and gait belt without difficulty or incident. Resident educated, reminded and encouraged to utilize call light for assistance. Resident voiced understanding. Up in wheelchair at this time, propelled by staff to dining room for lunch. MD/POA updated to fall. No intervention documented on the care plan for this fall. Intervention noted in the nursing note that the resident was educated, reminded, and encourage to use call light. R43 ' s Health Status Note dated 12/19/24 at 2:25 PM documents nurse alerted to resident on the floor in room, resident was lying on floor besides bed on his chest with legs lying on the side. resident stated he was trying to get into bed or into chair he couldn't specify which one he was attempting to do prior to fall. resident was assessed for pain and injury. He has a laceration to top of head, it was cleaned and tao (triple antibiotic ointment) applied. resident perrla (Pupils equal, round, reactive to light and accommodation) prom performed resident assisted off of floor into bed, vital taken b/p (Blood Pressure) 120/79 97.6 84 18 90. md and poa adon, notified. No intervention documented on the care plan for this fall. R43's Nursing Note dated 12/24/24 at 7:13 AM documents Observed laying on floor near bed, laying on face down with head propped up on folded arms, pt stated he tried to get out of bed without assistance, pt stated he did not hit his head, floor dry and free of clutter, bed in low position improper footwear on, pt alert and orientated x1, able to answer simple question and follow simple commands, some bouts of confusion observed, skin assessed, no apparent injuries, some redness to bilateral knees, ROM WNL, denies pain and discomfort, VS 97.8, 20,113/73,76, 97% RA, MD and POA notified, 72hr monitoring, neuro checks in place, encouraged pt to use call light for assistance. understanding verbalized, resting in bed eating candy, HOB elevated, call light in reach and grip socks on feet. No intervention documented on the care plan for this fall. Intervention noted in the nursing note was educated resident on using the call light assistance. R43's Health Status Note dated 12/30/24 at 3:45 AM documents Alerted to the resident's room by staff. Resident noted on floor, sitting on buttocks near the bathroom. Resident denies pain and denies hitting head. Head-to-toe assessment performed. Resident's vital signs WNL. Transferred from floor to bed with 2 assists and gait belt. No intervention documented on the care plan for this fall. R43's Nursing Note dated 1/5/25 at 3:21 AM documents 3:15am resident called out for help. CNA went to see what resident needed, he was on the floor. When asked what happened resident stated that he was trying to get to the bathroom and fell. Resident was assessed by this nurse. The only thing found on him was a red spot to the right hip where he fell. Resident denies pain or discomfort. ROM WNL. Vital signs taken and stable T 97.3 BP 124/69 P 85 R 18. Resident was assisted by two CNAs back into the bed and reminded to use his call light when assistance is needed. He agreed. He is currently resting in bed with call light in reach. Will continue to monitor. No intervention documented on the care plan for this fall. Intervention noted in the nursing note to remind resident to use call light. R43's Nursing Note dated 1/22/25 at 6:50 PM documents Noting the resident was observed lying on left side on the floor in dining room area. There were no liquids or obstacles in the area of the fall. The resident stated, he was trying to get up out of the w/c and suddenly went forward to the floor landing on left side and bi-lateral arm. A head-to-toe assessment was completed with no c/o pain or discomfort voiced or observed at this time. When questioned on rather he hit his head, the resident stated, I didn't hit my head.1mm brisk, PERRLA, A & O x2, Vitals: 145/60 B/P ,90P, 97.9T, 20R with glucose 277, ROM in bi-lateral arm area observed equal with raise, and grip. A 72-neurological observation has been started. (V30) and POA will be notified of the above note. No intervention documented on the care plan for this fall. R43's Health Status Note dated 2/16/25 at 11:09 AM documents resident found on the floor in the hallway of 500 hall outside of resident's room. Resident was lying on his right side with head on the floor his legs and feet under his wheelchair. with a small skin tear to his r elbow. resident states he did hit the front of his head. resident states he just fell forward. Resident was assessed for injury and pain, prom performed, perrla, assisted off of floor and into wheelchair. md and poa (V40) notified. Intervention: 02/16/2024 When assisting him to his wheelchair, staff to ensure it is HIS wheelchair, NOT anyone else's. Treatment to right elbow skin tear as ordered. R43's Nursing Note dated 3/15/25 at 1:56 PM documents CNA alerted this nurse that resident had fallen. Upon visualizing resident, noted wheelchair to be in resident doorway, resident is lying face down on floor with head turned to the right and legs straight out. Resident states I peed this nurse and CNA noted that resident was not incontinent of urine but of bowel. Noted small BM, brown and soft in adult brief. Peri care provided. VS 97.1 76 120/80 18 97%RA 118bs. Resident pleasant and cooperative with care and staff. Resident assisted via 2 assist and gait belt from floor to bed. ROM WNL. [NAME] without difficulty or complaint. MD aware, no new orders. POA made aware. Intervention: 03/17/2025 When noted to be going to his room, staff to cue him through mobility task while going through his doorway. Practitioner Note dated 4/4/25 at 8:38 AM documents Patient was found sitting on the floor in the restroom around 8:40. Notified staff who then got him up. Also discussed with nurse. Upon examination patient appears alert. No bruises noted. Good ROM to both upper and lower extremities. Denies hitting his head also does not appear to have hit his head. No erythema noted to head arms or legs at this time. Patient denies dizziness, shortness of breath, or any pain. Reports that he thinks therapy is going well he just can't get to the bathroom . Continues to work in therapy on strength for independence with ADLs. Intervention: 4/4/25: Staff to increase rounding on (R43). Take (R43) out of room when he is up. 3. On 4/22/2025 at 8:58 AM a Call don't fall sign was observed on R22's wall by R22's television, along with a sign stating Do not get out of bed by yourself sign on R22's side wall by bed. R22 observed sitting in wheelchair in the middle of the room and call light pinned to R22's bedsheets. 04/25/25 9:38 AM, R22 observed standing up in the room by self in front of the sink. R22's wheelchair noted in the middle of the room and call light on R22's bedsheets. 04/25/25 10:32 AM R22 observed sitting in chair watching television, call light observed noted on R22's bed. 4/25/25 at 11:08 AM, V35, Certified Nursing Assistant (CNA), stated See he is trying to get up now on his own. R22 observed trying to get out of chair by himself, call light was observed to be on R22's bedsheets. V35, CNA, helped R22 get up and get into his wheelchair. R22's Care Plan reviewed/revised on 12/5/2024 documents R22 has an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, weakness, hypotension, anemia, polyneuropathy, and shortness of breath (SOB) with exertion. Interventions include mobility/ambulation x1 supervision to limited assist with mobility. R22 uses a wheelchair without bilateral leg rests. Partial/Moderate to Substantial/Maximum assist with ambulation utilizing a wheeled walker. Partial/Moderate to Substantial/Maximum assist with transfers. Ensure he has on non-skid footwear (non-skid socks or shoes) when out of bed. Notify nurse if he complains of weakness, pain and/or shortness of breath. R22's Care Plan revised on 10/9/2022, documents R22 is at risk for falls related to syncope, hypotension, weakness, poor safety awareness. Care Plan documents intervention on 12/27/2024, ensure that he has on proper footwear, encouraged him to use call light for assistance with transfers and ADL's. If noted to be awake with rounds, ask if he needs to toilet. Intervention added on 03/12/2025, documents encourage him to request assist with weight bearing tasks/ADL's due to weakness and SOB with exertion/sitting/lying flat. Refer to therapy. Intervention a[TRUNCATED]

Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for R2's knee pain. This failure resulted in when R2 had continued pain and swelling from 11/15/24 until 12/7/24 at which time her femur bone was protruding through her skin. R2 was hospitalized with an open femur fracture requiring surgical intervention which caused pain and suffering, with an increased risk for infection, vascular issues, and subsequently could have resulted in death. The failure to provide ongoing assessment, monitoring, and treatment for R2's ongoing knee pain led to R2's undiagnosed femur fracture to develop into an open fracture. The Immediate Jeopardy began on 11/15/24 when R2's right foot injury was noted, and the facility failed provide ongoing assessment, monitoring, and timely treatment for R2's ongoing symptoms including an increase in swelling and pain. The facility did not seek treatment for R2's ongoing symptoms until R2's femur fracture penetrated through her skin on 12/7/24. On 12/13/24 at 12:40 PM V1, Administrator, was notified of the Immediate Jeopardy. The surveyors confirmed through interview and record review that the Immediate Jeopardy was removed on 12/15/24, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and quality assurance. Findings include: R2's Face Sheet, print date of 12/16/24, documented R2 has diagnoses of unspecified fracture of right femur, unspecified severe protein-calorie malnutrition, Alzheimer's disease, atherosclerosis, paranoid schizophrenia, drug induced dyskinesia, contractures, history of cerebral infarction, cognitive communication deficit, osteoporosis, and functional quadriplegia. R2's Minimum Data Set, MDS, dated [DATE], documented R2 is moderately cognitively impaired, is non-ambulatory, and is dependent on staff for transfers. R2's Care Plan, undated, documented R2 requires a mechanical lift for all transfers. R2's Resident Care Flow Sheet, undated, documented R2 is assist of 1 for transfers. R2's Electronic Medical Record, EMR, Progress Note dated 11/15/24 at 10:16 AM documented slight discoloration to right posterior foot observed, appears to be injury, green in color and edema to right foot, origin unknown, no incident reported, facial grimacing observed when palpated, NP (Nurse Practitioner) notified, and hospice nurse notified. R2's Incident Report, dated 11/15/24 at 10:06 AM, documented incident description: slight discoloration to R (right) posterior foot, appears to be injury green in color and edema to R foot. Resident unable to give description. Predisposing Situation Factors: during transfer. R2's EMR Progress Note, dated 11/15/24 at 12:35 PM documented call return for the hospice nurse, made aware that NP (Nurse Practitioner) would give an order for x-ray to foot if hospice approved, V13 hospice Registered Nurse, RN agreed to x-ray. R2's hospice aide visit note, dated 11/15/24 at 8:45 AM, documented patient's right foot swollen and bruised. Case manager updated on new concerns. R2's radiology results report, dated 11/16/24, documented reason for study: pain, right foot. Findings: There is mild osteopenia. There is mild degenerative joint disease seen. There is no fracture, dislocation, or soft tissue swelling. No osteomyelitis is seen. There is a plantar heel. Conclusion: Mild degenerative joint disease; otherwise, no fracture or dislocation seen. R2's radiology results report, dated 11/17/24, documented reason for study: localized swelling, mass and lump, right lower limb. Findings: views of the knee show mild joint space loss and subchondral sclerosis compatible with osteoarthritis. No acute fracture or dislocation is seen. No significant joint effusion is noted. Conclusion: Mild osteoarthritis, without fracture. R2's EMR Progress Note, dated 11/20/24 at 8:48 AM documented writer was notified that resident's knee was very swollen, and she has a black bruise on her left and right coccyx. Wound nurse was notified to take a look at the area. MD (Medical Doctor) is already aware of the situation, there was an x-ray performed. R2's EMR Progress Note, dated 11/22/24 at 3:12 AM, documented patient right knee is very swollen and c/o (complaint of) pain. Medicated for pain. R2's EMR Progress Note, dated 11/22/24 at 2:19 PM, documented writer was notified by CNA that resident only ate about 20% of her meal. CNA stated that she is having difficulty eating and drinking. R2's EMR Progress Note, dated 11/26/24 at 10:26 PM, documented resident remains on hospice. No s/s of distress. She is complaining of pain in her knee and foot. R2's hospice aide visit note, dated 11/29/24 at 8:30 AM, documented right leg, knee, and foot swollen. Case Manager and in house nurse updated on new concern and visit. R2's hospice nurse visit note, dated 11/29/24 at 10:30 AM, documented patient continues to have some increased swelling to her right foot and leg up to her knee at a +2 edema. There are no Progress Notes in R2's medical record from the facility from 11/26/24 through 12/1/24 regarding the condition or further assessment of R2's knee. R2's hospice nurse triage notes, dated 12/1/24 at 7:43 AM, documented patient's right knee is swollen and painful to touch. Advised to give patient pain medication. It continues, patient's right knee is more swollen than a week ago. R2's EMR Progress Note dated 12/1/24 at 11:13 AM documented aide notified nurse of resident right knee looking abnormal. Upon assessment resident knee was swollen with minimal pain to touch. MD notified and stated to refer resident to orthopedic surgeon as outpatient f/u (follow up). DON (Director of Nursing) notified, and hospice nurse will leave message for regular nurse to follow up with resident. R2's EMR Progress Note, dated 12/4/24 at 11:33 AM documented per nursing documentation R2 had c/o right knee pain during look back. 11/29 NOR (new order received) for Tylenol TID (3 times per day). R2's hospice nurse notes, dated 12/6/24 at 12:20 PM, documented our HHA (hospice health aide) found a small blister on her right knee today while bathing. It continues, treatment orders - cover blister with 3x3 foam dressing daily and prn (as needed). Increased pain related to blister. New orders received: tramadol 25mg BID (two times a day) and q4hrs PRN. Education provided to sign on the new order that was giving in order to help control R2's pain better. R2's EMR Progress Note dated 12/6/24 at 1:45 PM documented resident knee continues to be monitored; hospice nurse was consulted to look at patient knee. Upon evaluation the knee swollen, and red. Writer asked hospice nurse for an order for pain medication for her pain. Tramadol was ordered TID and PRN (as needed). R2's hospice aide visit note, dated 12/6/24 at 9:00 AM, documented patient has blister on right knee. Case Manager and in house nurse updated. R2's EMR progress note dated 12/7/24 at 1:40 PM documented this nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee to look like bone sticking out of knee with clear and red fluid flowing from area. Vitals WNL (within normal limits). Emergency services contacted. MD/hospice made aware. Phoned POA to inform. No answer. Admin notified. Ambulance in route. R2's hospice progress note, dated 12/7/24 at 1:43 PM documented patient bones popped through skin. Facility MD sent patient out. R2's EMR Progress Note dated 12/7/24 at 1:56 PM documented EMS (Emergency Medical Services) here to transport resident to hospital. R2's EMR Progress Note dated 12/9/24 at 5:27 PM documented writer received an update on resident, she was admitted for a right femur fracture. Administrator, DON, and MD notified. R2's Regional Hospital Emergency Medicine Notes dated 12/7/24, documented R2 presents to ED (Emergency Department) for evaluation of right leg deformity. Per EMS, patient was found in bed at her nursing home when staff found blood on her sheets and on further investigation noticed a deformity to the patients right distal femur with a poke hole oozing blood. Nursing home staff is unaware of any fall or when the trauma may have occurred. Patient has dementia so further history is limited secondary to patient mental acuity. Imaging notable for open fracture of the right distal femur. Orthopedics consulted. Given fracture and belief that had the patient fallen she would not have been able to get herself back into bed without staff being aware of her injury, will consult social work for concern of elder abuse. Will also get trauma scans and consult trauma surgery. R2's regional hospital orthopedic trauma surgery notes, dated 12/7/24, documented x-rays of right femur knee and tib-fib taken in the ED reviewed by me demonstrates right distal femur fracture with significant lateral displacement of the right proximal femur fragment. CT scan of the right knee taken in the ED and reviewed by me demonstrates right distal femur fracture with lateral displacement of the proximal femur fragment, appears to have significant callus formation around the fracture site indicating a nonacute fracture. There is gas tracking from open wound. It continues, given CT scan imaging showing callus formation around the fracture would lean towards this not being an acute fracture. Per son she has had no injury and was found in her bed today by nursing facility staff with open wound. Given also none reported injury to the right ankle 2 to 3 weeks ago cannot rule out NAT (Non-Accidental Trauma). R2's trauma admission history and physical dated 12/7/24 documented this is an [AGE] year-old female presenting as a level 3 - consult trauma following suspected fall/elder abuse. Concerns with safety at NH (nursing home). Son open to finding new establishment. R2's regional hospital x-ray results of right knee and right femur, dated 12/7/24, documented open fracture distal femoral shaft. R2's regional hospital trauma surgery progress notes, dated 12/8/24, documented right ankle pain, right knee pain, (moans to pain) right lower extremity in ace wrap to knee. R2's regional hospital physician progress note, dated 12/9/24, documented femoral shaft fracture, chronic - spoke to nursing home who stated swelling was first noted to leg/knee on 11/15/24 and this worsened along with surrounding erythema in the last few days leading up to admission. When noticed, hospice was notified prompting x-ray. R2's regional hospital operative progress notes, dated 12/9/24, documented this is an elderly woman who is very infirm and demented. Recently, the nursing home noted a small gradual ulcer and sore over the anterolateral distal femur, which actually was an open fracture. She apparently had a fracture of the distal femur, which was unrecognized; however, on presentation to regional hospital with the open wound, x-rays and CAT scan noted a significantly displaced comminuted but healed distal third femur fracture with significant malunion. Distal lateral spike from proximal segment was quite sharp and prominent and had eroded the skin and now was protruding approximately a center through the skin with skin breakdown, essentially an open delayed fracture. On 12/10/24 at 2:20 PM V2, Director of Nursing, DON, stated that he does not manage the resident incidents for the facility. V2 stated that the previous nurse who was in charge of investigating resident incidents and unknown injury investigations was terminated a while back and V4 (Licensed Practical Nurse, LPN)/Restorative Nurse/QA (Quality Assurance) is now in charge of incidents. V2 stated V4 started in this position 2 weeks ago. On 12/10/24 at 2:24 PM V4 stated she just started in this position a little over a week ago and is now following up on falls in the facility's risk management EMR. V4 stated she is not aware of any unknown injuries occurring since she started in this position. On 12/10/24 at 2:33 PM V1, Administrator, stated she is the one that is in charge of reporting and investigating unknown injuries. V1 stated R2 was admitted to the hospital this past Saturday, 12/7/24 with a femur fracture. V1 stated she spoke to R2's family and they told her the hospital physician stated that R2's femur fracture is 3-4 weeks old. V1 stated R2's knee was x-rayed in November and the x-ray was negative for any fracture. V1 stated she is still investigating R2's unknown injury/femur fracture. On 12/10/24 at 3:09 PM V5, Care Plan Coordinator, CPC, stated that she was putting interventions in for the resident falls/incidents in the time frame when the facility did not have a QA Nurse but that she did not investigate the fall/incidents during this time. On 12/10/24 at 3:30 PM V6, Certified Nurse Assistant, CNA, stated she is not aware of how R2 sustained the femur fracture. V6 stated she did report to R2's nurse that R2 as having a lot of leg pain and that it was swollen. V6 stated she does not recall when this was and that she does recall a nurse looking at R2's leg when she informed the nurse of R2's pain. V6 stated R2 is transferred via a mechanical lift with 2 assists. On 12/10/24 at 3:38 PM V7, Licensed Practical Nurse, LPN stated that she had been off work a week back in November and when she returned to work the CNAs told her R2's knee was swollen, bruised, warm, and red. V7 stated she thinks maybe R2's leg was broken around 11/17/24. V7 stated she told V2 that the in-house x-ray company they use may have missed the fracture on the x-ray. On 12/10/24 at 3:45 PM V8 stated she took care of R2 last Thursday, 12/5/24, and that she told the nurses that R2's bone was broken in her leg because you could see the bone poking through the skin. V8 then demonstrated how the bone looked under the skin by sticking her hand partially in a disposable glove and pressing a finger tightly up and out against the glove. V8 stated R2 was in severe pain and R2's knee was warm and swollen. V8 stated she reported this to R2's nurse, V7, and to another nurse on 12/5/24 and that they both said it was arthritis according to the x-ray. V8 stated that R2 should be transferred with a mechanical lift but staff just pick her up because she is 90 pounds and that is why she thinks someone dropped R2. V8 then presented a resident care flow sheet with a list of the residents' names on the hall that R2 resides on and stated look at this, it says R2 is to be transferred with an assist of one. On 12/11/24 at 9:37 AM Surveyor requested incident investigation from V1 for R2's injury that was documented in R2's progress notes on 11/15/24. V1 replied I don't see any incidents for that date, oh there is an incident report for that date in risk management, I am responsible for investigating and reporting incidents, but I didn't, and I don't know why it was not done. V1 stated that the facility does not have any staff statements nor any investigation notes for R2's unknown injury that was documented on R2's 11/15/24 incident report form. V1 stated that she does consider R2's injury that was documented on R2's 11/15/24 incident report to be an unknown injury. V1 stated that no staff notified her of R2's injury that was documented on 11/15/24 and that if she would have known about it then she would have investigated it. Surveyor asked V1 for more information regarding the statement V1 documented on R2's injury investigation that was initiated on 12/9/24, V1 documented V9 CNA usually works the front half of 600 so hasn't cared for her in some time but stated when she did work the back half of 600 1 time, she left R2 in bed due to the swelling. She stated that another CNA had spoken to her and told her that R2 had a fall. Surveyor asked V1 if she identified who the staff member was that told V9 that R2 had a fall and V1 stated I don't know who the CNA was because V9 could not recall the CNAS name. V1 stated she became aware of R2's injury on Saturday, 12/7/24 and reported the incident/unknown injury to IDPH on 12/9/24 after she was told by one of the facility's nurses that R2 had a femur fracture. V1 stated that she is the one who usually investigates the incidents since the facility terminated the QA nurse back in September of this year. V1 stated R2's injury to her right foot that was documented on 11/15/24 should have been investigated. V1 stated the Therapy Department determines how residents should be transferred and then the Medical Records staff update the transfer flow sheets at the nurse's station. V1 stated the CNAs transfer the residents according to the flow sheets. On 12/11/24 at 11:35 AM V9 stated she believes another CNA mishandled R2 during a transfer. V9 stated when she came in last week on day shift, maybe on Wednesday but not for sure, a night shift CNA told me R2's leg was swollen when she was giving me report that morning and this CNA said she was told that someone dropped R2 causing the leg injury. V9 stated she could not recall the name of the CNA that told her this nor did the CNA name the employee who allegedly dropped R2. V9 stated R2's leg was 3 times the size of her other leg last week. V9 stated R2 is very small so the CNAS can transfer R2 with one assist with the mechanical lift. V9 stated she assumes that is why the facility's care sheet has R2 down as a 1 assist with transfers. On 12/11/24 at 11:42 AM V7 LPN stated she thought one of the CNAs did tell her last week that R2's bone looked like it was popping through the skin, so she went and looked at R2's leg and did not think it looked like the bone was coming through. V7 stated she did call hospice at this time and got an order to increase R2's tramadol for her increase in pain. On 12/11/24 at 11:50 AM V10 LPN stated when she worked two weekends ago an agency nurse asked her to go down and look at R2's leg because the agency nurse thought the leg appeared fractured. V10 stated R2 grimaced when she touched R2's leg. R2 stated that the agency nurse informed her she called R2's hospice nurse and updated hospice on R2's leg but that she does not recall what hospice did about the nurse's concerns. On 12/11/24 at 11:57 AM V11 LPN stated she has been R2's nurse a few times over the past few weeks and that R2's right leg was red and swollen. On 12/11/24 at 12:20 PM V12 (R2's son) stated he received a call from R2's hospice nurse last Saturday on 12/7/24 and told him that the nursing home was sending his mom to the emergency room because she had a bone coming out of her right leg. V12 stated R2 then was transferred to a regional hospital and that the orthopedic surgeon told him R2's right leg was fractured approximately 3 weeks ago and that R2 had to of been dropped to cause this type of fracture. V12 stated this surgeon told him not to take R2 back to that nursing home. V12 stated the surgeon was unable to fix the fracture but did shave the bone off, cleaned out the injury, and then stitched the leg back up. V12 stated that he has not received any notifications from the nursing home about R2's leg and that the only information he has received about R2 in the past two months has been from the hospice nurse. V12 stated R2 is going to a different facility when she is discharged from the hospital. On 12/11/24 at 1:00 PM V13, Hospice RN, stated Oh my God, a few days prior, she (R2) had a small blister that had formed that looked like a pressure injury. V13 stated he was notified by V14 Hospice CNA, around 11/15/24, that R2 had bruising to the bottom of her ankle with swelling, the facility ordered an x-ray. V13 stated he notified V12, R2's son and he (V13) and V12 thought it was weird that she would have bruises and swelling since R2 barely moved and was either in the reclining wheelchair or her bed. V13 stated he assessed R2, and Tylenol and Lasix were ordered, the next week when V13 returned the leg was swollen, going up the calf and towards the knee and the knee had started to swell. V13 stated he reported this to the facility and V14, reported that she had also notified the facility. V13 stated the following week, there was a small area of redness that appeared to be a pressure injury from R2 being contracted and her knees rubbing together. V13 stated skin prep was ordered. The next time he was notified he was told that R2's bone was sticking out of her leg. V13 stated in his opinion, that type of an injury could have only occurred during a transfer or something of that nature because R2 didn't move, and she was either in the reclining wheelchair of the bed. V13 stated he was never notified of any of the changes in R2 by the facility only by V14. On 12/11/24 at 1:55 PM V14, Hospice CNA, stated approximately 3 weeks ago, and she noticed bruising from the bottom R2's heel and swelling in the foot. V14 stated when she would touch the heel, leg, or foot, R2 would jump, make noises and grimace. V14 stated she told V10, LPN, and she took V14 along with two other nurses, unsure of names, to look at R2's foot. When V14 stated she comes to bathe R2 on Thursdays, except the week of Thanksgiving and she came that Friday. V14 stated when she came the week of Thanksgiving, R2's entire leg and knee was huge, swollen, and went up the entire leg. V13 stated she notified R2's nurse, unsure of name. V13 stated there was a blistered area to the knee that was white in the center, and it looked like bone. V13 stated she then called V13 to notify him. On 12/11/24 at 3:11 PM V16 LPN stated she is the nurse that completed the incident report on R2 on 11/15/24. V16 stated that R2's hospice CNA was giving R2 a bed bath and that the hospice CNA reported to her that R2 had bruises on her right lower extremity. V16 stated she assessed R2, gave R2 pain medicine because R2 had facial grimacing. V16 stated she did notify V1, V2, and R2's doctor of the injury of unknown injury on 11/15/24. V16 stated that she was concerned something may have happened during a transfer causing R2's injury. V16 stated the nursing staff are supposed to transfer residents according to the resident care flow sheets that are in a book at the nurse's station. On 12/12/24 at 8:26 AM V18 LPN stated she was R2's nurse on 11/17/24 and that she contacted V19 R2's primary physician because R2's right knee was swollen. V18 stated she did not notice any bruising nor an increase in R2's pain symptoms V18 stated she notified V19 through the secure message system in (electronic medical record system). V18 stated she is an agency nurse, so she does not work regularly and when she worked on 12/1/24 the CNAS informed her they were not getting R2 out of bed because it looked like something was protruding from the side of R2's knee and it was hard. V18 stated she looked at R2's knee and the protrusion were hard. V18 stated she reported this to the DON, and he instructed her to get an order for x-rays of R2's knee. V18 stated she notified V19, R2's Physician, through the secure messenger system and sent V19 a photo of R2's knee. V18 said V19 replied that it looked like water under the knee, no x-ray ordered but did order a referral to an outpatient orthopedic doctor. V18 stated this occurred on a Sunday and she thinks she put in an order for the referral and passed it on in report, but she does not know if the appointment was ever set up. V18 stated she called the hospice nurse on 12/1/24 about R2 and that hospice said don't send R2 to the hospital and just keep her comfortable. V18 stated outpatient referral need to be approved by hospice but she did not inform the hospice nurse about V19 ordering the outpatient orthopedic referral. V18 stated she does not know if V19 was informed of the ongoing issues with R2's knee because she is just agency. V19 stated she messaged him on 11/17/24 and 12/1/24. R2's progress notes do not document any physician notification on 11/17/24. On 12/12/24 at 8:53 AM V1 stated she is not able to pull the secure messages for R2 from the EMR because they only save for two weeks, and the nurses are supposed to document the messages in the resident's progress notes. On 12/12/24 at 9:06 AM V1 stated no order for the outpatient orthopedic consultation was put into R2's record nor did the facility arrange an appointment for R2 to see an orthopedic surgeon. On 12/12/24 at 9:25 AM V19 stated he had received notifications from the facility regarding R2's edema via the secure message system. V19 stated he would have to check his records to see when and how many times he was notified. V19 stated he was notified from time to time on her. V19 stated he was not aware that the facility did not put in an order in the EMR for the orthopedic referral he gave on 12/1/24 nor was he aware of the facility not setting up this appointment. V19 stated that for R2's bone to come through her skin it had to be caused by trauma and that a pathological fracture would not cause this. V19 stated he would have expected the facility to immediately initiate an investigation on 11/15/24 when the EMR documented an injury to R2's right foot. On 12/12/24 at 11:19 AM, V19 stated he is not able to view secure messages from the facility nurses beyond 12/4/24 because the system deletes them after a week. On 12/7/24 he was notified bone was sticking through the skin and he had R2 sent to the ER. V19 stated the facility contacted him again on 12/9/24 that R2 was admitted to the hospital with a femur fracture and that he requested more information from the facility of how the fracture happened, and he has not heard back from the facility. V19 stated he does not recall being told by the nurse on 12/1/24 that R2's bone appeared to be protruding under the skin. On 12/16/24 at 11:25 AM V1 stated the facility should have reported and investigated R2's right leg injury when it was first found on 11/15/24. V1 stated the facility nurses should have been closely assessing R2's leg and should have updated R2's primary physician of R2's right leg condition changes. On 12/16/24 at 11:27 AM V20 Regional Director stated R2's leg injury should have been investigated when it was first noted on 11/15/24, R2's leg should have been closely monitored, and that R2's attending physician should have been updated of the ongoing changes of R2's condition. The Hospice Services Agreement dated January 2009 states, The services provided by (Hospice Provider Name) and Nursing Facility under the terms of this Agreement shall be in addition to, and not a substitute for, the services routinely provided to residents by Nursing Facility according to its agreements with residents and applicable state and federal laws and regulations. The facility's Notification Changes in Condition, dated 2/20/23, documented it is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status. Definitions: 1. Acute change in condition is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status that, without intervention, may result in complications or death. 2. Non-urgent change in condition is a deviation from a patient's baseline in physical, cognitive, behavioral, or functional status that is not reasonable expected to result in complications or death may be a persistent or intermittent result of the patient's diagnosed disease state. Policy guidelines and interpretation: 1. Upon identification of any change in condition licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change. 2. All notifications should be preceded by an appropriate physical, mental, or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions. 3. Following notification of the physician, licensed nursing personnel will contact the resident's responsible party/emergency contact/family member/POA or Guardian to inform him/her of the change. For acute changes in condition this should occur immediately when practicable and after addressing the resident's immediate needs and for non-urgent changes in condition the notification should occur within 72 hours of the noted change. 4. All notifications should be documented and should include; a. The date and time of the notification; b. The name of the individual contacted; c. The specific reason for the notification; d. And any specific responses that were given by the person contacted. 5. All changes of condition require follow-up assessment and documentation of resident condition which should include, at a minimum: a. Vital signs b. Pain c. Orientation d. Any change from baseline status e. Status of any pending labs/diagnostics. The Immediate Jeopardy that began on 11/15/24 was removed on 12/15/24 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. R2 was transferred to a hospital for treatment. R2 is no longer a resident of the facility. The facility has conducted an ongoing investigation into R2's injuries. 2. V2, Director of Nursing, or designee has assessed all residents, completed on 12/14/24, to identify any pain or injury of unknown origin not previously identified, assessed, reported, and treated. For any findings identified, the facility would follow its policy to ensure the pain/injury is reported, assessed, monitored, and treated timely. No residents with unreported/untreated pain or injuries identified. B. Actions to Prevent Occurrence/Reoccurrence: 1. On 12/13/24 V1 Administrator, V2 Director of Nursing, and V20 Regional Director and Facility Governing Body reviewed the facility's policies for Incidents/Accidents and Significant change to confirm policies provide a system for identifying, assessing, monitoring, and treating injuries and pain, as well as investigating the cause. No updates required, but Governing Body recommended retraining on policy requirements. 2. V2, Director of Nursing, or designee have provided in-service training to all direct care staff and nursing staff on facility policy for: Significant changes, with an emphasis on ensuring timely reporting, assessment, and follow-up when a resident demonstrates a significant change; and Incidents and Accidents, with an emphasis on policy section addressing injuries of unknown origin including the process for identifying, reporting, assessing, and facilitating treatment, as well as investigating the cause of any unknown injury. Any staff or agency who have not received the in-service training(s) by the Removal/Abatement date will receive the training before starting their next shift. 3. V2, Director of Nursing or designee will conduct random observations daily of at least 5 residents for 3 weeks then 5 residents monthly to determine if there is any pain or injuries of unknown origin that have been addressed per policy. V1, Administrator/designee will conduct daily review of PCC 24-hour Communication and Incident reports to ensure any change of condition/injury is monitored, assessed, investigated, reported, and treated. Any identified failures will be immediately addressed. Results will be documented and shared with QAPI for review, analysis and follow-up as needed. Date Facility Asserts Completion of Abatement: 12/15/24.

Based on interview and record review the facility failed to provide services per current standards of practice, rising to the level of neglect with R2 sustaining a femur fracture on an unknown date, with the femur bone ultimately penetrating through the skin after 15 days of documented continued pain and extremity abnormality. This failure resulted in R2 being hospitalized with an open femur fracture requiring surgical intervention which caused pain and suffering. Findings include: R2's face sheet, print date of 12/16/24, documented R2 has diagnoses of unspecified fracture of right femur, unspecified severe protein-calorie malnutrition, Alzheimer's disease, atherosclerosis, paranoid schizophrenia, drug induced dyskinesia, contractures, history of cerebral infarction, cognitive communication deficit, osteoporosis, and functional quadriplegia. R2's MDS (Minimum Data Set), dated 12/4/24, documented R2 is moderately cognitively impaired, is non-ambulatory, and is dependent on staff for transfers. R2's hospice aide visit note, dated 11/15/24 at 8:45 AM, documented patient's right foot swollen and bruised. Case manager updated on new concerns. R2's radiology results report, dated 11/17/24, documented reason for study: localized swelling, mass and lump, right lower limb. Findings: views of the knee show mild joint space loss and subchondral sclerosis compatible with osteoarthritis. No acute fracture or dislocation is seen. No significant joint effusion is noted. Conclusion: Mild osteoarthritis, without fracture. R2's EMR (Electronic Medical Record) progress note dated 11/22/24 at 3:12 AM documented patient right knee is very swollen and c/o (complaining of) pain. Medicated for pain. R2's EMR progress note dated 11/26/24 at 10:26 PM documented .she is complaining of pain in her knee and foot. R2's hospice aide visit note, dated 11/29/24 at 8:30 AM, documented right leg, knee, and foot swollen. Case Manager and in house nurse updated on new concern and visit. R2's hospice nurse visit note, dated 11/29/24 at 10:30 AM, documented patient continues to have some increased swelling to her right foot and leg up to her knee at a +2 edema. R2's hospice nurse triage notes, dated 12/1/24 at 7:43 AM, documented patient's right knee is swollen and painful to touch. Advised to give patient pain medication. It continues, patient's right knee is more swollen than a week ago. R2's EMR progress note dated 12/1/24 at 11:13 AM documented aide notified nurse of resident right knee looking abnormal. Upon assessment resident knee was swollen with minimal pain to touch. MD notified and stated to refer resident to orthopedic surgeon as outpatient f/u (follow up). DON (Director of Nursing) notified, and hospice nurse will leave message for regular nurse to follow up with resident. R2's EMR progress note dated 12/4/24 at 11:33 AM documented per nursing documentation R2 had c/o right knee pain during look back. 11/29 NOR (new order received) for Tylenol TID (3 times per day). R2's hospice aide visit note, dated 12/6/24 at 9:00 AM, documented patient has blister on right knee. Case Manager and in house nurse updated. R2's hospice nurse notes, dated 12/6/24 at 12:20 PM, documented our HHA (hospice health aide) found a small blister on her right knee today while bathing. It continues, treatment orders - cover blister with 3x3 foam dressing daily and prn (as needed). Increased pain related to blister. New orders received: tramadol 25mg BID (two times a day) and q4hrs PRN. Education provided to sign on the new order that was giving in order to help control R2's pain better. R2's EMR progress note dated 12/6/24 at 1:45 PM documented resident knee continues to be monitored; hospice nurse was consulted to look at patient knee. Upon evaluation the knee swollen, and red. Writer asked hospice nurse for an order for pain medication for her pain. Tramadol was ordered TID and PRN (as needed). On 12/16/24 at 11:35 AM V21 CNA (Certified Nurse Assistant) stated she was assigned to R2's hall on 12/7/24 and that she made her first rounds at 6:30 AM, checked on R2 and could see R2's bone tightly up against the skin near right knee. Stated she informed day nurse V11 LPN and the night nurse. V21 stated these two nurses went and looked at R2's knee shortly after she told them. V21 stated when she checked on R2 around lunch time the bone was through the skin and there was blood on the sheets. On 12/16/24 at 11:50 AM V11 LPN (Licensed Practical Nurse) stated she was R2's nurse on 12/7/24 on the day shift. V11 stated she and the night nurse went and looked at R2's leg at approximately 6:30 AM on 12/7/24 and R2's right leg was swollen, red, and it appeared bone was up against the skin. R2 stated the night nurse had given R2 pain medication. V11 stated she did not notify R2's doctor at this time because prior x-rays were negative and that she did send her out once the bone came through the skin around noon. R2's EMR progress note dated 12/7/24 at 1:40 PM documented this nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee to look like bone sticking out of knee with clear and red fluid flowing from area. Vitals WNL (within normal limits). Emergency services contacted. MD/hospice made aware. Phoned POA (power of attorney) to inform. No answer. Admin notified. Ambulance in route. R2's hospice progress note, dated 12/7/24 at 1:43 PM documented patient bones popped through skin. Facility MD sent patient out. R2's EMR progress note dated 12/7/24 at 1:56 PM documented EMS (Emergency Medical Services) here to transport resident to hospital. R2's regional hospital emergency medicine notes dated 12/7/24, documented R2 presents to ED (Emergency Department) for evaluation of right leg deformity. Per EMS, patient was found in bed at her nursing home when staff found blood on her sheets and on further investigation noticed a deformity to the patients right distal femur with a poke hole oozing blood. Nursing home staff is unaware of any fall or when the trauma may have occurred. Patient has dementia so further history is limited secondary to patient mental acuity. Imaging notable for open fracture of the right distal femur. Orthopedics consulted. Given fracture and belief that had the patient fallen she would not have been able to get herself back into bed without staff being aware of her injury, will consult social work for concern of elder abuse. Will also get trauma scans and consult trauma surgery. R2's regional hospital orthopedic trauma surgery notes, dated 12/7/24, documented x-rays of right femur knee and tib-fib taken in the ED reviewed by me demonstrates right distal femur fracture with significant lateral displacement of the right proximal femur fragment. CT scan of the right knee taken in the ED and reviewed by me demonstrates right distal femur fracture with lateral displacement of the proximal femur fragment, appears to have significant callus formation around the fracture site indicating a nonacute fracture. There is gas tracking from open wound. It continues, given CT scan imaging showing callus formation around the fracture would lean towards this not being an acute fracture. Per son she has had no injury and was found in her bed today by nursing facility staff with open wound. Given also none reported injury to the right ankle 2 to 3 weeks ago cannot rule out NAT (Non-Accidental Trauma). R2's trauma admission history and physical dated 12/7/24 documented this is an [AGE] year-old female presenting as a level 3 - consult trauma following suspected fall/elder abuse. Concerns with safety at NH (nursing home). Son open to finding new establishment. R2's regional hospital operative progress notes, dated 12/9/24, documented this is an elderly woman who is very infirm and demented. Recently, the nursing home noted a small gradual ulcer and sore over the anterolateral distal femur, which actually was an open fracture. She apparently had a fracture of the distal femur, which was unrecognized; however, on presentation to regional hospital with the open wound, x-rays and CT (computed tomography) scan noted a significantly displaced comminuted but healed distal third femur fracture with significant malunion. Distal lateral spike from proximal segment was quite sharp and prominent and had eroded the skin and now was protruding approximately a center through the skin with skin breakdown, essentially an open delayed fracture. On 12/10/24 at 3:38 PM V7 LPN stated that she had been off work a week back in November and when she returned to work the CNAS told her R2's knee was swollen, bruised, warm, and red. V7 stated she thinks maybe R2's leg was broken around 11/17/24. V7 stated she told V2 DON that the in-house x-ray company they use may have missed the fracture on the x-ray. On 12/10/24 at 3:45 PM V8 CNA stated she took care of R2 last Thursday, 12/5/24, and that she told the nurses that R2's bone was broken in her leg because you could see the bone poking through the skin. V8 then demonstrated how the bone looked under the skin by sticking her hand partially in a disposable glove and pressing a finger tightly up and out against the glove. V8 stated R2 was in severe pain and R2's knee was warm and swollen. V8 stated she reported this to R2's nurse V7 and to another nurse on 12/5/24 and that they both said it was arthritis according to the x-ray. On 12/11/24 at 11:42 AM V7 LPN stated I think one of the CNAS did tell me last week that R2's bone looked like it was popping through the skin, so she went and looked at R2's leg and did not think it looked like the bone was coming through. V7 stated she did call hospice at this time and got an order to increase R2's tramadol for her increase in pain. On 12/11/24 at 11:50 AM V10 LPN stated when she worked two weekends ago an agency nurse asked her to go down and look at R2's leg because the agency nurse thought the leg appeared fractured. V10 stated R2 grimaced when she touched R2's leg. R2 stated that the agency nurse informed her she called R2's hospice nurse and updated hospice on R2's leg but that she does not recall what hospice did about the nurse's concerns. On 12/11/24 at 11:57 AM V11 LPN stated she has been R2's nurse a few times over the past few weeks and that R2's right leg was red and swollen. On 12/11/24 at 1:00 PM V13, Hospice RN, stated Oh my God, a few days prior, she (R2) had a small blister that had formed that looked like a pressure injury. V13 stated he was notified by V14 Hospice CNA, around 11/15/24, that R2 had bruising to the bottom of her ankle with swelling, the facility ordered an x-ray. V13 stated he notified V12, R2's son and he (V13) and V12 thought it was weird that she would have bruises and swelling since R2 barely moved and was either in the reclining wheelchair or her bed. V13 stated he assessed R2, and Tylenol and Lasix were ordered, the next week when V13 returned the leg was swollen, going up the calf and towards the knee and the knee had started to swell. V13 stated he reported this to the facility and V14, reported that she had also notified the facility. V13 stated the following week, there was a small area of redness that appeared to be a pressure injury from R2 being contracted and her knees rubbing together. V13 stated skin prep was ordered. The next time he was notified he was told that R2's bone was sticking out of her leg. V13 stated in his opinion, that type of an injury could have only occurred during a transfer or something of that nature because R2 didn't move, and she was either in the reclining wheelchair of the bed. V13 stated he was never notified of any of the changes in R2 by the facility only by V14. On 12/11/24 at 1:55 PM V14, Hospice CNA, stated approximately 3 weeks ago, she noticed bruising from the bottom R2's heel and swelling in the foot. V14 stated when she would touch the heel, leg or foot, R2 would jump, make noises and grimace. V14 stated she told V10, LPN, and she took V14 along with two other nurses, unsure of names, to look at R2's foot. When V14 stated she comes to bathe R2 on Thursdays, except the week of Thanksgiving and she came that Friday. V14 stated when she came the week of Thanksgiving, R2's entire leg and knee was huge, swollen, and went up the entire leg. V13, stated she notified R2's nurse, unsure of name. V13 stated there was a blistered area to the knee that was white in the center, and it looked like bone. V13 stated she then called V13 to notify him. On 12/12/24 at 8:26 AM V18 LPN stated she was R2's nurse on 11/17/24 and that she contacted V19 R2's primary physician because R2's right knee was swollen. V18 stated she did not notice any bruising nor an increase in R2's pain symptoms V18 stated she notified V19 through the secure message system in PCC. V18 stated she is an agency nurse, so she does not work regularly and when she worked on 12/1/24 the CNAS informed her they were not getting R2 out of bed because it looked like something was protruding from the side of R2's knee and it was hard. V18 stated she looked at R2's knee and the protrusion was hard. V18 stated she reported this to the DON (Director of Nursing) V2, and he instructed her to get an order for x-rays of R2's knee. V18 stated she notified V19 through the secure messenger system and sent V19 a photo of R2's knee. V18 said V19 replied that it looked like water under the knee, no x-ray ordered but did order a referral to an outpatient orthopedic doctor. V18 stated this occurred on a Sunday and she thinks she put in an order for the referral and passed it on in report, but she does not know if the appointment was ever set up. V18 stated she called the hospice nurse on 12/1/24 about R2 and that hospice said don't send R2 to the hospital and just keep her comfortable. V18 stated outpatient referral need to be approved by hospice but she did not inform the hospice nurse about V19 ordering the outpatient orthopedic referral. V18 stated she does not know if V19 was informed of the ongoing issues with R2's knee because she is just agency. V19 stated she messaged him on 11/17/24 and 12/1/24. R2's progress notes do not document any physician notification on 11/17/24. On 12/12/24 at 9:06 AM V1 (Administrator) stated no order for the outpatient orthopedic consultation was put into R2's record nor did the facility arrange an appointment for R2 to see an orthopedic surgeon, although acknowledging a referral had been made. On 12/12/24 at 9:25 AM V19 R2's primary physician stated he had received notifications from the facility regarding R2's edema via the secure message system. V19 stated he would have to check his records to see when and how many times he was notified. V19 stated he was notified from time to time on her. V19 stated he was not aware that the facility did not put in an order in the EMR for the orthopedic referral he gave on 12/1/24 nor was he aware of the facility not setting up this appointment. V19 stated that for R2's bone to come through her skin it had to be caused by trauma and that a pathological fracture would not cause this. V19 stated he would have expected the facility to immediately initiate an investigation on 11/15/24 when the EMR documented an injury to R2's right foot. On 12/12/24 at 11:19 V19 (R2's physician and facility Medical Director) stated he is not able to view secure messages from the facility nurses beyond 12/4/24 because the system deletes them after a week. On 12/7/24 he was notified bone was sticking through the skin and he had R2 sent to the ER. V19 stated the facility contacted him again on 12/9/24 that R2 was admitted to the hospital with a femur fracture and that he requested more information from the facility of how the fracture happened, and he has not heard back from the facility. V19 stated he does not recall being told by the nurse on 12/1/24 that R2's bone appeared to be protruding under the skin. On 12/16/24 at 11:25 AM V1 stated the facility should have reported and investigated R2's right leg injury when it was first found on 11/15/24. V1 stated the facility nurses should have been closely assessing R2's leg and should have updated R2's primary physician of R2's right leg condition changes. On 12/16/24 at 11:27 AM V20 Regional Director stated R2's leg injury should have been investigated when it was first noted on 11/15/24, R2's leg should have been closely monitored, and that R2's attending physician should have been updated of the ongoing changes of R2's condition. Review of R2's Clinical Record documented despite multiple continued reports of pain, abnormal extremity presentation without signs of healing, and specific reports of a bone appearing the facility initiated no further diagnostic testing to evaluate and treat. R2's Clinical Record documents the only x-ray's R2 received following the initial bruising, in which a possible injury was suspected was on 11/16/24 and 11/17/24, both in the facility. The facility Abuse Prevention Program policy, revision date of 2/2023, documented this facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. It is the policy of this facility to develop a mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. It continues, neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review, the facility failed to prevent employee to resident physical abuse by a staff member for 1 of 3 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 sustaining a bloody lip causing him to be upset and having pain. Findings include: On 10/22/24 at 3:15 PM R2 was sitting outside on patio. He stated a CNA (Certified Nursing Assistant) hit him about a week ago. He stated they were talking stuff to each other and she hit him one time in the mouth with her fist. He stated it hurt. On 10/23/24 at 12:20 PM R2 stated when V4, CNA, hit him in his mouth with her fist he was very upset. He stated it hurt a lot. He stated V4 got a wet cloth and wiped the blood off his lips. The facility's Illinois Department of Public Health (IDPH) Notification Form dated 10/13/24 at 10:00 PM documents, under description of Accident, Causes, Injuries and Action taken by Establishment as a result of Accident: Reported to Administrator at 10:00 resident told family member CNA hit him in the mouth. CNA sent home. Investigation ongoing. R2 was identified as the resident referred to in the report. The form documents the police were not informed at time of the report. It documents the type of incident is alleged physical abuse. The facility's Final Report of the Abuse Investigation dated 10/18/24 at 8:38 AM documents, 10/16/24 I (V1, Administrator) called (V4, CNA) this AM and ask she come in as the investigation has been completed and we need to speak to her about the results. (V4) arrived at 11:08; she arrived to speak with myself and (V2, Director of Nursing (DON) in the multipurpose room. I presented the termination paperwork and reasoning being the investigation and camera review provided substantial evidence and it was believed this incident probably did happen. She refused to sign the termination paper. When she exited the building, she walked around to the back of the building then drove around; that's when the (local) police department blocked her in, she parked her car and (local) police department took her into custody. The facility's document labeled, (V4) Resident Abuse Incident 10/13/24 Video Investigation documents a timeline of what V15, the facility's IT director observed on the camera footage minute by minute as he reviewed the footage. It documents, 7:25:50 Employee appears to be punching at resident. On 10/22/24 at 1:30 PM the facility's video camera coverage dated 10/13/24 between 7:15 AM and 7:26 AM was observed with V1 Administrator. The camera footage showed the inside of R2's room with his feet and legs visible. On the footage V4 is observed entering R2's room and standing at the foot of his bed. V4 then grabs R2's sheets/blankets in her hands and pulls but it appears he is pulling against her and keeping sheet/blanket pulled up. V4 lets go of the sheet/blanket and raises her arms with hands fisted and thrusts both fists towards area where R2's torso and head would be located. Unable to see if she makes contact with R2 or not, but then V4 stops and closes the door to R2's room with her on the inside. On 10/23/24 at 9:43 AM V8, Licensed Practical Nurse (LPN) stated she heard about R2's allegation that a CNA had hit him in the mouth when staff were talking about it around her. She stated she did not do anything at the time because they were not talking directly to her, they were just talking around her. She stated it was about 6:30 PM and it was halfway through her shift, and they said it happened on day shift, so she thought it had already been reported. She stated she thinks she notified (V2), DON and (V13), Assistant Director of Nursing (ADON) at that time just to make sure they were aware. She stated she had talked to R2 at the beginning of her shift, and he had not said anything to her about a CNA hitting him at that time. V8 stated around 9:30 PM R2's sister, (V11) came walking out of the dining room and was irate, wanting to know what was going to happen to the CNA who hit R2. V8 stated she went and looked at R2's lip and had to pull it up to see the mark on it. She stated it was small area, described it as you could cover it with the tip of your finger, and was white, like it was old, not red or bleeding. V8 stated she had tele-messaged the DON and ADON earlier and told the sister it would be addressed tomorrow. V8 stated she did not notify the administrator because she did not know she was supposed to. She stated she was not aware the administrator is over the DON, so she messaged the DON and ADON. On 10/23/24 at 10:29 AM V2 stated the first he heard about the incident regarding R2 being hit in the mouth by V4, CNA was on 10/13/24 around 8:30 PM from V12, R2's niece. V2 stated he did not know if (V8) had sent him a message earlier that evening and stated he could not find the message on his phone. V2 stated he sometimes has problems with his phone, so he doesn't know if she tried to message him or not. V2 stated he did not call and talk to staff after R2's niece called him. He stated he came in the next day and talked to R2 and assessed him. V2 stated R2 didn't seem to remember the incident and did not have any marks or bleeding on his lip when he assessed him. He stated he would have expected V8 to assess the resident as soon as she heard about it to check for injuries and ask what happened, and to report it to the administrator. On 10/23/24 at 12:15 PM V11, R2's sister/POA (Power of Attorney) stated R2 had called her around 11:30 AM on Sunday, October 13, 2024, and told her he wanted her to come up and see him. She stated he did not say anything about the CNA hitting him, he just said he wanted her to come, so she did not get in a hurry to get up to the facility. V11 stated when she got to the facility it was around 4:30 PM and R2 was not in his room so she went and found him in the dining room. She stated he was eating dinner, and she noticed his left side of his mouth was swollen and she asked him what happened, and he told her (V4) got mad at him that morning because he did not want to get out of bed, and they were talking shit and she hit him in the mouth. V11 stated she looked in his mouth and his gums were bloody, and he had a little piece of meat (skin) hanging from him left upper lip. She stated he was complaining of pain while he was eating. V11 stated she went and asked the nurse (V8) that had just come on duty on the afternoon shift what had happened, and she stated she did not know anything about it and V11 stated she told her what (R2) had told her about the CNA hitting him in the mouth that morning. V11 stated she could not remember the nurse's name but stated She is here today. V11 walked up to the nurse's station and identified V8 as the nurse she spoke to on Sunday, October 13, 2024, about R2 stating he had been hit in the mouth by V4. V11 stated on that Sunday when she reported the incident to V8, V8 told her she would need to do a report and report it to the DON. V11 stated this conversation and V8's observation of R2's mouth happened in the hall after he left the dining room and was on the way back to his room at about 4:45 PM. V11 stated she did talk to V8 again because V8 thought R2 was talking about a different CNA but R2 clarified to V8 that it was V4, CNA who had hit him. V11 stated she and V8 both asked him why he did not tell staff what happened, but he didn't really have a reason. V11 stated she is upset because it is a resident's right to stay in bed a little longer if they want and he should not have been abused just because he didn't want to get up when V4 wanted him up. On 10/23/24 at 12:46 PM V14 Social Service Director (SSD) stated she did see R2 on Monday morning before lunch the day after V4 had allegedly hit him. She stated she did not see any active bleeding, but he did have a piece of meat hanging on his left upper lip. She stated he did complain of pain to his mouth. On 10/23/24 at 2:16 PM V10, CNA Supervisor, stated she did not work on Sunday, October 13, 2024, but she did work on the next day, and she saw R2 in the dining room where she helps pass breakfast trays. She stated he was acting his usual self, and she did see he had marks on his upper and lower lips that looked like impressions from his teeth. She stated she looked closer at his lips because she had seen some dried blood on his lips around that area. On 10/23/24 at 1:10 PM V1, Administrator, stated it would never be acceptable for a staff to hit a resident. V1 stated she had not reported V4 to the Department of Professional Regulations yet because she was waiting for the police report to send to them. She stated she did not immediately terminate V4 but did suspend her because she wanted to make sure the police got what they needed so she wouldn't get away with what she did. She stated the police viewed the camera footage on Monday afternoon and decided to press charges against V4 for assaulting R2. R2's Face Sheet documents his diagnoses to include Chronic Obstructive Pulmonary Disease, Unspecified, Chronic Kidney Disease, Stage 3B, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Other Seizures, Chronic Systolic (Congestive) Heart Failure, Schizophrenia, Need for Assistance with Personal Care, Peripheral Vascular Disease, Hypertension, Cerebral Infarction, and Generalized Anxiety Disorder. R2's Order Summary Report dated 10/22/24 documents his medications include Xarelto 15 milligrams (mg), a blood thinner which he takes daily. R2's Minimum Data Set (MDS) dated [DATE] documents his Brief Interview for Mental Status Score (BIMS) is 12, which indicates he is moderately cognitively impaired, and he requires substantial to maximal assist to perform bed to chair and chair to bed transfers. R2's Care Plan initiated on 2/22/22 and revised on 10/17/24 documents, (R2) is at risk for making repeated inappropriate sexual comments/gestures towards staff, verbal/physical/sexual abuse and threats/accusations against staff r/t (related to) impulsiveness, impaired cognition. The goal for this care plan documents, He will refrain from making inappropriate sexual comments and/or suggestions toward staff. He will not touch female staff in a sexually suggestive manner. This care plan was updated on 10/13/24 with the intervention: Monitor open area to lip for s/s (signs and symptoms) of infection. Notify Psyche NP (Nurse Practitioner) of incident. Offer comfort and reassurance as indicated. Per the care plan these interventions were initiated on 10/16/24. R2's Care Plan initiated on 12/21/21 and revised on 10/16/24 documents, (R2) is at risk for skin breakdown and injury related to incontinence, decreased mobility, poor safety awareness and renal disease. 10/13/24 Open area to lip (nosocomial)). Intervention added on 10/16/24 documents, Monitor open area to lip for s/s of infection. Administer pain medications as indicated / requested. The facility's document, Personnel Action Form, dated 10/15/24 documents V4 was terminated for inappropriate conduct. Description of Action or Event documented: 10/13/24 at 7:25 AM Resident complained a CNA hit him in the mouth with a closed fist. Investigation and camera review shows a reasonable probability that this did occur. Police plan to press charges. Action taken: Termination. The facility's policy, Abuse Prevention Program, revised 2/2023, documents, This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. this facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment.

Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications resulting in 1of 1 resident missing multiple doses of intravenous (IV) antibiotics in the sample of 9. This failure resulted in R2 missing multiple doses of IV antibiotics for acute infections prolonging IV antibtiotic course. Findings include: R2's Facesheet documents an admitted [DATE]. Diagnosis include Acute and subacute infective endocarditis, Bacteremia, Enterococcus as the cause of diseases, Dementia, Chronic Obstructive Pulmonary Disease. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired. R2 is dependent on staff for mobility and transfers. R2's Care Plan dated 9/12/2024 documents R2's daughter chose for R2 to be a Full Code. Full Treatment: Primary goal is attempting to prevent cardiac arrest by using all indicated treatments. R2's order sheet dated 9/13/2024 documents Ampicillin Sodium Injection Solution Reconstituted 2 Gm, use 2000 mg intravenously four times a day related to Infection and Inflammatory reaction due to other Cardiac and Vascular Devices, Implants and Grafts, Sequela. R2's order sheet dated 9/13/2024 documents Ceftriaxone Sodium Injection Solution Reconstituted 2 Gm, use 2 gram intravenously two times a day related to Infection and Inflammatory reaction due to other Cardiac and Vascular Devices, Implants and Grafts, Sequela. R2's progress notes dated 9/15/2024 at 2:33PM documents R2 has pulled out peripherally inserted central catheter, PICC, line. Physician notified and Power of Attorney, POA, is at bed side. R2 has new orders to go to hospital to have PICC line replaced. Hospital notified this nurse there is no one there to put it back in today. POA notified and staff will send R2 out in the morning to have replaced. Physician also notified. R2's progress notes dated 9/15/2024 at 4:15PM document Health Sutures were removed that secure the wings of the now dislodged PICC Line to the skin. No bleeding to the I.V. site noted. R2's progress notes dated 9/15/2024 10:12PM document Orders Ampicillin Sodium Injection Solution Reconstituted 2 GM. Use 2000 mg intravenously four times a day related to Infection and Inflammatory Reaction. PICC line dislodged. V2, Director of Nursing, DON, aware. R2's progress notes dated 9/15/2024 at 10:13PM documents Ceftriaxone Sodium Injection Solution Reconstituted 2 GM. Use 2 gram intravenously two times a day related to Infection and Inflammatory Reaction. PICC line dislodged. R2's progress notes dated 9/16/2024 at 10:32AM documents R2 is being transported to hospital per Physician orders for PICC line replacement. Transferred to recliner chair to stretcher via 3 assists, including EMS and nursing staff. R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ceftriaxone Sodium Intravenous Solution Reconstituted 2 Grams. Use 2000 milligrams, mg, intravenously every 12 hours for antibiotic. Start date on 9/13/2024 at 8:00AM. MARS document Ceftriaxone Sodium not administered on 9/15/2024 evening dose due to #9, other /see progress notes. Ceftriaxone Sodium not administered on 9/16/2024 due to #6 hospitalized . R2's MARS dated 9/25/2024 6:00PM has no signature that Ceftriaxone Sodium was administered. R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ampicillin Sodium Injection Solution Reconstituted 2 grams (Ampicillin Sodium). Use 2000mg intravenously four times a day related to Infection and Inflammatory Reaction. Start date on 9/13/2024 at 8:00AM. MARS document Ampicillin Sodium not administered on 9/15/2024 at 12:00PM and at HS, hours of sleep due to #9, other /see progress notes. R2's MARS dated 9/16/2024 at AM have no documentation of Ampicillin Sodium given. R2's MARS dated 9/25/2024 at 12:00PM and 6:00PM have no documentation that Ampicillin Sodium administered. R2's progress notes dated 9/16/2024 at 9:57AM document R2's wife called inquiring if R2 was sent out to hospital. Writer informed spouse that R2 was still at facility and waiting for ambulance to arrive. Writer called Emergency Medical Services, EMS, again and operator stated EMS would arrive in 30 minutes. On 10/1/2024 V8, R2's Power of Attorney, POA, stated My Dad had a blood infection and if he didn't get the antibiotics he would die. There were times I was in the room and no nurse came in and gave him his antibiotics. When his PICC line was out he missed several doses of his antibiotics. They did not care. They just said no one is able to reinsert the PICC line. On 10/1/2024 at 4:00PM V1, Administrator, stated R2 pulled out his PICC line on 9/15/2024. He then missed some doses of the antibiotic. We called the hospital and there was no one to reinsert the PICC line until 9/16/2024. That is the procedure if a resident's PICC line becomes dislodged, they are sent to the hospital for it to be reinserted. Then the hospital kept him for several days and transferred him to another hospital. We would not have taken R2 as a resident if we had known he had to get antibiotics every 6 hours. On 10/1/2024 at 8:30AM V2, Director of Nursing, DON, stated R2 pulled his PICC line out. He had to be sent out to the hospital to get it reinserted. We don't have many RN's, Registered Nurses, to give IV meds so it is usually me who gives them. On 10/1/2024 at 3:35PM V7 Pharmacist stated Whether or not the medication error is significant depends on the status of the resident. Intravenous antibiotics are a big deal and missing them is a big deal. On 10/3/2024 at 7:50AM V9, Licensed Practical Nurse, LPN, stated I took care of R2 a lot. I am the one who sent him out to the hospital when his PICC line was out. I remember the hospital had no one to put the PICC line back in, so he didn't go out over the weekend. Facility policy updated 1/14/2020 states Medications will be administered in a safe, efficient, and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice. Medication must be administered as ordered by the physician.

Based on interview and record review, the Facility failed to perform a safe and appropriate transfer for 1 of 3 residents (R14) reviewed for falls in the sample of 28. This failure resulted R14 obtaining a gash to head and sent out to hospital. Findings include: R14's Face Sheet documents R14 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, persistent vegetative state, chronic respiratory failure, tracheostomy status, multiple contractures, and bed confinement status. R14's Minimum Data Set (MDS) dated [DATE] documented R14 required total dependence with 2+ person assistance for bed mobility and transfer. R14's Care Plan initiated 8/17/21 documented R14 was dependent on staff for all ADL (Activities of Daily Living) needs related to suffering a closed head injury and remained in a non-verbal, vegetative state, responsive only to touch. The Care Plan documents R14 was at risk for fall and/or injury related to seizures. R14's Fall Risk assessment dated [DATE] documented R14 was at High Risk for falls. The Facility's Fall Log documents R14 fell during staff assist on 11/27/23. R14's Fall Investigation by V13, (Licensed Practical Nurse/ LPN), on 11/27/23 at 2:06 PM documents V14's (CNA /Certified Nurse Aid) reported he fell out of bed during patient care and has a dash (gash) on his right forehead. The investigation documented R14 was unable to respond and had a laceration to the top of his scalp. R14's Late Entry Progress Note dated 11/27/23 at 3:15 AM documents, The cna (CNA) informed this nurse during patient care that the resident fell out of bed. Resident has a dash to the r/t (right) side of his forehead, resident unable to speak to determine any pain, resident was transported to (Hospital) via EMT (Emergency Medical Technician) around 3:15 pm for further eval (evaluation), vitals were taken and his POA (Power of Attorney) were notified. R14's Hospital Records from 11/27/23 admission document R14 had superficial lacerations to forehead and right parietal scalp. R14's Care Plan revision on 11/27/23 documents, Educate staff that resident is 2 assist with patient care and transfers. On 12/5/23 at 10:20 AM, V3 (Social Services Director) stated R14 was usually lying in bed in the same position, and she had never seen him move about in his bed. On 12/5/23 at 10:39, V1 ( Administrator), stated V14 (CNA) turned R14 over during incontinent care, and he rolled out of bed. On 12/5/23 at 10:42 AM, V13 (LPN) stated R14 should have had two people with him during care. On 12/5/23 at 11:05 AM, V11 (LPN) stated R14 has a brain injury and requires total care with two person assistance for turning, repositioning, and transfer. On 12/5/23 at 11:32 AM, V14 (CNA) stated she was changing R14 by herself, and when she turned him onto his left side he started coughing really hard and just rolled off onto the floor. She stated she always performed care on R14 by herself in the past, but now he is a two person assist. On 12/5/23 at 11:45 AM, V2 (Director of Nursing /DON), stated V14 was cleaning R14, and R14 ended up on the floor. V2 stated he would have expected two CNA's to have been providing care to R14. On 12/5/23 at 1:30 PM, V1 stated she would expect two people to have been assisting R14 with care at the time of his fall. V1 stated the Facility does not have a policy regarding falls.

Based on observation, interview and record review, the Facility failed to follow physician orders to maintain acceptable parameters of nutrition in 5 of 6 residents (R16, R18, R19, R27, and R82) reviewed for nutrition in the sample of 31. This failure resulted in continued, significant weight loss for R18 and R82 and worsening of R27's pressure ulcer. Findings include: 1-R18's Face Sheet documents R18 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction; dysphagia, oropharyngeal phase; diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter; chronic obstructive pulmonary disease, unspecified; spastic quadriplegic cerebral palsy, abnormal weight loss, and contractures of left wrist, left hand, right hand, left ankle and foot, and right ankle and foot. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is severely cognitively impaired, requires total dependence with 2+ person physical assistance for bed mobility and transfer, and requires total dependence with one person assistance for eating. R18's Care Plan, undated, documents, (R18) is at risk for difficulty chewing/swallowing and weight loss r/t (related to) poor PO (oral) intake, dx (diagnosis) oropharyngeal dysphagia and having obvious caries. R18's Progress Note dated 4/14/23 documents, RD Note: weight status. Weight (4/11)-124.4 lbs (pounds), BMI (Body Mass Index)-16.4. Significant weight loss noted -6.8 lbs x 1 month (5.2%), -14.6 lbs x 6 months (10.5%). Regular, puree diet order with (fortified) cereal at breakfast, (high calorie) supplement 90 mL QID (four times daily), and HS (bedtime) snack. Assisted at meals. Per nursing conversation typically does not eat well at lunch but good at breakfast/dinner. Continue to encourage intakes and provide alternatives as indicated at meals. R18's Order Summary Report for the month of April 2023 documents order for regular diet, pureed texture, regular consistency, (fortified) cereal at breakfast, HS snack, (nutritional) shake for breakfast and dinner for impaired swallowing. There is an order for 90 milliliters (mL) of (high calorie) supplement four times daily dated 12/1/23. R18's Medication Administration Record (MAR) for the months of December 2022 through April 2023 does not document the high calorie supplement was given from 12/1/23 through 4/25/23. R18's Weights and Vitals Summary printed 4/26/23 documents R18 weighed 136.2 pounds on 1/3/23 and weighed 124.4 pounds on 4/11/23. This reflects an 11.8-pound weight loss or 8.6% weight loss over three months. 2-R82's Face Sheet documents R82 was admitted to the facility on [DATE] and has diagnoses including catatonic disorder due to known physiological condition; schizophrenia, unspecified; osteomyelitis of vertebra, sacral and sacrococcygeal region; pressure ulcer of sacral region, stage 4; gastrostomy status; and need for assistance with personal care. R82's MDS dated [DATE] documents R82 is moderately cognitively impaired, requires total dependence with 2+ person assistance for bed mobility, total dependence with one person assistance for eating, and activity of transfer did not occur. R82's Care Plan, undated, documents, (R82) is at risk for nutritional deficits r/t (related to) poor intake. (R82) is at risk for abdominal pain/discomfort, constipation r/t reduced motility, pain medication and poor PO (oral) intake. (R82) is at risk for fluctuations in weight r/t impaired cognition, hallucinations/delusions, poor intake with need for G-Tube (gastrostomy) placement. RD recommended Increased protein needs related to coccyx wound on 1/19/23. R82's CMP (Comprehensive Metabolic Panel) dated 3/17/23 documents albumin (blood serum protein) of 3.1g/dL (grams per deciliter) with reference range of 3.5-5.5 g/dL. R82's Progress note dated 4/14/23 documents, RD Note: TF (tube feeding)/wound status. Weight (3/3)-211 lbs, BMI-34.1. Significant weight loss -22.8 lbs x 1 month (9.8%), -41.4 lbs x 4 months (16.3%). Receiving regular diet order with double protein and (high calorie) supplement 90mL TID (three times daily) started 3/30 for added kcal (kilocalories)/pro (protein) support. Tube feeding support also in place to help meet nutritional needs: (controlled carbohydrate) formula 1.5 (calorie per mL) 55 mL/hr continuous from 6p-6a. Provides: 990 kcal/54g (grams) pro, 501 mL water (1101 mL total water with flushes). Tube feeding recently increased 3/30 due to weight loss. R82's Order Summary Report) printed 4/27/23 documents order for regular diet, regular texture, regular consistency, and double protein at breakfast for nutrition in addition to supplemental tube feeding 6P to 6A. There is an order for (carbohydrate controlled) enteral feeding at 60mL/hr (hour) continuous x 23 hours. There is an order for 90 mL (high calorie) supplement three times a day dated 3/30/23 and an order for 1 packet of (skin integrity) supplement twice per day dated 3/1/23. These orders do not specify whether the supplements are to be given by mouth or by feeding tube. R82's MARs for the months of March and April 2023 do not document high calorie supplement or skin integrity supplement were given, as of 4/27/2023. R82's Weights and Vitals Summary printed 4/27/23 document R82 weighed 252 pounds on 11/30/2022 and 202.4 pounds on 4/27/23 which reflects a 49.6-pound weight loss or 19.6% weight loss over 5 months. 3-R27's Face Sheet documents R27 was admitted to the facility on [DATE] and has diagnoses including dysphagia, oropharyngeal phase; mild protein-calorie malnutrition; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness, and pressure ulcer of sacral region, stage 3. R27's MDS dated [DATE] documents R27 is severely cognitively impaired, requires total dependence with 2+ staff assistance for bed mobility and transfer, requires total dependence with one person assistance for eating, and has one stage 3 pressure ulcer that was not present upon admission with treatments including nutrition or hydration intervention to manage skin problems. R27's Care Plan, undated, documents, (R27) is at risk for skin breakdown and infection r/t bowel and bladder incontinence. (R27) is at risk for weight loss r/t advancing disease and age. Interventions: Supplements and snacks as ordered. R27's Progress Note dated 3/9/23 documents, RD Note: weight/wound status. Weight (3/6)-151.8 lbs, BMI-22.4. Significant weight loss triggering -23.2 lbs x 6 months. Weight showing slow trend down the past 3 months. Multiple nutrition interventions in place. R27's Weights and Vitals Summary dated 4/28/23 documents R27 weighed 175 pounds on 9/6/22 and 153.4 pounds on 4/7/23. This reflects a 21.6-pound weight loss or 12.3% weight loss over 7 months. R27's Wound Care Plus Evaluation dated 3/16/23 documents stage 3 on coccyx measuring 1.3 centimeters (cm) length x 2.0 cm width x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 3/21/23 documents stage 3 on coccyx measuring 1.0 cm length x 1.7 cm length x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 3/30/23 documents stage 3 on coccyx measuring 4.3 cm length x 5.7 cm width x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 4/4/23 documents coccyx wound. No dimensions documented; however, it documents the length and width of the wound/skin issue deteriorated compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 4/14/23 documents stage 3 on coccyx measuring 6.0 cm length x 8.0 cm width x 0.4 cm length. The length and width of the wound/skin issue deteriorated compared to the previous visit's conclusion. R27's Order Summary Report printed 4/27/23 documents order for regular diet, pureed texture, regular consistency, (fortified) cereal at breakfast, variety snack TID (three times daily) 11am, 2pm, homemade shake at L/D (lunch and dinner). There is an order for 120 mL (high calorie) supplement four times daily dated 2/12/21 and an order for 120 mL (skin integrity) supplement four times daily dated 11/9/22. R27's MARs for the months of February 2022 through April 2022 do not document R27 received any (skin integrity) supplement. On 4/26/23 at 3:42 PM, V2, Director of Nursing (DON), stated, The orders for supplements should show up on the MAR. If the nurses see the order, they should know residents should get it, but if it's not on the MAR there is no other documentation that they have been receiving it. 4/28/23 at 8:10 AM, V30, Licensed Practical Nurse (LPN), stated she would not know she was supposed to give the supplements if they were not listed on the MAR. On 4/27/23 at 12:52 PM, V18, Registered Dietitian (RD), stated, The (high calorie supplement) is for extra calories and protein and is used for residents who are losing weight or are underweight. The (skin integrity supplement) is used to support wound healing. If they are not getting the supplements, they might continue to lose weight. On 4/27/23 at 12:10 PM, V25, Wound Nurse Practitioner, stated nutritional supplements and protein supplements play a big role in wound healing. She stated she tries to educate staff on the importance of giving supplements as ordered because of the effect they have on a resident's pre-albumin level which directly affects wound healing. V25 stated if a resident has supplements ordered, they should be getting them as ordered. On 4/28/23 at 9:44 AM, V1, Administrator, stated expects staff to follow physician orders for nutritional supplements 45302 4. R16's Undated Face Sheet, documents she was admitted to the facility on [DATE] diagnoses included paranoid schizophrenia and anxiety. R16's Care Plan, dated 11/22/2022 documents at risk for weight loss related to poor/decreased PO (by mouth) intake. Goal: maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs and symptoms) of malnutrition through review date. Interventions: administer medications as ordered, offer honey buns and juice just before dinner, eating 1 limited assist with all meals as indicated provide verbal and tactile cues prior to completing task for her. Invite her to activities that promote additional intake, observe/for report PRN any s/s of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN. Weights as ordered/monthly. Weekly weights. Monitor/record/report to MD PRN s/s of malnutrition. R16's MDS, dated [DATE] documents alert, 56 inches and 87 lbs. No weight loss or weight gain documented. R16's Registered Dietitian Progress Note, dated 3/9/2023 at 3:27 PM, documents weight (3/9) 84 pounds BMI 18.8 significant weight loss triggering -4.6 lbs x 1 month -10.6 lbs x 11/7 (11.2%) weight with noted fluctuations 82-89 lbs since mid-December 2022. Receiving mechanical soft diet order with meals in bowls, health shake with meals, 2 cal/ml supplement 90 ml QID, snack TID, super cereal at breakfast, magic cup at lunch and dinner and weekly weights to monitor nutritional status. Continue current POC (plan of care) with multiple interventions in place. Monitor, continue to encourage intakes and provide alternatives at meals as indicated. RD f/u PRN. Recommend: 1. reweigh to confirm weight status. 2. Currently with mechanical soft diet in orders, noted 2/20 health status note for upgrade to regular. suggest clarifying current diet texture in orders. R16's POS, dated 3/16/2023 documents regular diet regular texture and consistency. Serve all meals in bowls. Iced tea with all meals. Health shake with all meals. Super cereal at breakfast, snacks TID (three times a day) ice cream with meals for difficulty chewing/swallowing related to dysphagia. R16's POS, dated 3/2023 no documentation of a health shake, ice cream or snacks TID were administered or if the resident refused them. R16's MDS, dated [DATE] documents resident not able to complete the interview, 56 inches and 89 lbs. No weight loss or weight gain documented. R16's RD Progress Note, dated 4/14/2023 at 11:38 AM documents, weight (4/12)-80.8 lbs, BMI-18.1. Significant weight loss triggering -7.8 lbs x 1 month (8.8%), -13.8 lbs x 11/7(14.6%). Receiving regular diet with meals in bowls, health shake with meals, super cereal at breakfast, magic cup lunch/dinner, ice cream at meals, snack TID. 2 cal/ml supplement 120 ml QID for added nutrition support. Per nursing conversation resident will refuse meals if she is sleeping encouragement needed to get up and eat at meals. She will typically only eat in the dining room and accepts med pass supplement only if she is in the dining room. currently noted to be on isolation related to ESLB in urine which is likely cause of weight trend down. Recommend: 1. Provide increased encouragement/assist at meals while on isolation 2. when resident is off isolation encourage going to dining room for meals and provide 2 cal/ml med pass supplement at mealtimes as this is what resident prefers. 3. D/C magic cup at lunch/dinner as resident is already receiving ice cream with meals. Refer to RD PRN R16's Weight Change Progress Note, dated 4/14/2023 at 1:39 PM, documents resident has triggered for a 5% loss and dietitian consult has been sent and has new recommendation and guardian has been notified. R16's Electronic Medical Record, dated 4/19/2023 R16 weighed 80.6 lbs. R16's Weight Change Progress Note, dated 4/21/2023 at 11:44 AM documents resident has triggered for a 5% weight loss and there are no recommendations. R16's Electronic Medical Record, dated 4/25/2023 R16 weighed 84.8 lbs. R16's POS, dated 4/2023 no documentation of a health shake, ice cream or snacks TID were administered or if the resident refused them. On 4/26/2023 at 12:15 PM R16 observed sitting on the side of her bed eating grilled cheese. There was no health shake or ice cream on her tray and no dietary card on her lunch tray. 5. R19's Undated Care Plan documents she at risk for fluctuations in weight r/t poor appetite/PO intake, impaired cognition. Interventions: maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition through review date. Administer medications as ordered. Explain and reinforce to her the importance of maintaining the diet ordered. Encourage her to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Invite her to activities that promote additional intake. Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Observe for/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide, serve diet as ordered. Notify nurse of any refusal to eat/drink. RD to evaluate and make diet change recommendations PRN. R19's POS, dated 11/3/2022, documents regular texture, regular consistency, fortified foods lunch and dinner, ice cream and magic cup with lunch and supper, super cereal at breakfast snacks TID (3 times a day) ice cream for all meals. R19's Electronic Medical Record, documents weight 1/6/2023 101.2 pounds and 1/9/2023 102.4 pounds. R19's Weight Change Progress Note, dated 1/12/2023 2:05 PM documents consult sent to dietitian today r/t weight loss. R19's Registered Dietitian RD) Progress Note, dated 1/16/2023 12:02 PM, documents weight(1/9)-102.4 lbs, BMI-16. Significant weight loss triggering from 1/6 weight -6.4 lbs x 1 month(5.9%). Slight 1.2 lb trend back up x 3 days. Receiving regular diet, fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast. 2 cal/ml supplement 60 ml TID for added nutrition support. Setup help at meals. RD attempt to visit resident today- would not answer any of RD questions. Per previous notes resident has hx of only talking when she wants to. Mirtazapine 7.5 mg daily ordered which may help aid in appetite stimulation but noted per MAR is refusing medication often. At increased nutritional risk related to bipolar, MDD, schizophrenia dx. No further weight loss desired. Recommend: 1. Increase 2 cal/ml supplement to 90 ml TID for nutrition support 2. Offer snack TID between meals 3. Increased supervision at meals with encouragement for adequate PO intakes. RD to f/u PRN. R19's RD Progress Note, dated 1/18/2023 11:52 AM documents Per dietitian 1. Increase 2 cal/ml supplement to 90 ml TID for nutrition support. 2. Offer snack TID between meals. 3. Increased supervision at meals with encouragement for adequate PO intakes. RD to f/u PRN. Orders have been entered per MD and Guardian has been notified. R19's Medication Administration Record (MAR) dated 1/2023, no documentation of 2 cal supplement or snacks administered per physician's orders. R19's Electronic Medical Record, dated 2/2/2023 documents weight 110.8 lbs. R19's R19's Weight Change Progress Note, dated 2/3/2023 8:57 AM, documents Resident has triggered for a 5% weight gain and there are no recommendations and guardian has been notified. R19's Electronic Medical Record, dated 2/7/2023 documents weight 111.4 lbs. R19's Weight Change Progress Note, dated 2/9/2023 at 10:01 AM documents resident has triggered for a 5% weight loss and there are no recommendations. R19's RD Progress Note, dated 2/9/2023 at 2:12 PM, documents weight (2/7)-111.4 lbs, BMI-17.4. Significant weight gain triggering +9 lbs x 1 month (8.8%). Weight gain desired with low BMI status. Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml TID for added nutrition support. Setup help at meals. Continue current POC. RD to f/u PRN. R19's Electronic Medical Record, dated 2/16/2023 documents weight 100 lbs. R19's Electronic Medical Record, dated 2/20/2023 documents weight 100 lbs. R19's RD Progress Note, dated 2/20/2023 at 11:57 AM documents weight (2/20)-100 lbs, BMI-15.7. Significant weight loss triggering from gain on 2/2(-10.8 lbs x 2/2 9.7%). Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml TID for added nutrition support. Setup help at meals. Recommend: increase 2 cal/ml to 90 ml QID for added nutrition support and refer to MD (physician) for possible re-initiation of appetite stimulant. RD to f/u PRN. R19's Weight Change Progress Note, dated 2/21/2023 at 2:06 PM, documents resident had triggered for a 5% weight loss, and she has new orders and guardian has been notified R19's POS, dated 2/21/2023 documents an order 2Calories/ml four times a day (QID) for supplement. R19's Medication Administration Record (MAR) dated 2/2023, no documentation of 2 cal supplement or snacks administered per physician's orders R19's RD Progress Note, dated 3/2/2023 at 10:36 AM documents, weight (3/2)-99.6 lbs, BMI-15.6. Significant weight loss triggering -11.2 lbs x 1 month (10.1%). Weight overall stable since 2/16. Noted weight loss triggering from gain 2/2,2/7. Weight previously stable between 102-108 lbs since admit. Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml increased to QID 2/21 for added nutrition support. Setup help at meals with assist as needed. Noted behaviors with schizophrenia/bipolar dx which may be affecting intakes. Multiple interventions in place to help meet EEN. Continue to encourage intakes at meals and supplementation. Goal is for weight maintenance. Refer to RD PRN. R19's POS, dated 3/2/2023 a new physician's order for weekly weights. R19's Electronic Medical Record, dated 3/2/2023 documents weight 99.6 lbs. R19's Weight Change Progress Note, dated 3/3/2023 at 11:24 AM documents resident has triggered for a 5% weight loss and there are no recommendations. R19's Electronic Medical Record, dated 3/6/2023 documents weight 98.8 lbs. R19's Quarterly MDS, dated [DATE] documents resident is severely cognitively impaired, eating supervision with setup help only, 67 inches tall, weighed 99 pounds, weight loss of 5% in last month or loss of 10% or more in 6 months: no or unknown. R19's Electronic Medical Record, dated 3/15/2023 documents weight 96.4 lbs. R19's Weight Change Progress Note, dated 3/17/2023 at 8:53 AM, documents resident has triggered for a 5% weight loss and there are no recommendations. R19's Electronic Medical Record, dated 3/20/2023 documents weight 96.0 lbs. R19's Electronic Medical Record, dated 3/29/2023 documents weight 90.4 lbs. R19's Restorative Program Note, dated 3/31/2023 at 12:09 PM, documents resident has triggered for a 5% weight loss there are no recommendations and consult has been sent to dietitian. R19's Medication Administration Record (MAR) dated 3/2023, no documentation of 2 cal supplement or snacks administered per physician's orders R19's RD Progress Note, dated 4/3/2023 at 10:01 AM documents, weight (3/29)-90.4 lbs, BMI-14.2. Significant weight loss triggering -9.2 lbs x 1 month (9.2%), -10.8 lbs x 1/6(9.2%). -18.4 lbs x 11/9(16.9%). Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 120 ml increased to QID 3/30/2023 for added nutrition support. Setup help at meals with assist as needed. Weekly weights ordered to monitor nutrition status. Noted that mirtazapine previously ordered. Hx of refusing medications. Noted non-compliant with labs/outside appointments. RD has tried to visit resident to get food preferences/help assist with nutrition but wound not answer any questions. Noted behaviors with schizophrenia/bipolar dx which likely effecting intakes. Multiple interventions in place to help meet EEN (estimated energy needs.) Due to behaviors and noncompliance with meds/labs/outside appointments resident is not an appropriate candidate for tube feeding support-refer to MD about this if agreeable. Continue to encourage intakes at meals and supplementation. No further weight loss desired. Refer to RD PRN. R19's POS dated 4/4/2023 documents Mirtazapine 7.5 mg no reason ordered. R19's Electronic Medical Record, dated 4/6/2023 documents weight 98.0 lbs. R19's Electronic Medical Record, dated 4/12/2023 documents weight 90.0 lbs. 4/14/2023 1:49 PM Weight Change Nursing Progress Note, documents resident has triggered for a 5% weight loss and guardian has been notified. R19's Electronic Medical Record, dated 4/18/2023 documents weight 91.0 lbs. R19's Restorative Program Note, dated 4/21/2023 at 11:33 AM documents resident has triggered for a 5% weight loss, and she remains on weekly weights. R19's Electronic Medical Record, dated 4/25/2023 documents weight 91.0 lbs. R19's Medication Administration Record (MAR) dated 1/2023, no documentation of 2 cal supplement or snacks administered per physician's orders. On 4/25/2023 at 11:40 AM V13, CNA stated she recently told the facility RD that R19 was losing a lot of weight, but she wasn't sure anyone was doing anything about it. V13 stated she gives her a snack when she remembers but R19 doesn't always eat it and there was no place for her to documents a resident ate a snack in the CNA charting. V13 stated dietary staff put magic shakes on the resident's meal tray she's never seen R19 get a magic shake. On 4/25/2023 at 12:10 PM V11, CNA stated she told V1, Administrator R19 was losing weight a few days ago but she wasn't instructed to offer her anything other than take her to the dining room for meals. V11 didn't know what a magic shake was and didn't know who administers it to the resident. On 4/26/2023 at 8:15 AM R19's meal ticket documents ice cream lunch and dinner and super cereal for breakfast. R19 was observed eating breakfast in the dining room. R19 ate oatmeal, half a piece of toast and a bowl of cold cereal. There was no magic shake on her tray. R19 ate 50% of breakfast. On 4/26/2023 at 12:30 PM V17, CNA stated she told the charge nurse (name unknown) that V19 is losing weight a few weeks ago but no one gave her permission to give R19 snacks or anything additional. V17 didn't know what a magic shake was and stated that would come from dietary on the tray. On 4/27/2023 at 12:05 PM R19 sat up on the side of her bed eating a grilled cheese sandwich and strawberry ice cream. No magic shake was on her lunch tray. R19 ate 50% of lunch. The Facility's Skin Ulcer-Wound Policy effective 8/15/2018 documents, Policy: All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. Purpose: 1) To identify at risk residents for potential breakdown or ulcerations. 2) To prevent breakdown of tissue or ulcerations. 3) To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. Risk Factors included Under nutrition, malnutrition, and hydration deficits. Skin Ulcer Prevention included Following Registered Dietician recommendations to promote optimum nutrition when possible.

Based on interview and record review the facility failed to implement resident specific effective and progressive interventions to prevent falls for 2 of 3 residents (R6, R10) reviewed for falls in the sample of 10. This failure resulted in R10's fall sustaining a [CONDITION(S)] that required emergency department treatment of 5 staples. Findings include: 1. R10's Physician Order dated 05/20/22 documents history of Falling and generalized muscle weakness. R10's Face Sheet, printed 6/10/22, documents R10 was admitted [DATE] with diagnoses to include history of falling, Alzheimer's Disease, restlessness and agitation. R10's Minimum Data Set (MDS) dated [DATE] documents severe cognitive impairment, requires extensive assistance of two plus persons for transfer, bed mobility, is totally dependent on two plus persons for toileting, is not steady moving from seated to standing position only able to stabilize with staff assistance. R10's Care Plan dated 06/09/22 documents (R10) is at risk for falls r/t (related to) weakness, impaired cognition and poor safety awareness. With the Goal to be free of injury r/t falls. Interventions include: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Mattress on floor alongside bed. Bolstered low air loss mattress. R10 fell on [DATE] and 06/03/22. No new intervention added to care plan. R10's Health Status Note dated 06/01/22 at 2:35 PM documents Resident noted lying on floor on bedside pad on pillow. Awake and alert. Responding to name only noted bloody drainage to back of head with 5cm (centimeter) long laceration. Area cleansed with pressure dressing applied. PERRL (pupils equal and reactive to light) V/S (vital signs) 98.5 76 20 130/60 O2 (oxygen saturation) 97% ROM (range of motion) given x4 with no facial grimace. Facility Administration notified. 911 called RE: Questionable head injury and sutures need to laceration. MD (medical doctor) to be notified and family made aware. Hospice to be informed. R10's Care Plan was not updated with new interventions after this fall. R10's Health Status Note dated 06/01/22 documents Resident returned to facility via stretcher from (metropolitan) Hospital. Awake and alert. Transferred to bed with assist of two. Five staples to back of head at this with no drainage noted. R10's Nursing Note dated 06/03/22 at 9:35 AM documents resident was observed laying on left lateral side at 9:20am. Blood was noted on the floor and sutures were noted to not be intact. All vitals were stable, and pupils were constricted. Hospice was contacted at 9:23 in which they agreed to send resident to hospital. Resident's wife has been contacted at 9:30am and informed of the resident being sent to the hospital. I also informed her that if resident is unable to be seen at VA (Veterans Administration) hospital, he will be sent to (metropolitan) ED (emergency department). Vitals are T (temperature): 96.9 BP (blood pressure): 143/83 O2: 98% on RA (room air) P (pulse):76 R10's Fall investigation dated 06/01/22 at 2:35pm documents Resident noted lying on floor on bedside pad on pillow. Awake and alert. Responding to name only. Noted bloody drainage to back of head with 5 cm long laceration. R10's Care Plan was not updated with new interventions after this fall. On 06/10/22 at 10:15 AM, V10, CNA (Certified Nursing Aid) stated, (R10) tries to get up on his own a lot. He tried to get up yesterday. That's why he has the mattress on the floor and bed in low position. He's very confused. Normally it takes one person to get him up unless he's combative then you need help. On 06/10/22 at 12:50 PM, V5, LPN (Licensed Practical Nurse) stated, If a resident falls, I do skin assessment, vital signs before we get them up, Range of motion. Let the doctor and family know. check to see what intervention are in place. Make sure their environment is clear, make sure they are wearing non-slip socks. Either the MDS coordinator or the doctor might tell us the intervention. On 06/10/22 at 2:30 PM, V2, Director of Nursing (DON) stated, (R10's) wife said he liked to walk on a treadmill at home. I'm having 2 staff walk with him in the evening. We are hoping it helps wear him out and keeps him from wanting to get up. On 06/10/22 at 2:53 PM, V1, Administrator, stated, I couldn't find a fall policy. 2. R6's Physician Order dated 05/22/20 documents NEED FOR CONTINUOUS SUPERVISION. R6's MDS dated [DATE] documents that resident has no cognitive impairment, requires extensive assistance of two plus persons for transfer, requires extensive assist of one person for toileting, is not steady, only able to stabilize with staff assistance from seated to standing position or moving on and off toilet. R6's Care Plan dated 06/22/21 documents (R6) is at risk for falls r/t poor safety awareness, unsteady gait and weakness. It also documents R6 is at risk for [CONDITION(S)]/[CONDITION(S)] (temporary loss of consciousness caused by a fall in blood pressure) related to [CONDITION(S)]. The Care Plan documents R6 has a diagnoses of [CONDITION(S)] and Collapse. Fall interventions include: remind R6 to watch for liquids on the floor; remind R6 to dangle legs on side of bed for minute or two prior to standing, rise slowly when standing, drink plenty of water throughout the day, notify staff when light headed or dizzy; encourage to take breaks when fatigued/SOB (short of breath)/dizzy; notify nurse when weak, light headed, SOB; x1 assist with ambulation/transfers. R6 fell on [DATE] and 06/04/22. No new interventions added to care plan. R6's Fall investigation dated 05/29/22 at 5:30 PM documents (R6) was noted on the floor in a seated position by staff. BM (bowel movement) noted on the floor up under the resident, he has a foley catheter for urine. The resident did complain of minor pain to his right arm that was relieved by Tylenol 650 mg. Fall protocol including neuro-checks. R6's Care Plan was not updated with new interventions after this fall. R6's Nursing Note dated 06/04/22 at 4:21 AM documents Note Text: Resident was noted on room floor, head facing bathroom and feet under wheelchair. Shoes was on feet, foley intact. Resident pants pull down to ankle. Resident noted to have BM all over him and the floor. When ask, resident stated 'I WAS GOING TO THE BATHROOM AND fell DOWN'. ROM performed, all in normal limits. No bruises or injuries sustained. 2 assist back to wheelchair. Neuros started. MD made aware. POA (power of attorney) and DON will be made aware. R6's Care Plan was not updated with new interventions after this fall. On 06/10/22 at 2:20 PM, V13, LPN (Licensed Practical Nurse) stated, (R6) had a couple falls last month. He is unsteady. We had him start using a wheelchair. He wants to be independent and take himself to the bathroom. He is non-compliant.

Based on interview and record review the facility failed to permit readmission after an acute care hospitalization for 1 of 3 residents (R2) reviewed for involuntary discharge in the sample of 4. This failure resulted in causing R2 undue stress and worry regarding placement status and/or being placed in a facility that is not within proximity of family, and R2 remained in the hospital while waiting for his appeal. Finding includes: On [DATE] at 9:15 AM, V1, Administrator stated, The only involuntary discharge I have was on (R2). We could no longer meet his medical needs. This is my first involuntary discharge. He was on a [CONDITION(S)] (Continuous positive airway pressure) machine and now he has a [CONDITION(S)] (Bi-level positive airway pressure) machine, and we can no longer meet his medical needs because if he would stop breathing, we would not be able to perform CPR (Cardiopulmonary Resuscitation) on him. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set, dated dated dated [DATE] document Discharge assessment- return anticipated. Unplanned discharge. R2 was documented as having memory problems and some difficulty in new situations only. R2's Care Plan with date of initiated [DATE] does not document any behaviors. R2's Care Plan documents R2 requires extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The Care Plan documents R2 uses at [CONDITION(S)] with Oxygen at bed. He sleeps in a sitting/upright position due to shortness of breath when lying flat. R2's Care Plan with a date initiated of [DATE] document, (R2) is at risk for shortness of breath related to OSA (obstructive sleep apnea) and obesity hypoventilation syndrome, [CONDITION(S)] with episodes of exacerbation. History of acute on chronic hypoxic and hypercapnic respiratory failure. He uses [CONDITION(S)] with oxygen at bedtime. He sleeps in a sitting/upright position due to shortness of breath when laying down. R2's Care Plan Intervention, dated [DATE], documents continue the use of [CONDITION(S)] every night shift with 2 liters of oxygen bleeding into the device. Advised the patient to use H20 (water) with [CONDITION(S)] device, so the air is humified and decrease the incident of hemoptysis in the morning, every night shift for SOB (shortness of breath) when lying flat. R2's Progress Note dated [DATE] at 5:30 PM, Text: Patient was transported to (Hospital) by EMS (Emergency Medical Service) x (times) 3 assist at 5:30 pm. Patient was experiencing SOB (shortness of breath), altered mental status, and he defecated all over himself/floor trying to get to the bathroom. Patient stated, 'How did I get into the bathroom.' EMS did not let us clean him up before getting on the stretcher. After being on the stretcher he was unconscious briefly. Pulse ox (oxygen saturation) 93 right before EMS showed up. R2's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documents, Date of Notice given to R2 was on [DATE]. This was 7 days after he was transported to the hospital for a change in condition. The Notice documents the discharge was an Emergency Transfer or Discharge. The Notice documents This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and Long-term care facilities, 42 CFR 483.15 (c)(1) (i) (A). After this statement was a hand-written comment His health status has worsened to a point we can no longer meet his needs. The Notice documents On the date of transfer or discharge, you will be relocated to Facility, TBA (To Be Determined). On [DATE] at 9:32 AM, V2, Director of Nurse's stated, I talked with (V6) the Case Manager from the hospital and when (R2) went out to the hospital he was on a [CONDITION(S)] (continuous positive airway pressure) machine and his respiratory changed. When he got to the hospital, they said they (R2) needed a full mask with a [CONDITION(S)] (bilevel positive airway pressure) machine instead of the [CONDITION(S)] machine. They said he needed a [CONDITION(S)] machine with setting of ,d+[DATE]. (V6) acknowledged that the setting was high. (V6) advised me to talk with our medical director (V7) and so I talked with (V7's) nurse practitioner. (V8) and we told the hospital we had concerns over (R2's) [CONDITION(S)] settings, the full mask. If the mask would become dislodged or if (R2) was not wearing it and he would stop breathing, we would not be able to be effective in doing CPR because he weighs over 500 pounds and the CPR would not be effective. When he was wearing the [CONDITION(S)] machine it was not an issue but with the [CONDITION(S)] machine we felt it would be a concern. If he would be unresponsive, we do not feel that we could successfully code him. We are dealing with a high level of care. Because he may need oxygen immediately, I believe he needs a facility that has vents and respiratory specialist. We do not take vents here. We are dealing with high level of respiratory care. R2's Progress Notes dated [DATE] at 10:49 AM, Late Entry: Note Text: Call received from (V6), Case manager Hospital concerning R2's respiratory care needs. He stated that (R2) is on a [CONDITION(S)] machine with a full-face mask and would be discharged with it. He stated his settings would be ,d+[DATE] and explained the consequences of the mask not worn or dislodged during the night. He asked if I would review the concerns with (R2's primary care Physician) and call him back tomorrow. R2's Progress Notes dated [DATE] at 10:55 AM, Call placed to (V6) at hospital to inform him that the facility cannot support the level of respiratory care needed for (R2). (V6) stated that he will assist in placing (R2) in a suitable facility and will let us know where it is so that we can transfer his belongings to his new locations. On [DATE] at 9:50 AM, V6, Case Manager at hospital, stated, I have not been involved in this case since it was reported, but I can tell you what I know. We got (R2) here, and I cannot remember the exact time frame, but they thought he was retaining carbon [MEDICATION(S)]. (R2) had been on continuous positive airway pressure ([CONDITION(S)]) at the nursing facility but had been requiring bilevel positive airway pressure ([CONDITION(S)]) here in the hospital. At first, we questioned whether the facility [CONDITION(S)] was working appropriately. The Director of Nursing (DON) was notified that the [CONDITION(S)] may not be working properly and was notified for need of [CONDITION(S)] with settings of 22 and 10. The DON and I spoke a couple of times. She and administration stated they would not be able to take resident back because of his new [CONDITION(S)] need. Then the social worker got involved due to concern of resident being 'dumped' at the hospital. We let the DON and administrator know and from there the social worker took over. (R2) is still here at the hospital on another floor. On [DATE] at 11:15 AM, V6 stated, I talked with (V2) and told her about (R2's) [CONDITION(S)] machine and the full mask and his settings. I never mentioned anything about reviewing any concerns or issues with (R2's) [CONDITION(S)] machine with his physician. I do not discuss medical or device. I never said anything about the mask dislodging or any other concerns. I never said I would find placement as I do not do even do placement that would be our social worker. Those notes are incorrect, I never said any of that stuff other than the [CONDITION(S)] and settings. On [DATE] at 10:09 AM, V9, Hospital Social Worker, stated, I am working with (R2) and plan on calling in on his hearing next week if he is ok with that. The last time (V6) and I spoke with the administrator, they stated they will not accept him back to the facility because of his bilevel positive airway pressure ([CONDITION(S)]) requirements. Usually, the [CONDITION(S)] is not reason for exclusion from nursing homes. The facility said they were worried (R2) would rip the [CONDITION(S)] off at night and have a [CONDITION(S)], and they do not have the means to successfully code him. Here in the hospital, (R2) has been compliant with the [CONDITION(S)] and does not rip it off. He only wears it while sleeping and does not rip it off if he is sleeping. (R2) thinks the facility wants him out of there because he has Medicaid and does not have a lot of money or family connections within the facility. (R2) wants to go back to the facility. He has been ready to go back to the facility for a couple of weeks. I have sent out other referrals without success. (R2) is worried about his belongings and seeing his family, especially if he goes to another facility. On [DATE] at 10:48 AM, V10, Licensed Practical Nurse (LPN), stated, The day (R2) was sent to the hospital, the nurse giving me report said he had been having a decreased level of consciousness. The first moment I saw (R2), I knew something was wrong. He was sitting on the toilet, swaying, with feces on the floor. I immediately checked his oxygen saturation, and it was below 90%. I asked another nurse to help me, and we called the ambulance. (V8), Nurse Practitioner, was there. The ambulance came and (R2) actually lost consciousness on the stretcher and they had to put oxygen on him. I called the hospital to check on him and they said there might be a malfunction with (R2's) continuous positive airway pressure ([CONDITION(S)]), and they were going to arrange for (R2) to have a new [CONDITION(S)] when he came back to the facility. (R2) did have attention seeking behaviors, so it was hard to distinguish whether there was an issue or whether he just wanted to talk at times. In this case, I could tell right away that something was very wrong with him. I was told (R2) may not come back to the facility because we can't provide him the care he needs. On [DATE] at 11:35 PM, V4, Ombudsman stated, (R2) is a sex offender and he has been in the (Facility) for over 2 years. I have not gotten any complaints about him. We have an appeal scheduled on [DATE] for his involuntary discharge. His sister is nurse and said she would take him, but she has children and because of the children she is not allowed to have the children near (R2). The family is upset. They are worried and afraid he would be sent out of state or far away if they cannot find somewhere else to place him. It is tough because he is young, history of sex offender, not everyone is going to jump to take him. I have not received anything about him for 2 years. Why now? Bariatric part has not changed, prior (R2) wore a CPAC. (R2) wants to go back to the facility so his family can see him. The sister lives within an hour. And the family visits. If he would not find a facility closer this could potential affect his mental well -being if he was not able to see his family. It is a tough case. The (Facility) is trying to claim that because of the [CONDITION(S)] it would make it difficult to do CPR because he is large but when I asked them how that was different than his [CONDITION(S)], they just looked at me and had no answer. If he needed CPR, I do not think it would matter because if they can't do CPR with the [CONDITION(S)] then what would be different with the [CONDITION(S)]? The facility DON told a social worker at (hospital) that they can no longer meet (R2's) needs now that he needs a bilevel positive airway pressure ([CONDITION(S)]) machine, and the staff isn't trained. The ombudsman (I) spoke with the social worker, DON, and the Administrator about their refusal to take (R2) back and (R2) being a hospital dump. They argued that because the resident is on a [CONDITION(S)] and is bariatric they cannot guarantee they can revive him if something happens. When I asked how they planned to revive him prior to needing this equipment there was no response. It was at this time, I explained the involuntary discharge process but specified they had to take him back until placement was found. The involuntary discharge was sent out [DATE] as an emergency discharge. The discharge had N/A written through the appeal page and there was nothing listed as a place of discharge. I informed them this was invalid. (V1) said says she has to think of her staff first and refused to resend. On [DATE] at 10:26 AM, V13, R2's family, stated, (R2) has been really stressed, not knowing when he is going to get out of the hospital and where he is going to live. V13 stated (R2) said, 'I'm homeless.' I feel so bad for him. He really likes the staff at the facility, and I think he feels betrayed and the fact that his weight was mentioned is discrimination. Everyone knows he overindulges in food, and that is nothing new. My big concern is his respiratory status. Nobody from the facility contacted me to tell me he was going to the hospital, and nobody called to tell me he was being discharge. (V2) left me a voicemail to talk but she did not say anything about discharge. I was not aware of the upcoming hearing and did not get a letter. It would be a tremendous hardship if (R2) had to be placed far away from home. We are able to visit him now, but it would be much more difficult if he was farther away. On [DATE] at 2:40 PM, V15, Hospital Physician, stated, (R2) started off on bilevel positive airway pressure ([CONDITION(S)]), but we have been trying to transition him to continuous positive airway pressure ([CONDITION(S)]). It is really more of (R2's) preference to continue on the [CONDITION(S)] than medical necessity. (R2) has been really anxious and feels more comfortable on the [CONDITION(S)]. We are trying to get (R2's) anxiety under control with the hope of putting him back on the [CONDITION(S)]. [CONDITION(S)] is continual pressure and has more options with the face mask. [CONDITION(S)] is more advanced and delivers different pressures and is typically a full-face mask. Generally, the progression of increased oxygen requirements if [CONDITION(S)] first, then [CONDITION(S)] if respiratory status worsens. It is challenging to answer whether [CONDITION(S)] would exclude a resident from returning to their nursing facility. It really depends on what other needs they may have and what the facility is able to provide. Cardiopulmonary resuscitation (CPR) would be provided the same for people wearing both [CONDITION(S)] and [CONDITION(S)]. We would remove the mask and perform CPR. Obesity would make CPR more difficult, regardless of whether the resident has a [CONDITION(S)] or [CONDITION(S)]. The facility policy, Residents' Rights for People in Long-Term Care Facilities with a revision date of [DATE] documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. The facility must ensure that you are free from retaliation and discrimination in exercising your rights. Your facility must provide services to keep your physical and mental health, at their highest practical levels. You have the right to keep living in your facility. You must be given written notice if your facility wants you to move from the facility. The reasons for asking you to leave must only be for the following reasons: you are a danger to yourself or others; your needs cannot be met by the facility; your health has improved, and you no longer need the services of a long-term care facility; You have not paid your bill after reasonable notice; your facility closes. The notice must: tell you why your facility wants you to move; tell you how to appeal the decision to the Illinois Department of Public Health; provide a stamped and addressed envelope for you to mail your appeal in; and be received 30 days prior to the day they want you to move from a Medicare or Medicaid certified facility; be received 21 days prior to the day they want you to move from a State licensed facility. Before your facility can transfer or discharge you, it must prepare you to be sure that your discharge is safe and appropriate. You cannot be forced to leave your facility because you are applying for Medicaid, or you are on Medicaid and a Medicaid bed is available. It is important to ask the facility how many Medicaid beds it has available. You must be allowed to return to your facility after you are hospitalized as long as you still need that level of care. If you get Medicaid and are hospitalized for ten or fewer days, your facility must let you return when you leave the hospital even if the facility has given you a written discharge notice. If you are hospitalized for more than ten days, your facility must let you return if it has a bed available and you still need that level of care.

Based on interview, record review and observation, the facility failed to investigate falls and provide fall interventions and failed to follow recommendations for supervision and safety of other residents for 5 of 8 residents (R24, R26, R56, R57, R69) reviewed for accidents and supervision in the sample of 36. This resulted in R56 sustaining a fall with a [MEDICAL CONDITION] requiring 10 sutures. Findings include: 1. R56's Electronic Medical [DIAGNOSES REDACTED]. R56's MDS, dated [DATE], documents R56 is totally dependent on 2 staff members for bed mobility. R56's Care Plan documents, (R56) is at risk for falls r/t DX (diagnoses) [MEDICAL CONDITION] disorder, muscle spasms. 12/11/20 Observed on floor. 1/29/2021 Observed on floor next to bed. Interventions include: Use positioning device to assist with maintaining proper alignment/positioning when in bed due to muscle spasm (Dated 1/29/21). (the other interventions are undated) Bolsters mattress cover for over LAL (Low Air Loss) mattress. Check LAL mattress with all care and rounds to ensure proper inflation. x 2 with bed mobility. Keep bed in lowest position at all times except for when providing care. Mattress on floor along side bed. Do NOT position him close to wall, center him in the bed when positioning. Use positioning device to assist with maintaining proper alignment/positioning when in bed due to muscle spasm. Monitor for s/s (signs and symptoms) of [MEDICAL CONDITION]. Notify nurse when symptoms are present. Place resident on his side for safety during [MEDICAL CONDITION]. R56's Nurse Progress Note, dated 12/11/2020 at 7:07 PM, documents, Walked pass Pt. (patient) room & found Pt laying on the pad on the floor. Assessment found a 2 (inch) L shaped skin tear to (L) (left) eyebrow. Mother was made aware & she wanted Pt. sent to Hospital for an eval.(evaluation) Call placed to hospital emergency room & gave report. Call was placed to Ambulance for transfer. R56's Nurse Progress Note, dated 12/12/2020 at 04:34 AM, documents, Res returned from Hospital at this time Res has 10 sutures to L-shaped wound at left eyebrow line. No active bleeding noted. Sutures to come out in 5 days. The facility was unable to provide an investigation of this fall for review. R56's Nurses Notes, dated 1/29/2021 at 5:11 PM, documents, The resident was noted on the floor mattress at bedside, the lo-bed was in it's lowest position. Upon physical assessment, no signs of injury noted. The resident's vital signs were assessed and vital signs within the resident's normal limits. The resident was transferred from floor mattress to his bed via 2 assist without difficulty. R56's Fall Investigation, dated 1/29/21, documents, New Interventions: Mattress overlay bolster mattress over LAL (low air loss). Ensure proper inflation of LAL. Position center of bed. Bed in lowest position. Root cause: Res (resident) occasionally and will cough so hard he will throw self from bed. On 2/9/21 at 11:00 AM, R56 was in a LAL mattress. No bolster overlay was in place. V5, CNA, placed a small wedge cushion under R56's knees. On 2/9/21 at 11:00 AM, V5 stated that she was present when R56 was found on the floor and that R56 coughs very hard at times and he can fall out of bed while coughing. V5 further stated that staff use a wedge cushion to keep R56 from being able to fall out of bed. On 2/10/21 at 3:00 PM, V1 Administrator, stated that he was unable to locate an investigation of R56's fall on 12/11/20. V1 also agrees that R26's fall investigations do not document root cause analyses. On 2/11/21 at 2:09 PM, V1, Administrator, stated, The facility does not have a fall policy. V1 further stated, I would expect staff to do a full investigation of the fall and to determine a root cause analysis of the fall. 2. On 02/02/21 at 12:50 PM, R24 was sitting in his wheelchair in the doorway of his room. R24 propelled his wheelchair in his room. R24's room was located at the very end of the hallway, farthest from the nurses station. On 02/02/21 at 12:52 PM, V28, Certified Nurses Aide (CNA), stated, He does not wander into others rooms, but he does go up to the nurses station to make phone calls. On 2/9/2021 at 12:35 PM, V8, Social Services Director, stated, I am not sure why (R24) is at the end of the hall. I guess it is because the rooms at the top of the hall are not private rooms or private bathrooms. To my knowledge, he has not went to any other persons room. V8 was unable to state how long R24 had been in the very last room on the hall. On 2/9/21 at 1:39 PM, V13 Licensed Practical Nurse (LPN), stated that R24 has no special observations or monitoring. V13 further stated that he will go to the double doors at the top of the hall, but can be redirected. R24's Admission Record, print date of 2/10/21, documents R24 was admitted on [DATE] with [DIAGNOSES REDACTED]. R24's Illinois Department of Public Health Identified Offenders Program, dated 9/16/2019, documents, High Risk. The resident requires a single room in close proximity to the nursing station to permit ongoing visual monitoring. The level of observation should be sufficient for early detection of behavior changes. Regular assessment is necessary to determine whether closer monitoring or more frequent individual contact is indicated. R24's Minimum Data Set (MDS), dated [DATE], documents R24 is severely cognitively impaired, requires extensive assist of 1 staff member for transfer and R24 uses a wheelchair for locomotion. This MDS documents locomotion on the unit activity did not happen. R24's undated Care Plan, documents, (R24) is at risk for sexually inappropriate behavior towards others r/t (related to) Attempted Deviate Sexual Assault. He is a registered sex offender. Additional offenses include Narcotics, Burglary, Unlawful restraint, Murder, Battery. Interventions: Single room. Regular monitoring to determine whether close monitoring or more frequent individual contact is indicated. 1:1 visits to monitor for changes in behavior and mood as indicated. Private bath. No contact with children. Must stay 500 feet away from schools, daycare. Must notify the police department if he exits facility for any reason. Parole officer to visit as ordered by the judge. Monitor/document/report PRN (as needed) any s/sx (symptoms) of resident posing danger to self and others. He is not to go into other residents rooms, male or female. The facility Sexual Offender Policy, dated 7/21/2005, documents, Standard: In order to protect current residents in the facility, all potential admissions will be checked against the Sex Offender Registry and Department of Corrections websites for felony convictions in accordance with State, local and government rules and regulations. It continues, Policy: #6) The facility will follow all policies established by the local law enforcement in regards to registration of sex offenders. 3. R26's Admission Record, print date of 2/10/21, documents R26 was admitted on [DATE] with [DIAGNOSES REDACTED]. R26's MDS, dated [DATE], documents R26 is severely cognitively impaired, requires extensive assist of 2 staff members for bed mobility, and is totally dependant on 2 staff members for transfer. R26's Fall investigation, dated 11/3/2020, documents, Nursing Description: This nurse was called into residents room by CNA that stated she had sat resident up at her bedside turned and went to the door and heard her fall. Noted resident lying on her right side by her bed. Immediate Action Taken: Active and passive range of motion done. Resident was able to move all extremities without assistance with limited motions due to age without indications of having pain. Was able to tolerate Passive range of motion. CNA was informed not to leave any residents that requires assistance with transfers unattended when sitting up at the bedside. New Intervention: Instruct staff resident not to be left alone sitting on side of bed. R26's Nurses Notes, dated 12/6/2020 at 11:45 PM, documents, this pt's c.n.a. called this nurse down to her room, this pt was found laying on the floor next to her bed on her right side, her head was up on her tennis shoes. she was assessed, a mechanical lift pad was placed under her, she was placed back in bed by this nurse and her c.n.a. her range of motion has not changed, she stated she is ok. neuro checks were started at this time. R26's Fall investigation, dated 12/6/20, documents a New Intervention: Staff instructed to make sure resident in center of bed when turned. R26's Fall Investigation, dated 1/31/21 at 12:45 AM, documents, Nursing Description: Called to room by CNA and noted res (resident) lying on floor next to her bed on her left side of face resting on night stand. Immediate Action taken: assessed for injury, assisted to bed per mechanical lift, ice pack applied to face, positioned on right side facing wall with cushions behind her, kept in bed in lowest position and applied mat on floor next to bed. New Intervention: Bed at lowest position. Positioning away from side of bed during rounds. This fall investigation does not document a root cause analysis of the fall. R26's Fall Investigation, dated 2/2/21 at 10:30 AM, documents, Nursing Description: This nurse noted resident lying on the floor with her bed covers under her roommate called out for help. New Intervention: Resident rolled from bed. Instructed to use call light for assist. Head of bed lowered after meals. call light within reach. This fall investigation does not document a root cause analysis of the fall which would assist in determining appropriate interventions. R26 has severe cognitive impairment, instructions to use call light would be ineffective for this resident. 4. R69's Care Plan, dated 5/25/2020, documents, (R69) is at risk for injury, skin breakdown r/t (related to) DX [MEDICATION NAME] leakage at gtube (gastrostomy tube) site, impaired mobility, combativeness, moisture against skin. Intervention: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Roll up cloth and place between his left arm and body r/t him drawing his left arm into his body. Geri sleeves to RUE (right upper extremity) at all times, remove for shower and skin check then reapply. R69's Skin/Wound Note, dated 2/8/21 at 3:00 PM, documents Note Text: Noted skin tear to right hand 1.5 x 1.3 x 0.2 beefy red with moderate serosang drainage. MD (Physician) made aware and new order received to apply TAO (triple antibiotic ointment) and dry dressing daily and prn. Order noted and RP made aware. Dressing applied as orders. On 2/2/2021 at 9:55 AM, R69 was sitting in his reclining wheelchair with a short sleeve shirt on with both arms exposed. R69 had multiple bruising in various stages of healing to both arms and hands. Arm protectors and the rolled up cloth were not in place. On 2/3/2021 from 11:15 AM to 1:50 PM, based on 30 minute observation intervals, R69 was without arm protectors and rolled up cloth in place. On 2/4/2021 from 9:30 AM to 12:50 AM, at 30 minutes observation intervals, R69 was without arm protectors and the rolled up cloth were not in place. On 2/8/2021 at 930 AM, R69 was sitting in his recliner with a large bandage to his left hand. On/9/2021 at 9:45 AM, V5, CNA, stated, (R69's) skin is real thin. It's like newspaper. We have to be careful with his hands and arms. They bruise and tear easily. When he first got here, he was wrapped up all the time. You can barely touch him and he would bruise or his skin would tear. On 2/8/2021 at 1:40 AM, V12, CNA, stated, Day shift starts at 6:30 AM and ends at 2:30 PM. (R69) is gotten up on midnights and stays up until after lunch. He does not move around in his chair. On 2/9/2021 at 2:30 PM, V3, LPN, stated R69 bruises easily. He is supposed to have his arm protectors on. This will help prevent the bruising and skin tears. R69's Clinical Record does not document bruising to R69's arms and hands. On 2/9/2021 at 2:28 PM, R69's documentation related to bruising and any incidents related to bruising and skin tears requested. On 2/9/2021 at 2:30 PM, V2, Director of Nursing, stated she was not aware of R69's bruising and is not aware of an investigation into the areas. On 2/9/2021, V18, LPN, stated the skin assessments are done on shower days and documented on the shower sheets. CNA supervisor keeps those. 2/9/20 at 3:30 pm V5, CNA, stated the reason she hasn't brought the shower sheets in was because there is no documentation of R69's bruises. R69's Clinical Record had no documentation of his bruising or a root cause analysis to determine appropriate interventions for prevention. 5. R57's Care Plan, dated 2/5/2021, documents (R57) is at risk for falls r/t poor safety awareness, weakness and shuffled/scissor gait. Does not recall that he has limitations due to Alzheimer disease, history of [MEDICAL CONDITION], and impaired eyesight. 6/15/2020 Observed on floor, 9/1/2020 Observed on floor, 1/14/2021 Observed on floor, 1/20/2021 Observed on floor, 1/26/2021 Observed on floor, 1/28/2021 Observed on floor, 1/31/2021 Observed on floor. Interventions: Staff to assist with transfer to wheelchair or x1 assist with ambulation if noted to being awake and wanting to get out of bed. Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c. x1 assist with ambulating him on the hall when he is restless or agitated. R57's MDS, dated [DATE], documents R57 is severely cognitively impaired and requires limited assist of one person for transfers. R57's Morse Fall Scale, dated 12/24/2021, documents high risk for falls. From 1/1/2021 to 2/8/2021, the Incident and Accident Reports (IAR's) documented R57 had 6 falls. On 2/8/2021, R57 was ambulating, with socks on, in his room without assist. R57 was observed tripping over the wheels of his wheelchair. V12 attempted to redirect and grabbed a hold of R57 right arm and encouraged R57 to sit in the wheelchair. R57 fell to floor. V12 and V14 transferred R57 from floor to wheelchair. V12 and V14 lifted R57 placing their arms under R57's armpits and grabbed his pants. V12 and V14 did not use a gait belt with transfer and transferred before R57 was assessed for injury. On 2/8/2021, V12 stated It's hard because he (R57) doesn't remember things. He used to walk around. He stays in his room. We try to redirect him but it's only a sort time and he is back up.

Based on observation, interview and record review the facility failed to change an indwelling urinary catheter according to physician's order and failed to provide complete catheter care for 3 of 4 residents (R1, R2, R3) reviewed for catheter care in the sample of 7. The failure to timely change an indwelling urinary catheter led to hospitalization for R3 for removal of a calcified catheter and treatment of [REDACTED]. Findings include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has an indwelling urinary catheter and [DIAGNOSES REDACTED]. R3's electronic Physician Order Sheet (POS), dated 3/2018, documents, Change 16 French (indwelling urinary catheter) monthly and as needed one time a day starting on the 20th and ending on the 21st every month for urethral stricture/[MEDICAL CONDITION] -start date 11/20/17. R3's 11/2017, 12/2017, 01/2018 TREATMENT Administration Records (TAR) which document, Change 16 Fr catheter monthly and prn one time a day starting on the 20th and ending on the 21st every month for urethral stricture/[MEDICAL CONDITION], were signed by V3, Treatment Nurse, on those 3 months. R3's 2/2018 TAR was not signed indicating R3's catheter was not changed in the facility. R3's Care Plan, dated 2/3/18, documents, Has indwelling catheter related to Urology Urodynamic testing at the end of (MONTH) (YEAR). At risk for infection due to catheter placement. Goal: will remain free from catheter related trauma and infection thru review date. Approaches: Change catheter and tubing per MD (Physician) orders. See POS and MAR (Medication Administration Record). Monitor/document for pain/discomfort due to catheter . Document output and report any blood, pus, foul odor from (catheter) bag. R3's Nurses Note, dated 2/23/18 at 11:49 AM, documents, Urology appointment today accompanied by his mom. R3's Urology Specialty Care Clinic Notes, dated 2/23/18, documents, Chief Complaint: Follow Up after UROD. Assessment/Plan: Patient to have (urinary indwelling) catheter changes at facility. RTC (Return to clinic) in 3 months. Electronically signed by (V13, Nurse Practitioner). The Urology Notes did not document R3's indwelling urinary catheter was changed during that visit. R3's Nurses Note Late Entry, dated 2/23/18 at 6:21 PM, documents, (V2, Director of Nursing (DON)) called Doctor's office inquiring about (indwelling urinary catheter). Doctor explained resident's (catheter) was changed at office and facility can change (catheter) every month. R3's Nurses Note, dated 3/22/18 at 10:15 PM, documents, Call placed to (V15, Physician) related to patient color very pale, Temperature 100.2, catheter draining very dark, brownish red concentrated urine and thick brownish mucus coming out of tip of penis. MD aware, new orders received [MEDICATION NAME] 500 milligrams by mouth daily x 7 days related to UTI and to change (catheter). R3's Nurses Note, dated 3/22/18 at 11:15 PM, documents, Attempted to change patient's catheter and (catheter) tube would not dislodge. Call placed to (V15). New orders to Send to ER (emergency room ) for evaluation and treatment. R3's Nurses Note, dated 3/22/18 at 7:55 PM, documents, Call placed to (local hospital) to check on patient's status. Patient was admitted with Diagnosis: [REDACTED]. R3's Hospital [MEDICAL CONDITION]-Consult Notes, dated 3/22/18, document, Patient is nonverbal, nonresponsive [AGE] year old African American male with [MEDICAL CONDITION] who has had an indwelling (catheter) not changed since (MONTH) (YEAR), unable to be removed. (V12, Urologist) removed (catheter) without incident. There was some calcification around the deflated balloon. Instructed ER staff to place an 18 French coude catheter. Would give him 3 days antibiotics. He should have (catheter) changed every 4 weeks. On 3/26/18 at 11:10 AM, V3, Treatment Nurse, stated if the resident's catheter change comes up due she changes it or the floor nurses does. V3 stated she changed R3's catheter on 11/21/17, 12/21/17 and 01/21/18, but R3 had a Urology appointment on 2/23/18 and as far as she knew his catheter was changed at the time. V3 stated she did not change R3's catheter on 2/22/18, only his urinary bag as ordered. On 3/27/18 at 09:32 AM, V2, Director of Nursing (DON), stated R3's last urology visit was on 2/23/18 and she was informed by phone the catheter was changed at that time. V2 stated there was an order from the clinic notes to have R3's catheter changed in the facility every 4 weeks and an earlier order, dated 11/29/17 from the urology clinic, to have R3's catheter changed every 6 weeks. V2 stated the facility tried to change R3's catheter on 3/22/18, a day earlier than the due date, but it would not come out so R3 was transferred to the ER. V2 stated she called the Urology clinic that saw R3 on 2/23/18 and she was informed R3's catheter was a 'TURP catheter with a hook' that was why it would not come out. On 3/29/18 at 8:54 AM, V11, emergency room Nurse Practitioner, stated that on 3/22/18, she was called to the ER to remove R3's catheter, but was unable to remove it. V11 stated V12, Hospital Urologist, was able to remove the catheter. V11 stated she herself noted calcification around the deflated balloon of the catheter when it was pulled out. V11 stated indwelling urinary catheters need to be changed every 4 weeks to avoid infection and or calcification and encrustations. V11 stated R3 had pretty bad urinary tract infection when he arrived at theER on [DATE]. V11 stated it was a (Foley) catheter that was removed from R3 at the ER. On 4/05/18 at 7:55 AM, V13, Urology Clinic Nurse Practitioner, stated she saw R3 during the 2/23/18 visit and R3's indwelling catheter was not changed during that visit. V13 stated the visit was for a follow up of R3's Urodynamic Testing which V14, R3's Mother/POA (Power of Attorney), stated during the visit she does not want surgical treatment for [REDACTED]. V13 stated she wrote an order for [REDACTED]. The Facility Policy on Catheterization, dated 3/2016, documents, Standard: To help restore or facilitate effective function of renal and urologic systems, and provide comfort and protection from urinary incontinence that exacerbates a clinical condition. Policy: Indwelling urethral catheters should be inserted only when necessary and left in place only for as long as necessary. They should not be used only for the convenience of staff. 2. R1's MDS, dated [DATE], documents R1 has an indwelling urinary catheter with [DIAGNOSES REDACTED]. R1's Care Plan, dated 1/17/18 documents, Has indwelling catheter related to [MEDICAL CONDITION], and Chronic Prostatitis. At risk for infection due to catheter placement. Goal: will remain free from catheter related trauma and infection thru review date. Approaches: Change catheter and tubing per MD orders. See POS and MAR. Monitor/document for pain/discomfort due to catheter . Document output and report any blood, pus, foul odor from (catheter) bag. On 3/26/18 at 12:51 PM, V6, Certified nursing Aide (CNA), provided catheter care to R1. V6 prepared 2 basins half filled with water and regular soap added to one of the basins. V6 washed hands and donned gloves. Using wash cloths wet with soapy water, V6 washed the tip of the penis, shaft, scrotum, groin area, and meatus and catheter. V6 rinsed all areas washed with soapy water. V6 replaced R1's incontinent pad and straightened R1's bed clothes. V6 stated she was done. V6 failed to dry all areas that were wet. 3. R2's MDS, dated [DATE], documents R2 has an indwelling urinary catheter with [DIAGNOSES REDACTED]. R2's Care Plan, dated 3/10/18, documents, Has a history of Bacteremia and UTI. At risk for infection related to catheter use and decreased mobility. Goal: will remain free from infection thru review date. Approaches: Monitor/document/report to MD as needed signs and symptoms of UTI: frequency, urgency, malaise, foul odor smelling urine, dysuria, fever, nausea and vomiting, flank pain, suprapubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavior changes. On 3/26/18 at 1:52 PM, V8 and V9, both CNAs, provided catheter care to R2. Both washed hands and gloved. V9 used wet washcloths sprayed with no rinse perineal wash to cleanse the shaft of the penis, underside of the scrotum, retracted the foreskin, cleansed the meatus and the catheter. V9 dried all wet areas. V8 turned R2 to his left and cleansed the rectal area, perianal area and buttocks and dried all wet areas in the back. V9 turned R2 on his back and covered R2 with his bedclothes. V9 and V8 took off their gloves and stated they were done with care. V9 or V8 did not pull back R2's foreskin to its normal position. On 3/29/18 at 3:25 PM, V2 stated she expect staff to provide complete catheter care to residents by pulling back the foreskin after washing the penis and wiping the wet areas dry with clean towels. V2 stated staff are expected to follow the facility policy as they are inserviced to do. The Facility Policy on Catheter Care, dated 4/15/07, documents, Procedure: 9. Wash the genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. The Policy further documents, under 15. to retract the foreskin of the uncircumcised male and continues, 18. (After rinsing and drying) return foreskin to normal position.

Based on record review and interview the facility knowingly failed to follow their fire evacuation policy during an actual fire. Facility staff did not notify fire personnel of residents left in the burning building. Facility staff failed to follow policy/procedures for leaving smoke barrier doors closed to contain the fire and smoke. Facility staff neglected to evacuate the residents closest to the fire first and those away from the fire origin later. Facility staff evacuated the entire facility without clear instructions from any person in charge. Facility management staff neglected to ensure that all staff was adequately trained to respond to an actual fire, resulting in poor communication and a prolonged relocation of all 106 residents. These failures resulted in fire department personnel using search and rescue operations to recover four residents. These failures resulted in an immediate jeopardy with fourteen residents (R1-R6, R11-R15, R19, R23, R24) requiring hospital visits for smoke inhalation and other fire related conditions including anxiety/panic attacks. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 31, 2016 when facility staff failed to notify the Fire Department of residents still in the burning building, failed to ensure that smoke barrier doors were used appropriately, failed conduct orderly evacuation ensuring that residents closest to the fire were evacuated first, and failed effectively execute the disaster plan during an actual fire in the nursing facility. While the immediacy was removed on 7/12/16, the facility remains out of compliance at a Severity Level 2 as additional time is required to evaluate the ability of staff to fully implement and execute the revised disaster plan, demonstrating knowledge of the plan related to fire rescue and response. Findings include: Facility Fire Safety and Disaster Preparedness Manual (revised 03/31/13) documents the following: the main objective and first consideration during any disaster or emergency is the safety and well-being of the residents. Employees should always remain calm and reassure the residents so that transfer or evacuation procedures can be carried out effectively and with the least amount of problems or accidental injury. This same manual also documents the following: In case of any emergency, evacuation of residents, staff, and visitors should first be from the area of immediate danger. If a complete evacuation from the facility becomes necessary, residents are to be removed from the facility utilizing the nearest and safest exits and taken outside to the front parking lot where a head count will be taken. On 05/31/2016 at 5:10PM Z13 (Illinois Department of Health Emergency Services Coordinator) states he notified Z14 (Illinois Department of Public Health Field Supervisor) that there was a fire with total resident evacuation at facility. Fire Department form NFIRS-1 dated 05/31/2016 documents that the local fire department responded for a reported fire in a room on the 500 hall (E) at the facility. This same report documents that upon arrival of fire units and personnel they found heavy smoke coming from the right rear of the building located near (F) and (E) hallways with police officers and employees from the business breaking windows to remove residents from the 500 hall. This same document reports that fire personnel .found the fire quickly and contained to room [ROOM NUMBER] while other fire personnel were in rescue operations. It was at this time that several residents were still inside (500 Hall) where a female victim (resident) was found in the hallway. Primary searches were performed (by fire personnel) from room [ROOM NUMBER] to 516 where several victims were found. One male (resident) was removed from room [ROOM NUMBER] through the window. In room [ROOM NUMBER] a male resident was removed through a window. A male resident from room [ROOM NUMBER] was removed out of the room and down the hallway in a wheelchair. On 06/15/2016 at 1:30PM Z10 (Emergency Management Services/EMS Operations Manager) stated that when he arrived on the scene no facility staff were in charge for the first 15 minutes. Z10 stated that after that, E2 (Facility Regional Operations Manager) assumed control. Z10 stated that when they arrived, facility staff could not tell them how many residents were still in the building. Z10 stated, There was no coordination whatsoever. Z10 stated it took 45 minutes to one hour after their arrival for EMS to be given any kind of information about resident's medical needs only to be asked by E2 (Facility Regional Operations Manager) for their (EMS) plan to find placement for residents. E2 provided a 54 page document titled Fire Safety and Disaster Preparedness Manual (Revised 3/31/2013) on 6/1/2016. Pages 19-25 include names, addresses, and contact information as well as skill level for area nursing home facilities. However, during the fire response, Z13's (Emergency Services Coordinator) written account indicates that there was quite a bit of confusion regarding the actual number of nursing home residents present, how many still required transport and the destination of those waiting. I heard resident numbers from multiple people that ranged from 103-106 .Illinois Department of Public Health (IDPH) Long Term Care (Z14, Z15, Z16) along with a Senior Citizen Ombudsman were attempting to lock down Nursing Home bed availability in the region. There was no pre-planned sheltering facility identified by management to get these residents out of the elements which included the threat of rain and at times visible lightening. On 06/16/2016 at 5:30PM Z1 (local Fire Chief) stated that he and his men rescued a total of four residents from the fire hall, (500 hall) with one resident rescued by accident when Z1 and some of his men were standing at the entrance to room [ROOM NUMBER] (where fire started). When Z12 (Fire Department Captain) stepped back and bumped into a person on the hall corridor floor. Fire personnel checked to see if the person was alive. The person (resident) moaned and then Z12 helped to evacuate her. Z1 also stated that no nursing personnel of the facility informed him of any potential residents left in the building. On 06/16/2016 at 5:40PM Z12 stated that no facility staff informed him of anyone in the building. When Z12 entered the 500 hall and got to room [ROOM NUMBER] he heard a moan coming from the corridor floor just outside room [ROOM NUMBER]. He then helped to evacuate R1, who resided in room [ROOM NUMBER]. On 06/16/2016 at 5:30 pm Z1 stated that when he arrived on the scene and was about to enter the facility, Z1 was met by two nursing staff with masks on. Z1 asked the two nursing staff if there were any residents in the building. The two staff members did not provide any answers and instead ran back into the building and Z1 lost them in the smoke. Z1 stated when he entered the 500 hall from the core area (nursing station) he noticed the entrance to 500 hall was standing open which allowed the smoke to get into the core area. Z1 stated that he would have expected the door to have been closed. Z1 stated that nursing staff was out of control. Staff was all over the scene. They did not follow directions and kept moving (residents) without permission causing problems for resident movements. Page 8 of the Fire Safety and Disaster Preparedness Manual (Revised 3/31/2013) documents that staff is to once outside the facility, account for all residents, visitors and staff and report any missing persons to the fire department or other local law agency personnel at once. Page 9 of this manual instructs staff to remain calm. If the fire is minor enough to be fought safely, do so. Movement in an evacuation due to fire should always be away from the travel of the heat and smoke. Residents should always be moved to an area that places a fire barrier door between them and the fire, removing those closest to the danger first. Fire and smoke barrier doors provide temporary (1-2 hour) protection from the spread of fire and smoke. Fire and smoke barrier doors separate all the halls from the facility core and will automatically close when the fire alarm is activated. At no time should barrier doors be propped open. On 06/16/2016 at 11:00 AM E1 (Maintenance Supervisor) stated that he was working inside the ceiling when he heard someone say there was a fire. E1 stated he got off the ladder and saw smoke down the 500 hall. E1 stated there was a resident lying in the 500 hall, he got a wheelchair and put the resident in it and pushed the resident out through the 500 hall fire door. E1 stated he was unsure who the resident was. E1 also stated that the acting Director of Nursing was present, but he was not sure what she was doing. E1 stated that in the event of a fire, the Administrator runs everything. If the Administrator isn't present, the Director of Nurses is in charge, then the Assistant Director of Nurses, then the Charge Nurse, then Maintenance. E1 stated that the Administrator was not on site and had to be notified by phone. E1 verified that before the fire department arrived, residents were still in the building on the 500 wing. E1 stated that he has never received training about how to train other staff for fire safety; and was given a training manual to use. E1 stated what he teaches in fire safety is how to use the fire extinguisher, what all staff members responsibilities are in case of fire, and evacuation procedures. On 06/14/2016 at 12:05 pm E10 (Maintenance Assistant) stated that on 05/31/2016 E10 heard a staff person say there was a fire. E10 stated he could see smoke coming from behind the fire door on the 500 hall. E10 entered the 500 hall, saw fire extinguisher lying on the floor, picked it up and started spraying it at the fire. E10 stated he used up two or three extinguishers. E10 then noticed (R1) lying in her bed. E10 picked her up, laid her on the floor in the hallway and called for help. E10 saw another resident who he believes is R9 laying on her bed. E10 took her tube feeding machine off the pole, picked her up and laid her on the floor in the hallway and yelled for help. E10 stated at that point somebody yelled get out of the building, so he exited the building from the fire exit on the 500 hall. On 06/14/2016 at 12:30PM E11(Licensed Practical Nurse) stated that on 05/31/2016 at 4:15PM an unidentified C.N.A. (Certified Nursing Assistant) came running up the hall saying there's a real fire. E11 had been instructed by E1 (Maintenance Supervisor) to hold down the fire alarm on the fire panel due to a false alarm earlier. Upon hearing that there was an actual fire, E11 stated she let go of the fire alarm switch and ran down the 500 hall where E11 saw smoke. E11 stated that she observed E5 C.N.A. standing by room [ROOM NUMBER] holding a fire extinguisher. E5 opened the door to room [ROOM NUMBER] and sprayed the fire with the extinguisher. E11 stated someone came by with a fire extinguisher. E11 grabbed the extinguisher from them and sprayed the fire. E11 then states she went in to room [ROOM NUMBER] to check it. E11 made no comment as to whether room [ROOM NUMBER] was occupied by residents. E11 stated that on 05/31/2016 she was the Charge Nurse (for 500 hall), but she is not sure what the Charge Nurses' duties are in a fire. E11 stated that the nurse assigned to the hall is charge nurse for that hall. As to who is in charge during the fire, E11 stated, I guess it would be my job to give directions as charge nurse, but I've never been given a job description of exactly what being charge nurse entails, especially with what a fire entails. E11 verified that she is not aware of anyone calling for an evacuation. Fire Safety and Disaster Preparedness Manual (Revised 3/31/2013) documents, The chain of command at Cahokia Nursing and Rehabilitation is: 1. Administrator 2. Director of Nursing 3. Assistant Director of Nursing 4. Designated Charge Nurse in the facility. On 06/21/2016 at 2:10pm, E7 (Certified Nursing Assistant) stated that on 05/31/2016 she was on the 500 hall at the time she became aware of the fire. E7 stated that she, E5 (Certified Nursing Assistant), E10 (Maintenance) and E8 (Licensed Practical Nurse) were working together during the fire but nobody was clearly in charge. E7 stated, It was overwhelming and everybody was running. On 06/21/2016 at 10:10 am E26 (Social Services Assistant) stated that to her knowledge, no one placed identification bands on residents at the time they were evacuated. E26 stated the identification bands were located in the Social Services Office at the time of the fire. E30 (Licensed Practical Nurse) stated on 6/9/2016 at 3:08 pm that she does not know who was in charge on May 31, 2016 at time of the fire. E30 first stated it was the charge nurse, E11 (Licensed Practical Nurse), but then stated that E1, Maintenance Supervisor, was making the decisions and directing E11. E30 evacuated residents on hall 100 without anyone directing her. E30 stated that she saw E13, Quality Assurance/Education/Licensed Practical Nurse, come through the door of 100 hall, saw smoke follow her in and, just made the decision to evacuate the residents. Patient List Cahokia Nursing and Rehab with Destination and Hospital records dated 5/31/2016 provided by Z11 (Emergency System Services System Coordinator) document that fourteen residents (R1-R6, R11-R15, R19, R23, R24) from four wings were ultimately transferred to four area hospitals due to fire related conditions. Face sheet dated 9/01/2015 documents that R2's (500 Hall) date of birth is 05/27/27 with [DIAGNOSES REDACTED]. The Hospital physician's orders [REDACTED]. Hospital Physical Exam dated 5/31/2016 noted that R2 was coughing up thick black phlegm and subsequently had some emesis in the emergency room as well as decreased breath sounds. The Hospital Assessment Plan Sheet dated 5/31/2016 indicates that R2 had fever, maybe due to exposure to heat exposure and possible [MEDICAL CONDITION], will treat .and monitor closely. The Hospital Transfer Summary noted dated 6/01/2016 states R2 is an [AGE] year old woman admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. There is notation she is a hospice patient, but we do not have confirmation of which agency is involved. R1's (500 Hall) Hospital Inpatient Record face Sheet dated 5/31/2016 lists R1's birthdate as 2/02/1929. Prehospital Care Report Summary for R1 notes Due to patient upper extremities being contracted ambulance crew was unable to obtain a blood pressure at this time. Blood glucose analysis assessed at this time with a result of 59. Patient administered oral glucose at this time. Patient unable to answer any EMS (Emergency Management Services) questions at this time. Hospital History and Physical Note dated 5/31/2016 documents This is an [AGE] year old .admitted from the emergency room with smoke inhalation. She is a resident of Cahokia Nursing and rehabilitation Center. There was a fire at the facility last evening and she was exposed to smoke. She was experiencing a cough which prompted her visit to the emergency room . Problems: Smoke inhalation injury. The Hospital Patient Discharge Instruction sheet dated 6/01/2016 states, Discharge Diagnosis: [REDACTED]. R 12's (100 Hall) Hospital Face Sheet dated 5/31/2016 notes date of birth as 10/21/1933. Hospital emergency room Visit report dated 5/31/2016 indicates that R12 presents via EMS (Emergency Management Service) from nursing home. Patient's nursing home had a fire this evening and when patient was in a bus for transport, he reportedly had a syncopal episode while sitting in his seat .Patient with history of [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION] . An Emergency Department Progress Note dated 5/31/2016 at 9:59 pm stated, It has been reported that the bus was quite warm and nurse noted that a bottle of water the patient had with him was warm when he arrived. Other residents from the same situation have been brought in for similar complaint .spoke with (Z19) regarding patient and findings and he agreed likely situational [MEDICAL CONDITION] due to elevated temperature and hectic environment. Intervention/Assessment Treatment documentation dated 5/31/2016 noted R12's temperature was 99.1 and blood pressure was 199/84. Facility census records for 5/31/2016 indicate R12 resided on 100 hall. Face sheet for R14 (500 Hall) documents that R14's date of birth is 9/19/1950. Emergency Medical Service report for 5/31/2016 notes female pt (patient) with possible low blood sugar, dizziness, and weakness .patient sitting upright and slumped to the right in her wheelchair. Nursing home staff tells EMS (Emergency Medical Service) that pt has seemed to be close to passing out, sweating, and is weak. Pt has been outside in triage area for approximately 90 minutes following evacuation from building. The Hospital emergency room Visit Report dated 5/31/2016 notes [AGE] year old female presents to Emergency Department .status [REDACTED]. Patient was in an unaffected wing. She was evacuated and sat outside for nearly 1.5 hours in the heat when she started feeling dizzy and lightheaded. She feels better now .has a history of stroke and her right side is affected. The Hospital Emergency Department Progress note dated 5/31/2016 documents that R14 presents for lightheadedness after being outside .in mid-80 weather status [REDACTED]. A Hospital Face Sheet dated 5/31/2016 notes R13 (600 Hall) date of birth as 6/8/1969. Hospital emergency room Visit Report dated 5/31/2016 states [AGE] year old female with history of dementia presents to Emergency Department by EMS (Emergency Medical System) status [REDACTED].shortness of breath resolved once in ambulance. Past medical history-[MEDICAL CONDITION]/Dementia, [MEDICAL CONDITIONS], Depression. Prehospital Care Report Summary for R6 (300 Hall) documents Upon arrival pt (patient) was laying on a bed and on non-rebreather at 15 liters, and it was placed over his trach. Pt (patient) was then transferred to the stretcher and was taken to the truck and loaded in the back with other pt. The other pt was a nurse from the facility that knew the pt. Once in the back, vitals were taken .There was no info on the pt except for knowing his name per the other pt. R6's Physician's Certificate of Medical Necessity from a regional hospital dated 5/31/2016 lists [DIAGNOSES REDACTED]. R11's (500 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R11 is a [AGE] year old male with history of [MEDICAL CONDITION] due to car accident and is unable to answer any question at this time. Hospital Patient Health Summary dated 5/31/2016 lists Active Problems: Ileus, [MEDICAL CONDITION] Disorder, Smoke Inhalation . A Hospital Face Sheet dated 5/31/2016 lists R15 (600 Hall) date of birth as 9/08/44. Hospital emergency room Visit Report dated 5/31/2016 noted,Patient presents .after nursing home where she was a resident had a fire. Patient states she was not in the area of the fire and did not inhale any smoke, but when they were preparing to transport her to another facility, she had increased pulse and shaking as well as feeling anxious. Patient states this has somewhat improved since coming here and son feels it was likely a panic attack.R15 stated on 6/2/2016 when visited in the destination facility that ,she went to the hospital due to a panic attack. R15's Prehospital Care Report Summary dated 5/31/2016 notes this Emergency Services transport was dispatched to an emergency call for Cahokia Nursing and Rehab on fire with multiple pt (patients) outside in parking lot needing transported. This patient is complaining of severe anxiety problems at this time .The patient told EMS (Emergency Management Service) ' I just can't calm down. I was so scared that I wasn't going to make it out of the building in time and I would be burned alive.' The triage team advised EMS that this pt (patient) was not in the area of the fire and was evacuated well before she was in any harm. A staff member of the SNF (Skilled Nursing Facility) advised EMS that this pt (patient) has a severe anxiety problem and is normally very nervous as it is and this situation has made her very nervous. Upon arrival patient found sitting outside in the triage area .The pt (patient) over all has very high levels of anxiety and is having severe difficulty in calming down and relaxing . This same report documents that R15 was transported from the fire scene at 5:47 pm. Prehospital Care Report Summary for R4 (500 Hall) dated 5/31/2016 documents that R4 was having chest pain .Pt (patient) believes that he has swallowed some smoke and that is giving him chest paint. Pt states that the pain is on the right side just below the nipple line and is a constant pain which he rates it at 10/10 pain scale .pt then stated that he was becoming short of breath so 4L of 02 via a NC was established and pt states that he feels better . R3's (600 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R3 is [AGE] years old. Under Comments in this document is listed Dementia with Alzheimer's. The report states that R3 is conscious, alert, to person only, sitting in a chair and staff states that she isn't acting right. Pt (patient) has a history of dementia and Alzheimer's and is unable to tell us if anything is wrong or if she is in pain. Staff states that before EMS (Emergency Management System) arrived she wasn't acting right but now she is in her normal state. Staff states that the pt (patient) is on 4L (liters) of O2 (oxygen) at all times. Report titled Cahokia Nursing and Rehab Patient List with Destination with date of 5/31/2016 indicates R5, R19, R23, and R24 were also transported to area hospitals on the date of the fire, from the halls of 300, 500, 500, 500, respectively. On 6/21/2016 at 9:15 AM, Z17, Administrator of Caseyville Nursing and Rehab Center, stated of the 23 residents received from Cahokia Nursing and Rehab on 5/31/2016, only 1 admitted to the Caseyville Nursing and Rehab Center came with a face sheet, with the other face sheets faxed by 11:30 pm. Z17 stated all residents were given supper as they were all hungry. Z18, POC Administrator of Caseyville Nursing and Rehab Center on 6/21/2016 at 11:55 am stated that the residents arrived around 8 pm on 5/31/2016. The Disaster Preparedness Manual (Revised 3/31/13) on the Introduction page notes All personnel, on all shifts, will be trained to perform assigned tasks in case of a facility emergency. The training will include: 1. Disaster response procedures 2. Location and proper use of fire extinguishers 3. Established emergency response codes 4. Locale and proper use of manual pull boxes 5. Floor plans and means of egress/exit 6. Assembly areas 7. Location and proper use of fire and smoke barrier doors 8. Evacuation procedures for residents, visitors, and staff 9. Chemical spill procedures 10. Carrying methods for evacuation On 06/14/2016 at 11:12 am, E1 (Maintenance Supervisor) stated that all staff responded to the fire in the manner in which they had been trained. According to E1, he is responsible for training staff on fire safety. E1 stated that he has never received training about how to train other staff for fire safety; E1 said he was given a training manual to use. E1 stated what he teaches in fire safety is how to use the fire extinguisher, what all staff members responsibilities are in case of fire, and evacuation procedures. E1 stated he does fire drills once a month so that every shift gets one at least every 90 days. E1 stated he trains new staff on fire safety during their orientation. E1 stated the facility ' s most recent fire drill was 05/20/2016 on day shift. He stated the purpose of fire drills is so employees know what they have to do and where they're supposed to be. E1 stated residents are not evacuated during drills. E1 stated if fire safety training is done when staff is off, their training is rescheduled. On 6/9/2016 at 3:08 PM, E30 (Licensed Practical Nurse) stated that she is aware that the facility has an emergency plan and that it is kept at the nurses station but has not seen it. She states that she has not been through an actual fire evacuation drill; it was only a verbalized training. E30 stated she evacuated residents on hall 100 without anyone directing her on 5/31/2016. She stated that she saw E13, Quality Assurance/Education/Licensed Practical Nurse, come through the door of 100 hall and saw smoke follow her in and just made the decision to evacuate the residents. E30 was asked how residents were accounted for. She stated that she grabbed the census sheet/room roster for the building and the elopement risk book which is located at the secretary's desk but she did not know who was responsible for that as she stated she was not aware of anyone specific or assigned to that task. On 6/9/2016 at 3:45 PM, E24 (Registered Nurse) stated she was not aware of any emergency plan that the facility had regarding this type of event (fire), but she has seen the Cahokia Nursing & Rehabilitation Center Policies, Standards, Protocols, and Procedures Manual dated 01/01/06. E24 stated that she has not had any training where residents are evacuated. When asked who instructed her to evacuate residents on 5/31/2016, E24 stated she saw smoke and started to evacuate residents on 100 hall before moving on to 600 hall. E24 did not know who was in charge or who was to secure the census data sheet in an event of an evacuation. E24 does not know where residents are to be taken when evacuated; she just got them out and away from the building. All training records related to fire, fire drills, and disaster preparedness were requested from the facility. Based on all available information provided at the time of the survey there is no system in place to effectively track training efforts. Training records are incomplete and in many cases contain illegible signatures making verification of training difficult. E1 provided documents titled REPORT OF FIRE DRILL on 6/14/16, indicating that these were all the documents available. Monthly Report of Fire Drill documents were provided for June 2015 through November 2015 and January through March 2016. Fire Drill Sign In Sheets were only available for Report of Fire Drill documents dated 6/14/2015 and 7/25/2015. Ten signatures were present on the document dated 6/14/2015 and 17 signatures were present on the document dated 7/25/2015. The Monthly Report of Fire Drill reports have a series of nine questions with the words YES and NO after them. These questions include: 1. Was signal received by ADT? 2. What time was signal received? 3. Was all staff aware of their responsibilities? 4. Were any problems noted? 5. Did the fire alarm sound? 6. Were the strobe lights operational? 7. Were the hall fire door closers operational? 9. Were the delayed egress locks released? At the bottom of this report, it states: List any problems, corrective actions, and/or teaching required as a result of this drill: Monthly Report of Fire Drill reports for 8/18/2015, 9/30/2015, 10/13/2015, 11/10/2015, 1/19/2016, 2/21/2016, and 3/18/2016 did not contain specific locations for the fireor fire drill. Reports for September 2015, October 2015, November 2015, January 2016, February 2016, and March 2016 all have YES circled for question 4 Were any problems noted? However, the area where facility staff is to identify the problems with corrective action is blank in all cases. Forms for June and July 2015 are signed and dated. Form for August 2015 is not signed. Forms dated September through November 2015 and January through March 2016 are signed and dated by E1 (Maintenance Supervisor). There was no document provided for April 2016. Document provided for May 2016 notes that Monthly Fire Drill was done on first shift 5/20/2016 and contains 26 signatures. Training record provided for December is dated 12/16/2015 and is titled Disaster Drill Report. This document indicates that the drill was conducted on 7-3 shift. Fourteen signatures are included on this single page document. There is no information on this document to indicate what type of disaster the drill addressed, nor does it give any location. There are also no information/answers given for any of the following questions printed on the Disaster Drill Report. During Drill 1. Did staff use proper judgment? 2. Was announcement made over the intercom? 3. Were residents placed in an area of safety? 4. Were all corridor doors closed? 5. Did staff respond appropriately? After the Drill 1. Were all staff aware of their responsibilities? 2. Did personnel in different areas of the facility respond promptly? 3. did staff standby until All Clear was given? The Immediate Jeopardy was identified on July 7, 2016. E3 Administrator was notified of the Immediate Jeopardy on 07/07/16 at 1pm. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility reviewed and revised its disaster/emergency manual on 6/1/16 including but not limited to sections on reporting chain of command, evacuation procedures and fire response procedures. 2. On 6/6/16, 6/7/16, 6/8/16,6/10/16, and 6/17/16 E3 Administrator and/or E13 QA Nurse conducted inservices for all staff on revision to disaster/emergency manual related to chain of command during a disaster, R.A.C.E. and P.A.S.S. Any staff not present on the dates the inservice training was provided were required to attend the training before they worked another shift, and random questions were asked of staff related to proper procedures during the inservice. 3. On 6/30/16 the facility updated the Fire Watch Policy and Fire Procedure Policy based on the review of their independent Life Safety Consultant. 4. On 7/1/16, E3, Administrator, E4 Regional Nurse Consultant, or E23, DON, conducted repeat training for all staff on the revised Fire Watch and fire Procedure. The inservice included facility wide response to the fire, individual duties during a fire alarm, the fire extinguisher and P.A.S.S. procedure, general fire instructions, and 'all clear'. A copy of the revision was given to staff during the inservice and posted in the disaster/emergency manual at the nurses station and receptionist desk in a red binder. A posttest has been completed based on revision made to test staffs knowledge on the inservice training that was done. Staff that did not attend were required to attend the training before they worked another shift. 5. E3 and E13 were educated by E4 on 7/8/16 on the fire procedure and a verbal test of their knowledge was completed at the time. E3 and E13 will be re inserviced and a verbal or written test of their knowledge completed by E4 on 7/12/16 on the fire procedure. The facility put a dry erase board in place at the nurses station. The dry erase board is to be used at the time of a fire to identify who is in charge. E3 and E13 inserviced staff on this process in person or by phone and it was completed by 7/8/16. Any staff not present on the dates of the inservice training was provided were required to attend the training before they work another shift.

Based on observation, record review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This administrative failure was demonstrated during the facility's response to an actual fire in the building. Key management personnel did not demonstrate knowledge of the facility's disaster plan or leadership in directing staff during the fire response. Fire personnel were not notified of residents and their location in the burning building. Facility staff neglected to evacuate the residents closest to the fire first and those away from the origin of the fire later. The entire building was evacuated without clear instructions from any person in charge. The response was describe as chaotic and resulted in a prolonged delay before transfer to other facilities. Failures by management staff to follow their disaster plan for retrieving medical records and medication prolonged the resident's ultimate transfer to other facilities. Facility management staff neglected to ensure that all staff was adequately trained to respond to an actual fire. These failures resulted in an immediate jeopardy with fourteen residents (R1-R6, R11-R15, R19, R23, R24) requiring hospital visits for smoke inhalation and other fire related conditions including anxiety/panic attacks. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 31, 2016 when facility management staff failed to demonstrate knowledge of the Disaster Plan, failed to effectively direct staff in an orderly evacuation of the residents, failed to provide leadership in managing the response, failed to notify the Fire Department of residents still in the burning building, failed to effectively execute the disaster plan during an actual fire in the nursing facility and failed to ensure that staff had previously been adequately trained to implement the disaster plan. While the immediacy was removed on July 12th, 2016,the facility remains out of compliance at a Severity Level 2 as additional time is required to evaluate the knowledge and ability of management staff to direct all staff related to disaster preparedness training, implementation of the revised disaster plan, ongoing training efforts, including tracking to ensure that all staff are fully trained, and that management personnel responsible for training are qualified and capable to do so. Findings include: On 05/31/2016 at 5:10PM Z13 (Illinois Department of Health Emergency Services Coordinator) states he notified Z14 (Illinois Department of Public Health Field Supervisor) that there was a fire with total resident evacuation at facility. Fire Department form NFIRS-1 dated 05/31/2016 documents that the local fire department responded for a reported fire in a room on the 500 hall (E) at the facility. This same report documents that upon arrival of fire units and personnel they found heavy smoke coming from the right rear of the building located near (F) and (E) hallways with police officers and employees from the business breaking windows to remove residents from the 500 hall. This same document reports that fire personnel .found the fire quickly and contained to room [ROOM NUMBER] while other fire personnel were in rescue operations. It was at this time that several residents were still inside (500 Hall) where a female victim (resident) was found in the hallway. Primary searches were performed (by fire personnel) from room [ROOM NUMBER] to 516 where several victims were found. One male (resident) was removed from room [ROOM NUMBER] through the window. In room [ROOM NUMBER] a male resident was removed through a window. A male resident from room [ROOM NUMBER] was removed out of the room and down the hallway in a wheelchair. On 06/15/2016 at 1:30PM Z10 (Emergency Management Services/EMS Operations Manager) stated that when he arrived on the scene no facility staff were in charge for the first 15 minutes. Z10 stated that after that, E2 (Facility Regional Operations Manager) assumed control. Z10 stated that when they arrived, facility staff could not tell them how many residents were still in the building. Z10 stated, There was no coordination whatsoever. Z10 stated it took 45 minutes to one hour after their arrival for EMS to be given any kind of information about resident's medical needs only to be asked by E2 (Facility Regional Operations Manager) for their (EMS) plan to find placement for residents. E2 (Regional Operations Director) stated to Z14 (IDPH Field Supervisor) at 5:59 pm that the census of the facility was 104. This number conflicts with later census numbers of 106 according to the Census Sheet dated 5/31/2016 and the Cahokia Nursing and Rehab Patient List with Destination document dated 5/31/2016 Z16 (Illinois Department of Public Health Regional Supervisor) was on scene at the fire on 5/31/2016. Z16 reported on 5/31/2016 at 9:34 pm in response to Department question of who is in charge? Is Adminstrator there? that E2 (Facility Regional Operations Manager) is said to be in charge, he's been in and out. No straight answer who the Administrator is, been given two names but not confirmed. Still chaotic. E3 and E4 were identified as the two names given at time of fire. Department of Public Health records as of 6/17/2016 document that E41 is the Adminstrator of Cahokia Nursing and Rehab Center and has been Administrator of record since July 1, 2015. E41 was not one of the names given to IDPH staff the night of the fire and her name does not appear on any listing of personnel provided by the facility. On 6/6/2016 at 2:05 pm E3 (Administrator) stated that her title was Administrator and that she was in that position on 5/31/2016. During interview on 6/15/2016 at 11:35 am E3 indicated that she started at the facility as Adminstrator on 4/25/2016. E3 indicates that she has a Missouri Administrator's license. Illinois Department of Financial and Professional Regulations records note as of 6/17/2016 that E3 has no records found for active nursing home administrator license for Illinois. E3 stated during this same interview that on the night of the fire, she was not on the premises when the fire broke out. E3 related that she had left to take an employee to be fingerprinted around 2:45 pm. E3 stated that she was notified by phone around 4:20 pm, however call went to voice mail. E3 returned to the facility and was briefed by (E2). E3 stated that she checked on residents to see who needed treatment and water. During interview on 6/15/2016 at 11:15 am, E3 states that E4 is acting Administrator of the facility. This information conflicts with information previously provided by E3 on 6/6/2016 when E3 stated she was Administrator of the building. E4 stated on 6/16/2016 at 1:25 pm that E3 has been Administrator since 5/23/2016. According to E4, E4 was Administrator less than 30 days at this facility. Cahokia Nursing and Rehab Center Department Head and Key Personnel phone list dated 5/2/2016 documents E3 as Administrator. E2 (Regional Operations Director) provided a 54 page document entitled Fire Safety and Disaster Preparedness Manual with a revision date of 03/31/13. This document lists under EMERGENCY PROCEDURE: BASIC LINES OF AUTHORITY; The main objective and first consideration during any disaster or emergency is the safety and well-being of the residents. Employees should always remain calm and reassure the residents so that transfer or evacuation procedures can be carried out effectively and with the least amount of problems or accidental injury. The chain of command at Cahokia Nursing and Rehabilitation is: 1. Administrator 2. Director of Nursing 3. Assistant Director of Nursing 4. Designated Charge Nurse in the facility If the Administrator, Director of Nursing or Assistant Director of Nursing is not in the building at the time of a fire or disaster, the designated Charge Nurse will: 1. In case of a fire, ensure that the fire department has been notified. 2. Notify the Administrator of the situation 3. Assign aides to assist as needed. 4. Assign other staff (i.e. dietary, housekeeping laundry, etc.) as needed. 5. Notify the Director of Nursing and Maintenance Supervisor. 6. Keep calm and assure resident that the situation is under control. 7. Keep telephone lines as clear as possible. On the same page is a listing of staff including Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Dietary Manager, Maintenance and Medical Director with spaces for Phone number and Cell Phone. There are no phone numbers listed for any staff. On 6/16/2016 at 5:30 PM, Z1, Chief, Cahokia Volunteer Fire Department, stated that he and his men rescued a total of 4 residents from the fire hall, hall 500. One resident was rescued by accident, that is, when Z1 and some of his men were standing at the entrance of door to room [ROOM NUMBER] (where fire started), after laying water on the door, they stepped back and bumped into a person on the hall corridor floor. One of his men checked to see if the person was alive, the person moaned, they evacuated her. No nursing staff informed him of any potential residents left in the building. Z1 (Chief Cahokia Volunteer Fire Department) stated on 6/16/2016 at 6 pm that when he arrived on the scene and was about to enter the building, Z1 was met by two nursing staff with masks on. Z1 asked the two nursing staff if there were any residents in the building. The nursing staff did not provide any answers; instead ran back into the building and Z1 lost them in the smoke. Z1 stated when he entered the 500 hall from the core area (nursing station); he noticed the entrance to 500 hall was standing open which allowed the smoke to get into the core area. Z1 stated that he would have expected the door to have been closed. He further stated that nursing staff was out of control. Staff was all over the scene. They did not following directions and kept moving patients without permission causing problems for patient movements. When Z1 was asked if he or his department received any emergency planning/coordination prior to the fire and or after the fire from the facility, he answered no. On 6/16/2016 at 5:45 PM, Z11, EMS System Coordinator, stated he never received an emergency planning/coordination planning from the facility prior to or after the fire incident. On 6/16/2016 at 5:40 PM, Z12, Captain, Cahokia Volunteer Fire Department, stated that no facility staff informed him of anyone in the building. When Z12 entered 500 hall and got to the room identified as the origin of fire, he heard a moan coming from the corridor floor just outside this room. Z12 instructed one of his men to check this person. Z12 then helped evacuate this resident (R1). Z13's (Emergency Management System Coordinator) written account of his on-scene experience on 5/31/2016 at the nursing home fire documents that he arrived on the scene shortly after 6 pm. Z13 noted that the outside temperature was 83 degrees according to his weather app. Z13 also documented that there were multiple Police Department, Fire Department, and Emergency Medical Service agencies present with many transport vehicles available. According to Z13's report, upon further inquiry regarding transport plans it seemed that there was quite a bit of confusion regarding the actual number of NH (nursing home) residents present, how many still required transport and the destination of those waiting. Z13 report indicates that I heard resident numbers from multiple people that ranged from 103 to 106 and that possibly some residents had been counted twice. IDPH LTC (Long Term Care) (Z14, 15, 16) along with a Senior Citizen Ombudsman was attempting to lock down NH bed availability in the region. There was no pre-planned sheltering facility identified by management to get these residents out of the elements which included the threat of rain and at times visible lightning. Fire Safety and Disaster Preparedness Manual on pages 19-25 list area nursing homes with contact information including phone numbers as well as level of care provided. Document indicates that it was last revised on 3/31/2013. At the time of the fire, this information was not utilized by management staff. Management staff relied on IDPH staff and EMS staff to contact facilities. E1 (Maintenance Supervisor) stated on 6/16/2016 at 11 am that E18 was the acting Director of Nurses at the time of the fire, but he was not sure what she was doing during the fire. E1 stated in the event of a fire, the Administrator runs everything. If the Administrator isn't present, the Director of Nurses is in charge, then the Assistant Director of Nurses, then the Charge Nurse, then Maintenance. E1 stated he thinks the receptionist called the fire department. E1 stated he notified the Administrator of the fire by phone because she was not on site. E1 stated he is not sure if the sprinklers came on. E1 stated that before the fire department arrived, residents were still in the building on the 500 hall. According to E1 smoke was so thick nobody could tell where the fire was. E1 stated that at this point, he made the decision for staff to begin breaking windows to get residents out. E1 stated that all staff was responding to the fire in the manner in which they had been trained. E1 stated that he has been employed at the facility for two years, but has never received training about how to train other staff for fire safety; he said he was given a training manual to use. E1 stated what he teaches in fire safety is how to use the fire extinguisher, what all staff members responsibilities are in case of fire, and evacuation procedures. E23 (Director of Nurses) stated on 6/2/2016 at 1:40 pm that she started work with the facility on 6/2/2016. E23 noted on 6/22/2016 at 3:00 pm that E18 was the interim Director of Nurses from 3/22/2016 until 6/2/2016. E18 confirmed on 6/17/2016 that she the Acting Director of Nurses at the time of the fire. E18 stated she was not on site at the time of the fire, but returned to the scene around 6 pm. Information provided by the facility documents that E44 was Assistant Director of Nurses at time of the fire on 5/31/2016. E23 (Director of Nurses) confirmed on 6/15/2016 at 1:45 pm that E44 was the Assistant Director of Nurses, but her last day was considered 6/2/2016 as a no show. IDPH personnel did not receive any call backs when attempts were made to contact E44 by phone. On 6/21/2016 at 1:50 pm E3 (Administrator) stated that the Quality Assurance committee has not met since she has been Administrator and had not met in the facility since the fire. E2 (Regional Operations Director) on 6/7/2016 at 11 am telephoned the Department Regional Office and stated that the facility was ready to move residents back today. This phone call preceded any notification to the Department that the fire alarm/sprinkler system was fully functional. As of 7/8/2016 official notice had still not been given. Facility census records for 5/31/2016 indicate that twenty seven residents resided on the 500 hall at the time of the fire. These residents include R1, R2, R4, R7, R8, R10, R11, R14, and R16-R34. Patient List Cahokia Nursing and Rehab with Destination and Hospital records dated 5/31/2016 provided by Z11 (Emergency System Services System Coordinator) document that fourteen residents (R1-R6, R11-R15, R19, R23, R24) from four wings were ultimately transferred to four area hospitals due to fire related conditions. Centers for Medicare and Medicaid form 672 provided by facility notes that at the time of the fire, eleven residents (R1, R2, and R16 who resided on the 500 Hall, as well as R5, R6, and R35-R40) had tube feedings; ten residents received hospice services (R1, R2, R24, R25 who resided on the 500 Hall, and R3, R48, R53-56); four residents received [MEDICAL TREATMENT] (R14 and R32 who resided on the 500 Hall in addition to R41 and R42); and eighteen residents who received respiratory services (R2, R16, and R33 who resided on the 500 Hall, as well as R3, R5, R6, R9, R15, R43-R52.) Face sheet dated 9/01/2015 documents that R2's (500 Hall) date of birth is 05/27/27 with [DIAGNOSES REDACTED]. The Hospital physician's orders [REDACTED]. Hospital Physical Exam dated 5/31/2016 noted that R2 was coughing up thick black phlegm and subsequently had some emesis in the emergency room as well as decreased breath sounds. The Hospital Assessment Plan Sheet dated 5/31/2016 indicates that R2 had fever, maybe due to exposure to heat exposure and possible [MEDICAL CONDITION], will treat .and monitor closely. The Hospital Transfer Summary note dated 6/01/2016 states R2 is an [AGE] year old woman admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. There is notation she is a hospice patient, but we do not have confirmation of which agency is involved. R1's (500 Hall) Hospital Inpatient Record face Sheet dated 5/31/2016 lists R1's birthdate as 2/02/1929. Prehospital Care Report Summary for R1 notes Due to patient upper extremities being contracted ambulance crew was unable to obtain a blood pressure at this time. Blood glucose analysis assessed at this time with a result of 59. Patient administered oral glucose at this time. Patient unable to answer any EMS (Emergency Management Services) questions at this time. Hospital History and Physical Note dated 5/31/2016 documents This is an [AGE] year old .admitted from the emergency room with smoke inhalation. She is a resident of Cahokia Nursing and Rehabilitation Center. There was a fire at the facility last evening and she was exposed to smoke. She was experiencing a cough which prompted her visit to the emergency room . Problems: Smoke inhalation injury. The Hospital Patient Discharge Instruction sheet dated 6/01/2016 states Discharge Diagnosis: [REDACTED]. R 12's (100 Hall) Hospital Face Sheet dated 5/31/2016 notes date of birth as 10/21/1933. Hospital emergency room Visit report dated 5/31/2016 indicates that R12 presents via EMS (Emergency Management Service) from nursing home. Patient's nursing home had a fire this evening and when patient was in a bus for transport, he reportedly had a syncopal episode while sitting in his seat .Patient with history of [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION] . An Emergency Department Progress Note dated 5/31/2016 at 9:59 pm stated, It has been reported that the bus was quite warm and nurse noted that a bottle of water the patient had with him was warm when he arrived. Other residents from the same situation have been brought in for similar complaint .spoke with (Z19) regarding patient and findings and he agreed likely situational [MEDICAL CONDITION] due to elevated temperature and hectic environment. Intervention/Assessment Treatment documentation dated 5/31/2016 noted R12's temperature was 99.1 and blood pressure was 199/84. Facility census records for 5/31/2016 indicate R12 resided on 100 hall. Face sheet for R14 (500 Hall) documents that R14's date of birth is 9/19/1950. Emergency Medical Service report for 5/31/2016 notes female pt (patient) with possible low blood sugar, dizziness, and weakness .patient sitting upright and slumped to the right in her wheelchair. Nursing home staff tells EMS (Emergency Medical Service) that pt has seemed to be close to passing out, sweating, and is weak. Pt has been outside in triage area for approximately 90 minutes following evacuation from building. The Hospital emergency room Visit Report dated 5/31/2016 notes [AGE] year old female presents to Emergency Department .status [REDACTED]. Patient was in an unaffected wing. She was evacuated and sat outside for nearly 1.5 hours in the heat when she started feeling dizzy and lightheaded. She feels better now .has a history of stroke and her right side is affected. The Hospital Emergency Department Progress note dated 5/31/2016 documents that R14 presents for lightheadedness after being outside .in mid 80 weather status [REDACTED]. A Hospital Face Sheet dated 5/31/2016 notes R13 (600 Hall) date of birth as 6/8/1969. Hospital emergency room Visit Report dated 5/31/2016 states [AGE] year old female with history of dementia presents to Emergency Department by EMS (Emergency Medical System) status [REDACTED].shortness of breath resolved once in ambulance. Past medical history-[MEDICAL CONDITION]/Dementia, [MEDICAL CONDITIONS], Depression. Prehospital Care Report Summary for R6 (300 Hall) documents Upon arrival pt (patient) was laying on a bed and on non-rebreather at 15 liters, and it was placed over his trach. Pt (patient) was then transferred to the stretcher and was taken to the truck and loaded in the back with other pt. The other pt was a nurse from the facility that knew the pt. Once in the back, vitals were taken .There was no info on the pt except for knowing his name per the other pt. R6's Physician's Certificate of Medical Necessity from a regional hospital dated 5/31/2016 lists [DIAGNOSES REDACTED]. R11's (500 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R11 is a [AGE] year old male with history of [MEDICAL CONDITION] due to car accident and is unable to answer any question at this time. Hospital Patient Health Summary dated 5/31/2016 lists Active Problems: Ileus, [MEDICAL CONDITION] Disorder, Smoke Inhalation . A Hospital Face Sheet dated 5/31/2016 lists R15's (600 Hall) date of birth as 9/08/44. Hospital emergency room Visit Report dated 5/31/2016 noted Patient presents .after nursing home where she was a resident had a fire. Patient states she was not in the area of the fire and did not inhale any smoke, but when they were preparing to transport her to another facility, she had increased pulse and shaking as well as feeling anxious. Patient states this has somewhat improved since coming here and son feels it was likely a panic attack. R15 stated on 6/2/2016 when visited in the destination facility that she went to the hospital due to a panic attack. R15's Prehospital Care Report Summary dated 5/31/2016 notes this Emergency Services transport was dispatched to an emergency call for Cahokia Nursing and Rehab on fire with multiple pt (patients) outside in parking lot needing transported. This patient is complaining of severe anxiety problems at this time .The patient told EMS (Emergency Management Service) I just can't calm down. I was so scared that I wasn't going to make it out of the building in time and I would be burned alive. The triage team advised EMS that this pt (patient) was not in the area of the fire and was evacuated well before she was in any harm. A staff member of the SNF (Skilled Nursing Facility) advised EMS that this pt (patient) has a severe anxiety problem and is normally very nervous as it is and this situation has made her very nervous. Upon arrival patient found sitting outside in the triage area .The pt (patient) over all has very high levels of anxiety and is having severe difficulty in calming down and relaxing . This same report documents that R15 was transported from the fire scene at 5:47 pm. Prehospital Care Report Summary for R4 (500 Hall) dated 5/31/2016 documents that R4 was having chest pain .Pt (patient) believes that he has swallowed some smoke and that is giving him chest pain. Pt states that the pain is on the right side just below the nipple line and is a constant pain which he rates it at 10/10 pain scale .pt then stated that he was becoming short of breath so 4L of 02 via a NC (nasal cannula) was established and pt states that he feels better . R3's (600 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R3 is [AGE] years old. Under Comments in this document is listed Dementia with Alzheimer's. The report states that R3 is conscious, alert, to person only, sitting in a chair and staff states that she isn't acting right. Pt (patient) has a history of dementia and Alzheimer's and is unable to tell us if anything is wrong or if she is in pain. Staff states that before EMS (Emergency Management System) arrived she wasn't acting right but now she is in her normal state. Staff states that the pt (patient) is on 4L (liters) of O2 (oxygen) at all times. Report titled Cahokia Nursing and Rehab Patient List with Destination with date of 5/31/2016 indicates R5, R19, R23, and R24 were also transported to area hospitals on the date of the fire. The Immediate Jeopardy was identified on July 7, 2016. E3, Administrator, was notified of the Immediate Jeopardy on July 7, 2016 at 1pm. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility retained an independent Life Safety Consultant to review and make additional recommendations for revisions to disaster/emergency manual before it was finalized on 6/30/16. 2. The disaster/emergency manual (was)reviewed and revised on 6/1/16 including but not limited to sections on reporting chain of command, evacuation procedures, and fire response procedures. 3. On 6/6/16, 6/7/16, 6/8/16, 6/10/16, and 6/17/16, E3 Administrator and/or E13 QA(Quality Assurance) Nurse conducted inservices for all staff on revision to disaster/emergency manual related to chain of command during a disaster, disaster evacuation procedures, emergency response procedures including R.A.C.E. and P.A.S.S. Any staff not present on the dates the inservice was provided were required to attend the training before they worked another shift. 4. On 6/30/16, the facility updated the Fire Watch Policy and the Fire Procedure Policy based on the independent Life Safety Consultants review. 5. E3 and E13 were educated by E4 Regional Nurse on 7/8/16 on the fire procedure and a verbal test of their knowledge was completed at that time. E3 and E13 were re-inserviced and a verbal or written test of their knowledge was completed by E4 on 7/12/16 on the fire procedure. The facility put a dry erase board in place at the nurses station. The dry erase board is to be used at the time of a fire to identify who is in charge.E3 and E13 are inservicing all staff on this process in person or by phone and was completed by 7/8/16. Any staff not present on the dates the inservice training was provided were required to attend the training before they worked another shift. The inservice material included chain of command;the evacuation plan, ie removing reidents in the area of the fire first unless the fire does not permit; who can give the order to evacuate;not propping the barrier doors; and maintenance personel or the assigned person will report to the main door of the building to receive the fire department. 6. E3 applied for her Administrator's license on 4/25/16. E3 was notified on 5/6/16 she was approved to sit on 10/13/16 for the Illinois Administrator's(exam). Application for the temporary license is complete. E3 contacted the Illinois Department of Professional Regulation on 7/11/16 to obtain a status on her temporary license, they reported the check was cashed on 6/22/16 and to allow a week and a half for processing.

Based on observation, interview, and record review the facility failed to effectively execute their disaster plan during an actual fire in a resident's room. Staff failed to fully implement the disaster plan resulting in total facility evacuation and a response effort described as chaotic. Evacuation of the residents was done backwards; those residents who were not in the direct area of the fire were evacuated first, while those residents in the hall where the fire was located were evacuated later. The facility ' s failure to have a clear chain of command and the resultant poor communication contributed to delays in identifying the whereabouts of all residents and subsequent transfer of residents to other facilities. Staff failed to alert and direct fire fighters to residents still in the direct area of the fire when fire fighters responded to the alarm. Four residents were found by Fire Fighters. Fourteen residents (R1-R6, R11-R15, R19, R23, R24) were sent to the hospital with smoke inhalation or conditions associated with the fire and evacuation. Despite facility disaster plan having information related to location/contact information for local facilities who could potentially receive residents, facility staff failed to utilize this information and implement an orderly response for transfer. Staff failed to implement the portion of the disaster plan related to identification of residents, securing medical records and medications. These failures caused physical harm (smoke inhalation) and discomfort as well as psychosocial harm with residents fearing they would be burned alive. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when facility staff failed to effectively execute the disaster plan during an actual fire in the nursing facility. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as additional time is required to evaluate the ability of staff to fully implement and execute the revised disaster plan. Findings include: Z13 (Illinois Department of Health Emergency Services Coordinator) notified Z14 (Illinois Department Public Health Field Supervisor) on [DATE] at 5:10 pm that there was a fire with total resident evacuation at Cahokia Nursing and Rehab. Z14 and Z15 (Illinois Department Public Health Field Supervisor) arrived onsite at 5:50 pm. on [DATE]. Z14 and Z15 noted that at 5:55 pm on [DATE], ten ambulances, four fire trucks, and three school buses were present at the scene of the nursing home fire. E2 (Regional Operations Director) stated to Z14 at 5:59 pm that the census of the facility was 104. This number conflicts with later census numbers of 106 according to the Census Sheet dated [DATE] and the Cahokia Nursing and Rehab Patient List with Destination document dated [DATE]. Fire Department form NFIRS-1 dated [DATE] documents that the Cahokia Fire Department responded for a reported fire in a room on the 500 hall (E) at Cahokia Nursing and Rehab. Upon arrival of fire units and personnel they found heavy smoke coming from the right rear of the building located near (F) and (E) hallways with police officers and employees from the business breaking windows to remove residents from the 500 hall that were still inside. This same document reports that fire personnel .found the fire quickly and contained to room [ROOM NUMBER] while other fire personnel were in rescue operations. It was at this time that several residents were still inside . found a female victim in the 500 hallway .Primary searches were performed from room [ROOM NUMBER] to 516 and several victims were found. One male was removed from 503 through window .room [ROOM NUMBER] a male resident removed through window .room [ROOM NUMBER] a male resident removed out of room and down hallway in wheelchair . This document notes that the Fire Department received an alarm at 4:17 pm on [DATE], with arrival time noted as 4:21 pm. Z1 (Chief Cahokia Volunteer Fire Department) stated on [DATE] at 6 pm that when he arrived on the scene and was about to enter the building, Z1 was met by two nursing staff with masks on. Z1 asked the two nursing staff if there were any residents in the building. The nursing staff did not provide any answers; instead ran back into the building and Z1 lost them in the smoke. Z1 stated when he entered the 500 hall from the core area (nursing station); he noticed the entrance to 500 hall was standing open which allowed the smoke to get into the core area. Z1 stated that he would have expected the door to have been closed. He further stated that nursing staff was out of control. Staff was all over the scene. They did not follow directions and kept moving patients without permission causing problems for patient movements. E2 (Regional Operations Director) provided a 54 page document entitled Fire Safety and Disaster Preparedness Manual with a revision date of [DATE]. This document lists under EMERGENCY PROCEDURE: BASIC LINES OF AUTHORITY; The main objective and first consideration during any disaster or emergency is the safety and well-being of the residents. Employees should always remain calm and reassure the residents so that transfer or evacuation procedures can be carried out effectively and with the least amount of problems or accidental injury. The chain of command at Cahokia Nursing and Rehabilitation is: 1. Administrator 2. Director of Nursing 3. Assistant Director of Nursing 4. Designated Charge Nurse in the facility If the Administrator, Director of Nursing or Assistant Director of Nursing is not in the building at the time of a fire or disaster, the designated Charge Nurse will: 1. In case of a fire, ensure that the fire department has been notified. 2. Notify the Administrator of the situation 3. Assign aides to assist as needed. 4. Assign other staff (i.e. dietary, housekeeping laundry, etc.) as needed. 5. Notify the Director of Nursing and Maintenance Supervisor. 6. Keep calm and assure resident that the situation is under control. 7. Keep telephone lines as clear as possible. On the same page is a listing of staff including Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Dietary Manager, Maintenance and Medical Director with spaces for Phone number and Cell Phone. There are no phone numbers listed for any staff. On [DATE] at 5:30 PM, Z1, Chief, Cahokia Volunteer Fire Department, stated that he and his men rescued a total of 4 residents from the fire hall, hall 500. One resident was rescued by accident, that is, when Z1 and some of his men were standing at the entrance of door to room [ROOM NUMBER] (where fire started), after laying water on the door, they stepped back and bumped into a person on the hall corridor floor. One of his men checked to see if the person was alive, the person moaned, they evacuated her. No nursing staff informed him of any potential residents left in the building. When Z1 was asked if he or his department received any emergency planning/coordination prior to the fire and or after the fire from the facility, he answered no. On [DATE] at 5:45 PM, Z11, EMS System Coordinator, stated he never received an emergency planning/coordination planning from the facility prior to or after the fire incident. On [DATE] at 5:40 PM, Z12, Captain, Cahokia Volunteer Fire Department, stated that no facility staff informed him of anyone in the building. When Z12 entered 500 hall and got to the room identified as the origin of fire, he heard a moan coming from the corridor floor just outside this room. Z12 instructed one of his men to check this person. Z12 then helped evacuate this resident (R1). Z13's (Emergency Management System Coordinator) written account of his on-scene experience on [DATE] at the nursing home fire documents that he arrived on the scene shortly after 6 pm. Z13 noted that the outside temperature was 83 degrees according to his weather app. Z13 also documented that there were multiple Police Department, Fire Department, and Emergency Medical Service agencies present with many transport vehicles available. According to Z13's report, upon further inquiry regarding transport plans it seemed that there was quite a bit of confusion regarding the actual number of NH (nursing home) residents present, how many still required transport and the destination of those waiting Z13 report indicates that I heard resident numbers from multiple people that ranged from 103 to 106 and that possibly some residents had been counted twice. IDPH LTC (Long Term Care) (Z14, 15, 16) along with a Senior Citizen Ombudsman was attempting to lock down NH bed availability in the region. There was no pre-planned sheltering facility identified by management to get these residents out of the elements which included the threat of rain and at times visible lightening. This facility is a single level facility with five wings (halls) for resident rooms extending out from a center core area where the nurse's station is located (wagon wheel configuration). The 400 Hall houses the main dining room, kitchen, and activity room. Moving clockwise around the spokes, starting with the 400 hall, the spokes are 500 hall, 600 hall, 100 hall, 200 hall, and 300 hall. The fire on [DATE] was determined to be located on the 500 Hall. On [DATE] at 1:30pm Z10 (Emergency Management Services (EMS)/Operations Manager) stated that when he arrived on the scene no facility staff were in charge for the first 15 minutes. Z10 stated that after that, E2 (Regional Operations Manager) assumed control. Z10 stated when he arrived on the scene; residents were still being evacuated from the building. Z10 stated EMS and fire had to demand the number of residents, and were never told the correct number of residents on site. Z10 stated when they arrived, facility staff could not tell them how many residents were still in the building. Z10 stated, There was no coordination whatsoever. Z10 stated it took 45 minutes to one hour after their arrival for EMS to be given any kind of information about residents' medical needs. Z10 stated that E2 (Facility Regional Operations) asked Z10 What is your plan? regarding finding placement for residents. During the After Action Review meeting held on [DATE], an unidentified responder commented that she asked nursing staff where were these residents going and nursing staff responded that they did not know and they didn't care where they were going to-just get them out of here. Z10 stated during the After Action Review meeting that with the amount of transport vehicles present at the facility, they could have easily transported all residents quicker to where they were needed to be, however facility staff could not produce the face sheet and the medications for the residents. Fire Safety and Disaster Preparedness Manual on pages ,[DATE] list area nursing homes with contact information including phone numbers as well as level of care provided. Document indicates that it was last revised on [DATE]. At the time of the fire, this information was not utilized by management staff. Management staff relied on IDPH staff and EMS staff to contact facilities. This same Fire Safety and Disaster Preparedness Manual with a revision date of [DATE] contains multiple detailed instructions related to evacuation and response to fire that were not followed during the actual fire response on [DATE]. This manual documents on page 2 under EVACUATION OF RESIDENTS notes: There are three types of evacuation, depending on the particular disaster situation: 1. Evacuation of residents from one section or wing of the facility to another section or wing. 2. Temporary evacuation of residents out of facility to outside assembly area 3. Complete evacuation of all residents to another facility or facilities. Page 5 of this document lists under INTRODUCTION: The following fire safety and disaster preparedness manual is designed to detail the basic steps needed to prepare for and the course of action to follow, in the event of a fire or other facility disaster. This document continues on page 8 under heading Preparing for Evacuation stating: The authority to order evacuation from the facility rests with the Administrator, or designee. Evacuation can also be ordered by the fire department, local law agency or civil defense. In case of any emergency, evacuation of residents, staff and visitors should first be from the area of immediate danger. If a complete evacuation from the facility becomes necessary, residents are to be removed from the facility utilizing the nearest and safest exits and taken outside to the front parking lot where a head count will be taken. In the event that the front parking lot is unusable, assemble in the parking lot located at the back of the building. Item numbers 3 and 5 under the section Before Evacuating Facility addresses how facility staff is to manage medications and medical records and when to evacuate the building. 3. Gather all medications and open medical records and prepare to move them to a safe area or to the evacuation site, when possible. 5. Do not evacuate until order is given. Under the title Evacuation (still on page 8), specific instructions related to the evacuation are given. Items 5 and 6 address again medications and accounting for residents. This document instructs staff to: 1. After the order for an evacuation has been given, utilize only those exits that are declared as usable. 4. At least one person shall be assigned to the outside assembly area to assure that all persons remain in the area. No resident or visitor shall be allowed to return to the facility or danger area until an all-clear signal has been sounded. 5. Move all medication and open medical records to evacuation site, if possible. Use Kardex or current census sheet to account for all residents.6. Once outside the facility, account for all residents, visitors and staff and report any missing persons to the fire department or other local law agency personnel at once. On page 2 of this document under the section Temporary Evacuation from Facility to Outside Assembly Area: There may be situations where evacuation from the facility is temporary (such as during a fire where the Fire Chief orders evacuation or a bomb threat where the local law agency orders evacuation). 1. After order for evacuation has been given, utilize only those exits that are declared usable. 2. Evacuate residents in the following order: a. Ambulatory residents-Residents should be led or directed along routes of evacuation. If there are enough personnel, one able bodied person should lead the residents and one person should bring up the rear. All residents should form a chain holding hands and walk, not run, to the nearest exit. Residents should not stop for clothing or personal belongings. b. Wheelchair residents-Should be wheeled outside. c. Bed-bound residents-by bed, stretcher or carries (see Appendix D for carrying methods). 2. Outside assembly area for evacuation of residents from building will be the front parking lots. If this area is not useable, the secondary assembly areas will be the parking lot at the back of the building. Page 9 of the Disaster Preparedness Manual is titled Fire Safety Points to Remember and includes the following points: 1. Fire prevention is the responsibility of all staff, residents, and visitors. 3. If the facility sprinkler or fire alarms systems are inactivated for repair fire watch procedures must be initiated. 5. When the fire alarm sounds: · Stop all non-emergency tasks · Begin removing residents from hallway and close doors · Get a fire extinguisher and report to nurse's station to await further instructions · Remain calm 9. If fire is minor enough to be fought safely, do so. 10. Movement in an evacuation due to fire should always be away from the travel of the heat and smoke. Residents should always be moved to an area that places a fire barrier door between them and the fire, removing those closest to the danger first. Fire and smoke barrier doors provide temporary (,[DATE] hour) protection from the spread of fire and smoke. Fire and smoke barrier doors separate all the halls from the facility core and will automatically close when the fire alarm is activated. At no time should barrier doors be propped open. 11. If a resident, visitor or staff member become frightened and/or combative and you cannot move him/her to a point of safety, tell the fire department or local law agency personnel immediately, so they can accomplish rescue. Page 10 of this document titled ACTUAL FIRE PROCEDURE includes the following instructions to staff: During a fire or when the fire alarm sounds, all departments will function as follows: CHARGE NURSE: The Medicare Hall nurse will serve as charge nurse and will exercise complete authority until relieved by the Administrator or fire department personnel. When the alarm sounds, the charge nurse will report to the nurse's station and delegate staff responsibilities .The charge nurse will get a copy of the census sheet for a head count, in the event of an evacuation from the facility .The ,[DATE] hall nurse will also be responsible for getting med books and med carts ready for evacuation. NURSING STAFF: Nursing staff will ensure resident's safety by checking their halls for pulled manual alarms or lighted smoke detectors, closing all doors and putting residents that are out in the hallway into the closest room and closing the door. Once the location of the alarm is announced, evacuate the area in a safe and timely manner. Movement should place a fire door between residents and the fire. If the fire is not on your assigned hall, be prepared to go to area of emergency to assist. Always leave a skeleton staff on the hall not affected, including the charge nurse. Remember in a fire: The acronym RACE Rescue, remove all occupants directly involved with the fire emergency Alarm, make sure fire alarm signal summons all staff and building occupants Contain, confine the effects of the fire by closing doors to isolate the area Evacuate the immediate area and smoke compartments. Extinguish minor fires as able. On [DATE] at 11:12am, E1, Maintenance Supervisor, stated that on [DATE], he was getting ready to end his shift when the fire alarm went off. E1 checked the fire panel; the fire panel indicated the problem area was Zone D, which is the 400 hall. E1 found water dripping out of the smoke detector due to the air conditioner drip pan overflowing. E1 reset the fire panel. E1 then went up into the ceiling in the 300 hall and drained the drip pan. During subsequent interview on [DATE] at 11 am, E1 stated that it was approximately 3:15 pm-3:30 pm when the fire alarm went off the first time and again between 4:15 pm -4:20 pm. E1 stated the fire department came to the facility after the first alarm went off; E1 told the Fire Department it was a false alarm triggered by water dripping through the smoke detector. E1 stated that about 3:45 pm on [DATE] E1 instructed E3, Licensed Practical Nurse, to hold down a switch at the fire panel to silence the fire alarm while E1 worked on it. E1 stated no fire watch protocol was initiated as it only has to be initiated if the system will be down four hours or more. While E1 was working inside the ceiling, he could hear somebody say there was a fire. E1 got off the ladder and saw smoke down the 500 hall. E1 stated that nursing staff had already started evacuating residents on 500 hall. E1 stated there was a resident lying in the 500 hall, he got a wheelchair and put the resident in it and pushed her out through the 500 hall fire door. E1 stated he is unsure which resident this was. E1 stated the acting Director of Nurses was present at the time of the fire, but he was not sure what she was doing. E1 stated in the event of a fire, the Administrator runs everything. If the Administrator isn't present, the Director of Nurses is in charge, then the Assistant Director of Nurses, then the Charge Nurse, then Maintenance. E1 stated he thinks the receptionist called the fire department. E1 stated he notified the Administrator of the fire by phone because she was not on site. E1 stated he is not sure if the sprinklers came on. E1 stated that before the fire department arrived, residents were still in the building on the 500 hall. According to E1 smoke was so thick nobody could tell where the fire was. E1 stated that at this point, he made the decision for staff to begin breaking windows to get residents out. E1 stated that all staff was responding to the fire in the manner in which they had been trained. E1 stated that he has never received training about how to train other staff for fire safety; he said he was given a training manual to use. E1 stated what he teaches in fire safety is how to use the fire extinguisher, what all staff members responsibilities are in case of fire, and evacuation procedures. On [DATE] at 12:05 pm E10 (Maintenance Assistant) stated that on [DATE] he was assisting E1, Maintenance Supervisor by draining the air conditioner drip pan which was making the fire alarm go off. E10 heard a staff person say there was a fire. E10 lowered himself down the ladder. E10 stated he could see smoke coming from behind the fire door on the 500 hall. E10 entered the 500 hall, saw a fire extinguisher lying on the floor, picked it up and started spraying it at the fire. E10 stated he used up two or three extinguishers. E10 then noticed (R1) lying in her bed. E10 picked her up, laid her on the floor in the hallway and called for help. E10 saw another resident who he believes is R9 laying on her bed. E10 took her tube feeding machine off the pole, picked her up and laid her on the floor in the hallway and yelled for help. E10 stated at that point somebody yelled get out of the building, so he exited the building from the fire exit on the 500 hall. E10 stated the sprinkler system did not come on during the fire. According to E10 staff began breaking windows to continue getting residents out. E10 stated he does not recall any staff giving directions, but recalls E7, Licensed Practical Nurse saying, get the residents out. E10 stated that once he was outside, he instructed nursing staff to start doing a head count. E10 was not sure who contacted the Fire Department or the Administrator. On [DATE] at 12:30pm E11 (Licensed Practical Nurse) stated that on [DATE], time unknown, she was standing at the nurse's station when the fire alarm went off. E11 went to the fire panel and determined the problem area was D hall (400 hall). E11 called a CODE RED (fire) for D hall. E11 then felt water leaking out from the smoke detector on D hall onto her. E11 went back to the nurse's station where either E1 (Maintenance Director) or E10 (Maintenance Assistant) said it was false alarm. E11 was not certain which staff person said it was a false alarm. According to E11, E1 was at the fire panel at about 3:45pm. E1 asked E11 to hold down the switch to de-activate the fire alarm while E1 and E10 went to room [ROOM NUMBER] to work on the ceiling. E11 was at the fire panel holding down the switch until 4:15 pm when an unidentified Certified Nursing Assistant came running up the hall saying there's a real fire. E11 then let go of the switch and ran down the 500 hall, where she saw smoke. E5 (Certified Nursing Assistant), was standing by room [ROOM NUMBER] holding a fire extinguisher. E5 opened the door to room [ROOM NUMBER] and sprayed the fire with the fire extinguisher. According to E11, Somebody came by with a fire extinguisher. E11 grabbed it from them and sprayed the fire. E11 then went into room [ROOM NUMBER] to check it. E11 stated there was smoke in the room, but no fire. E11 stated she was the Station Nurse on [DATE], but she is not sure what the Station Nurse's duties are in a fire. E11 stated that the nurse assigned to the hall is charge nurse for that hall. As to who was in charge during the fire, E11 stated, I guess it would be my job to give directions as charge nurse, but I've never been given a job description of exactly what being charge nurse entails, especially with what a fire entails. E11 stated she is not aware of anyone calling for an evacuation. E11 is not sure if the sprinklers came on and does not know who called the fire department. E11 does not remember when she last had fire safety training. E11 stated that once residents were being evacuated to the outside, E2 (Regional Director of Operations) had a list of residents and was doing a head count. E11 stated that emergency medical staff was triaging resident's needs outside, but she was not sure if facility nursing staff were triaging resident's needs. E11 stated that during a fire drill, the alarm goes off; staff check the panel for the location, get on the intercom, call a code red, get a fire extinguisher, and then search the room for the fire. On [DATE] at 10am, E5 (Certified Nursing Assistant) stated he was assigned to work the 500 hall on [DATE]. E5 stated the fire alarm went off at 2:30pm and at some point somebody said it was a false alarm. Around ,[DATE]:10pm, a family member asked E5 if he smelled smoke. E5 stated there was smoke coming from R2's room. E5 opened the R2's room door and fire shot out over his head. E5 said the residents (R1, R2) were in the room. E5 went and got a fire extinguisher, tried to extinguish the fire, but it made it very dark and he couldn't see. E5 stated it was hard to breathe. E10 (Maintenance Assistant) then came in with a fire extinguisher. E5 stated he (E5) got R2 and took her to the nurse's station; meanwhile E10 put (R1) on the floor in the hallway. E5 stated he was going into rooms to check for residents and heard windows breaking. E5 stated he saw residents being moved out through windows. According to E5 he has worked at the facility over a year and a half, had fire safety in orientation, but is not sure when he last had fire safety training. E5 stated the policy to follow in a fire is to call the fire department and get residents out. E5 stated the nurse on 500 hall that night was E9 (Licensed Practical Nurse). E5 stated the sprinklers did not come on. E5 stated he does not know if anyone was doing a resident head count. During interview on [DATE] at 10:45 am, E8 (Licensed Practical Nurse) stated that on [DATE] she was working on 500 hall after the end of her 6:30am-2:30pm shift. E8 said that E5 (Certified Nursing Assistant) reported he saw smoke and flames coming out of the top of room [ROOM NUMBER] ' s door. E8 stated she ran to alert everybody. E8 got a fire extinguisher and gave it to E10, Maintenance Assistant. E5 and E10 were trying to get the fire out. E8 stated she let everybody know they needed to get the residents out when she saw fire on the ceiling in room [ROOM NUMBER]. E8 stated she called for evacuation, although she was not in charge. E8 stated E9 (Licensed Practical Nurse) was in charge of the evening shift on 500 hall, but E8 did not see E9 during the fire. E8 stated the procedure to be followed in a fire is to check the box for location, get a fire extinguisher, and go to that location. E8 stated E31 was counting heads outside the building. E8 stated the fire doors shut when the alarm went off. E8 stated there were no residents in the hallway of 500 hall when the fire broke out. During interview on [DATE] at 2:15 pm E9 (Licensed Practical Nurse) stated that she worked on the even side of 100 hall and also the 500 hall on the 2:30pm - 10:30pm shift on [DATE]. E9 was on the 100 hall when the fire alarm went off. E9 stated that we automatically went to 500 hall as someone said CODE RED at 500 hall. When asked about her responsibility in fire situation, E9 replied that it is to make sure residents/people are out. Person should be at nurse's station desk to monitor. Someone is to get the extinguisher. This would be those who can get to it first. In this instance, it was E1 (Maintenance Supervisor). On [DATE] at 3:05 pm, E13 (Licensed Practical Nurse/LPN/Education/Quality Assurance) stated that on [DATE] at the time of the fire, she was in medical records (300 Hall). E13 saw smoke and told nursing staff to get residents behind the fire doors. E13 stated that E14 (Licensed Practical Nurse) said It's really bad so she (E13) said to get everybody out. E13 stated that after the fact, she was told that E8 (Licensed Practical Nurse) ordered the evacuation; however, E13 stated nobody was doing anything so I took over and ordered it (the evacuation). E13 stated E11 (LPN) called the fire department. E13 stated the procedure to be followed in case of fire is that staff is to come to the nurses station with a fire extinguisher to await instruction and be told where the fire is. E13 stated she is not sure when the most recent fire drill was. E13 stated she does part of fire safety at orientation-teaches RACE (Rescue, Alarm, Contain, Evacuate) and PASS (Pull, Aim, Squeeze, Sweep). E13 stated the chain of command during a fire goes from 1) Operations Manager of Regional Office 2) Administrator, 3) Director of Nurses, 4) Charge Nurse. E13 stated she did not see the sprinklers come on during the fire. During interview on [DATE] at 1:55 pm, E12 (Certified Nursing Assistant/CNA) stated she was on the 600 hall when the fire alarm went off around ,[DATE]:30pm. E12 stated she thinks an all clear was called, and everybody went back to what they were doing. E12 stated about ,[DATE]:30pm a second alarm went off. E12 grabbed a fire extinguisher, and saw everybody looking for the fire. E12 realized it was on the 500 hall. E12 stated she can't say any specific person said to evacuate, but staff started getting residents out. E12 stated there was nobody in particular who was in charge. E12 stated the most recent fire drill has been in the past 30 days. E12 stated she thinks she had fire safety training earlier in 2016. E12 stated the policy of how to respond in a fire is 1) grab fire extinguisher 2) use extinguisher if it's a small fire 3) start getting residents out, and if you can't get them out, listen to the charge nurse, she will give you directions. E12 stated that there was no staff clearly in charge of triage outside the building. E12 stated the sprinklers did not come on down the 600 hall. On [DATE] at 2:10pm, E7 (Certified Nursing Assistant) stated that on [DATE] she was on the 500 hall at the time she became aware of the fire. E7 stated that she, E5 (Certified Nursing Assistant), E10 (Maintenance) and E8 (Licensed Practical Nurse) were working together during the fire but nobody was clearly in charge. E7 stated It was overwhelming and everybody was running. E7 stated in case of fire staff are to close the doors where the fire is. E7 stated fire extinguishers are located on 500 hall when you first walk into the hall from the nurse's station. E7 stated to use a fire extinguisher You pull, aim, and sweep, I think. E25 (Certified Nursing Assistant) stated on [DATE] at 12:55pm that on [DATE] she was assigned as shower aide for all halls. E25 stated she was outside in back of the building when she became aware of the fire. She entered through F hall (600 Hall) and saw smoke on the 500 hall. E25 went back outside because she couldn't breathe. According to E25, she broke the glass of a room on 500 hall with her arm, but is not sure which room. E25 stated she is not sure if anybody on 500 hall was in charge. She stated CNA's and nurses were accounting for residents outside the building, but there was nobody in charge outside. E25 stated if the fire alarm goes off, staff is to clear residents out of hallways and report to the nurse's station. E25 stated if you discover fire in a resident's room, you should get the resident out if they are in there. E25 stated she does not know where the fire alarms are located. E25 stated she does not think she has received training on using a fire extinguisher. On [DATE] at 11:15am E28 (Certified Nursing Assistant) stated that on [DATE] he was assigned to the 200 hall on evening shift. E28 stated he was in R10's room when the fire alarm sound

Based on observation, record review, and interview the facility failed to train all employees on emergency procedures when they were initially employed and failed to periodically review the procedures with all existing staff. The facility failed to ensure that management staff responsible for the emergency procedures training was adequately trained in emergency preparedness. The facility failed to ensure that periodic review of emergency procedures prepared staff for an actual fire. These failures resulted in staff not implementing and executing the disaster plan when an actual fire broke out in a resident ' s room on 5/31/2016. Fourteen residents (R1-6, R11-15, R19, R23, R24) required treatment at a hospital for smoke inhalation or other fire related symptoms; all 106 residents were subjected to a mass evacuation which was described as chaotic. These failures caused physical harm (smoke inhalation) and discomfort as well as psychosocial harm with residents fearing they would be burned alive. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 31, 2016 when facility staff demonstrated their lack of training when responding to an actual fire in the nursing facility. While the immediacy was removed on July 8, 2016, the facility remains out of compliance at a Severity Level 2 as additional time is required to evaluate the effectiveness of the recent training of staff and the staff's ability to retain and demonstrate the training. Findings include: Fire Department form NFIRS-1 dated 5/31/2016 documents that the Cahokia Fire Department responded for a reported fire in a room on the 500 hall (E) at Cahokia Nursing and Rehab. Upon arrival of fire units and personnel they found heavy smoke coming from the right rear of the building located near (F) and (E) hallways with police officers and employees from the business breaking windows to remove residents from the 500 hall that were still inside. This document notes that the Fire Department received an alarm at 4:17 pm on 5/31/2016, with arrival time noted as 4:21 pm. This same document reports that fire personnel .found the fire quickly and contained to room [ROOM NUMBER] while other fire personnel were in rescue operations. It was at this time that several residents were still inside . found a female victim in the 500 hallway .Primary searches were performed from room [ROOM NUMBER] to 516 and several victims were found. One male was removed from 503 through window .room [ROOM NUMBER] a male resident removed through window .room [ROOM NUMBER] a male resident removed out of room and down hallway in wheelchair . Z1 (Chief Cahokia Volunteer Fire Department) stated on 6/16/2016 at 6 pm that when he arrived on the scene and was about to enter the building, Z1 was met by two nursing staff with masks on. Z1 asked the two nursing staff if there were any residents in the building. The nursing staff did not provide any answers; instead ran back into the building and Z1 lost them in the smoke. Z1 stated when he entered the 500 hall from the core area (nursing station); he noticed the entrance to 500 hall was standing open which allowed the smoke to get into the core area. Z1 stated that he would have expected the door to have been closed. He further stated that nursing staff was out of control. Staff was all over the scene. They did not following directions and kept moving patients without permission causing problems for patient movements. On 6/2016/2016 at 5:40 PM, Z12, Captain, Cahokia Volunteer Fire Department, stated that no facility staffed informed him of anyone in the building. When Z12 entered 500 hall and got to room [ROOM NUMBER], origin of fire, he heard a moan coming from the corridor floor just outside room [ROOM NUMBER]. He instructed one of his men to check to see if person was alive. He then helped evacuate the person, who is a resident of room [ROOM NUMBER]. On 06/15/2016 at 1:30pm Z10 (Emergency Management Services (EMS)/Operations Manager) stated that when he arrived on the scene no facility staff were in charge for the first 15 minutes. Z10 stated that after that, E2 (Regional Operations Manager) assumed control. Z10 stated when he arrived on the scene; residents were still being evacuated from the building. Z10 stated EMS and fire had to demand the number of residents, and were never told the correct number of residents on site. Z10 stated when they arrived, facility staff could not tell them how many residents were still in the building. Z10 stated, There was no coordination whatsoever. Z10 stated it took 45 minutes to one hour after their arrival for EMS to be given any kind of information about residents' medical needs. Z10 stated that E2 (Facility Regional Operations) asked Z10 What is your plan? regarding finding placement for residents. On 06/14/2016 at 11:12 am, E1 (Maintenance Supervisor) stated that all staff was responding to the fire in the manner in which they had been trained. According to E1, he is responsible for training staff on fire safety. E1 stated that he has never received training about how to train other staff for fire safety; E1 said he was given a training manual to use. E1 stated what he teaches in fire safety is how to use the fire extinguisher, what all staff members responsibilities are in case of fire, and evacuation procedures. E1 stated he does fire drills once a month so that every shift gets one at least every 90 days. E1 stated he trains new staff on fire safety during their orientation. E1 stated fire extinguishers are checked once a month and at the time of the fire were current within that time frame. E1 stated the facility's most recent fire drill was 05/20/2016 on day shift. E1 stated drills are unannounced; he notifies the fire department of the drill, and uses artificial smoke to trigger the alarm. He stated the purpose of fire drills is so employees know what they have to do and where they're supposed to be. E1 stated residents are not evacuated during drills. E1 stated if fire safety training is done when staff is off, their training is rescheduled. E1 stated fire watch protocol policy consists of a designated staff member checking all halls and signing off. During interview on 6/14/2016 at 12:05 pm, E10 (Maintenance Assistant) stated he has never received fire safety training at the facility. E10 stated he has not had training about using a fire extinguisher. E10 stated the most recent fire drill at the facility was last month. He stated drills consist of getting the alarm off line, going into a room with a smoke detector, activating it with smoke in a can, and waiting for staff to come and locate the fire. On 06/14/2016 at 12:30pm, E11 (Licensed Practical Nurse) stated E1 (Maintenance Director) was at the fire panel around 3:45pm on May 31, 2016. E1 asked E11 to hold down the switch to de-activate the fire alarm while E1 (Maintenance Director) and E10 (Maintenance Assistant) went to room [ROOM NUMBER] to work on the ceiling. E11 stated she was at the fire panel holding down the switch until 4:15 pm when an unidentified Certified Nursing Assistant came running up the hall saying there's a real fire E11 then let go of the switch and ran down the 500 hall, where she saw smoke. E5 (Certified Nursing Assistant), was standing by room [ROOM NUMBER] holding a fire extinguisher. E5 opened the door to room [ROOM NUMBER] and sprayed the fire with the fire extinguisher. According to E11, Somebody came by with a fire extinguisher. E11 grabbed it from them and sprayed the fire. E11 stated she was the Station Nurse on 05/31/2016, but she is not sure what the Station Nurse's duties are in a fire. E11 stated that the nurse assigned to the hall is charge nurse for that hall. As to who was in charge during the fire, E11 stated, I guess it would be my job to give directions as charge nurse, but I've never been given a job description of exactly what being charge nurse entails, especially with what a fire entails. E11 did not remember when she last had fire safety training. E11 stated that during a fire drill, the alarm goes off; staff checks the panel for the location, gets on the intercom, calls a code red, gets a fire extinguisher, and then searches the room for the fire. On 06/14/2016 at 10am, E5 (Certified Nursing Assistant) stated he was assigned to work the 500 hall on 05/31/2016. Around 4-4:10pm, a family member asked E5 if he smelled smoke. E5 stated there was smoke coming from R2's room. E5 opened the R2's room door and fire shot out over his head. E5 said the residents (R1, R2) were in the room. E5 went and got a fire extinguisher, tried to extinguish the fire, but it made it very dark and he couldn't see. E5 stated it was hard to breathe. E10 (Maintenance Assistant) then came in with a fire extinguisher. E5 stated he (E5) got R2 and took her to the nurse's station; meanwhile E10 put (R1) on the floor in the hallway. E5 stated he was going into rooms to check for residents and heard windows breaking. E5 stated he saw residents being moved out through windows. According to E5 he has worked at the facility over a year and a half, had fire safety in orientation, but is not sure when he last had fire safety training. E5 stated the policy to follow in a fire is to call the fire department and get residents out. E5 stated he did not remember when the most recent fire drill was. E5 stated if the fire alarm goes off, you should make sure there's a fire, and if so, get residents to the nearest exit. E5 stated to use a fire extinguisher; you should pull the pin and sweep from the bottom up. On 6/9/2016 at 2:15 pm E9 (Licensed Practical Nurse), when asked about her responsibility in fire situation, E9 replied that it is to make sure residents/people are out. Person should be at nurse's station desk to monitor. Someone is to get the extinguisher. This would be those who can get to it first. On 06/14/2016 at 3:05 pm, E13 (Licensed Practical Nurse/LPN/Education/Quality Assurance) stated that on 05/31/2016 at the time of the fire, she was in medical records (300 Hall). E13 saw smoke and told nursing staff to get residents behind the fire doors. E13 stated the procedure to be followed in case of fire is that staff is to come to the nurses station with a fire extinguisher to await instruction and be told where the fire is. E13 stated she is not sure when the most recent fire drill was. E13 stated she does part of fire safety at orientation-teaches RACE (Rescue, Alarm, Contain, Evacuate) and PASS (Pull, Aim, Squeeze, Sweep). E13 stated the chain of command during a fire goes from 1) Operations Manager of Regional Office 2) Administrator, 3) Director of Nurses, 4) Charge Nurse. On 6/14/2016 at 1:55 pm E12 (Certified Nursing Assistant) stated the most recent fire drill has been in the past 30 days. E12 stated she thinks she had fire safety training earlier in 2016. E12 stated the policy of how to respond in a fire is 1) grab fire extinguisher 2) use extinguisher if it's a small fire 3) start getting residents out, and if you can ' t get them out, listen to the charge nurse, she will give you directions. On 6/9/2016 at 3:08 PM, E30 (Licensed Practical Nurse) stated that she is aware that the facility has an emergency plan and that it is kept at the nurses station but has not seen it. She states that she has not been through an actual fire evacuation drill; it was only a verbalized training. E30 stated she evacuated residents on hall 100 without anyone directing her on 5/31/2016. She stated that she saw E13, Quality Assurance/Education/Licensed Practical Nurse, come through the door of 100 hall and saw smoke follow her in and just made the decision to evacuate the residents. E30 was asked how residents were accounted for. She stated that she grabbed the census sheet/room roster for the building and the elopement risk book which is located at the secretary's desk but she did not know who was responsible for that as she stated she was not aware of anyone specific or assigned to that task. On 6/9/2016 at 3:45 PM, E24 (Registered Nurse) stated she was not aware of any emergency plan that the facility had regarding this type of event (fire), but she has seen the Cahokia Nursing & Rehabilitation Center Policies, Standards, Protocols, and Procedures Manual dated 01/01/06. E24 stated that she has not had any training where residents are evacuated. When asked who instructed her to evacuate residents on 5/31/2016, E24 stated she saw smoke and started to evacuate residents on 100 hall before moving on to 600 hall. E24 did not know who was in charge or who was to secure the census data sheet in an event of an evacuation. E24 does not know where residents are to be taken when evacuated; she just got them out and away from the building. On 06/15/2016 at 1:45pm, E23 (Director of Nurses), stated she took the position of DON on 06/02/2016. E23 stated the chain of command in an emergency is 1) Administrator, 2) Director of Nursing 3) Charge nurse which is whoever is at the desk. According to E23 this could depend on who is in the building because whoever is at the fire panel can initiate the protocol for fire safety. On 06/21/2016 at 1:40pm, E23 stated if the fire alarm goes off, you should go to the fire panel, check for the location, assign staff to make calls, get an extinguisher, and go to the location of the fire, and rescue, alarm, contain/confine, and extinguish/evacuate. E23 stated if she discovered fire in a resident's room, she would remove the resident, alarm staff, and confine the fire by shutting the door where it is and the adjacent doors then extinguish the fire and if unable, evacuate. E23 stated she could not give exact locations of fire extinguishers within the facility without having a map, but she knows there is one on each hallway. On 06/21/2016 at 2:35pm, E6 (Certified Nursing Assistant) stated there are three fire extinguishers located on the 500 hall, and two fire alarms located on the 500 hall. E6 stated if she discovered fire in a resident's room, E6 would pull the resident out if they could be removed, let the nurse know there was a fire, then evacuate residents from adjacent rooms. E6 stated if the fire alarm goes off staff are to go down halls checking for fires, close doors, then mark the door with an X, get a fire extinguisher and report to the nurse's station. On 06/21/2016 at 2:10pm, E7 (Certified Nursing Assistant), stated that on 05/31/2016 she was on the 500 hall at the time she became aware of the fire. She stated that she, E5 (Certified Nursing Assistant), E10 (Maintenance Assistant) and E8 (Licensed Practical Nurse) were working together during the fire but nobody was clearly in charge. E7 stated It was overwhelming and everybody was running. E7 stated in case of fire, staff is to close the doors where the fire is. E7 stated fire extinguishers are located on 500 hall when you first walk into the hall from the nurses station. E7 stated to use a fire extinguisher You pull, aim, and sweep, I think. On 06/21/2016 at 2:05 pm, E27 (Housekeeper) stated that if the fire alarm goes off, staff should check the fire panel to see where its located, get a fire extinguisher, go to the hall where it is, the light above the door should tell you which room it's in. Then go into the room with the extinguisher and wait for the all clear. E27 stated if she discovered fire in a resident's room, E27 would go to the fire alarm and pull it. E27 stated fire extinguishers are located on the end of the halls closest to the nurse's station and the exits. E27 stated to use a fire extinguisher you pull, aim, sweep and spray. On 06/21/2016 at 12:55pm E25 (Certified Nursing Assistant) stated that on 05/31/2016 she was assigned as shower aide for all halls. E25 stated if the fire alarm goes off, staff is to clear residents out of hallways and report to the nurse ' s station. E25 stated if you discover fire in a resident's room, you should get the resident out if they are in there. E25 stated she does not know where fire alarms are located. E25 stated she does not think she has received training on using a fire extinguisher. On 06/21/2016 at 11:15am, E28 (Certified Nursing Assistant) stated that on 05/31/2016, E28 was assigned to the 200 hall on evening shift. E28 stated when the fire alarm went off, he went down the 300 and 200 halls and checked. He saw smoke coming from the 500 hall. He then immediately started getting residents out, taking them out the 200 and 300 hall doors. According to E28, he chose these exits as those halls were not smoky and other staff were going out that way with residents. E28 stated if he discovered fire in a resident's room; he would get the resident out and try to put the fire out. E28 stated extinguishers and fire alarms are located at the end of each hall. E28 stated if the fire alarm goes off, staff should get fire extinguishers, check halls and make sure residents are in their rooms, and make sure no residents are in harm's way. E28 stated to use a fire extinguisher you should point, spray down, and side to side. On 06/15/2016 at 10:45 am, E8 (Licensed Practical Nurse) stated that on 05/31/2016 she was working on 500 hall. She stated that E5, Certified Nursing Assistant, said he saw smoke and flames coming out of the top of the door of room [ROOM NUMBER]. E8 stated she ran to alert everybody. E8 got a fire extinguisher and gave it to E10, Maintenance Assistant. E5 and E10 were trying to get the fire out. E8 stated she let everybody know they needed to get the residents out when she saw fire on the ceiling in room [ROOM NUMBER]. E8 stated she called for evacuation but was not in charge. E8 stated she's not sure when the most recent fire safety training was. E8 stated the procedure to be followed in a fire is to check the box for location, get a fire extinguisher, and go to that location. E8 stated the fire doors shut when the alarm went off. E8 stated there were no residents out in the hall of 500 hall when the fire broke out. E8 stated she is not sure if there was a (elopement risk) list outside or whose responsibility it would be to get it or the census with which to do the head count. E8 stated she is not sure if she had fire safety training during orientation. On 06/17/2016 at 1:28 pm, E18 (Registered Nurse) stated that on 05/31/2016, she clocked out at 3:20pm and was not onsite at the time of the fire. E18 stated on 05/31/2016 she was Acting Director of Nurses. E18 stated she returned to the facility around 6pm that evening. E18 stated her most recent fire safety training she believes was January or February 2016. E18 stated she thinks there was a mock evacuation drill in 2015. On 06/15/2016 at 1:20pm, E22 (Medicare Billing Associate) stated she was in the adjacent regional office building when she became aware of the fire. E22 stated the most recent fire training she's had was in 2013 and it consisted of a fire drill and how to use a fire extinguisher. On 06/15/2016 at 1pm, E16 (Business Office Manager) stated she was in her office on 5/31/2016 when she became aware of the fire. E16 stated she went to the 100 hall and directed the 100 hall residents out of the building. E16 stated I knew if there was a fire, the 100 hall was my hall to evacuate-I didn't need anybody to tell me to evacuate, and I could see smoke on the 500 hall. E16 stated she then came back into the building and got the census for the whole facility and started a head count for the 100 hall, E16 stated she was not sure if doing the head count was an expectation of her job, but it's the responsibility of all staff. E16 stated the (elopement risk) book is kept at the receptionist's desk, but she is not sure whose responsibility it is to take that book out in case of evacuation. E16 stated the most recent fire drill was in the middle of May 2016. E16 stated she has never had annual fire safety training per se except for drills. Facility census records for 5/31/2016 indicate that twenty seven residents resided on the 500 hall at the time of the fire. These residents include R1, R2, R4, R7, R8, R10, R11, R14, and R16-R34. Patient List Cahokia Nursing and Rehab with Destination and Hospital records dated 5/31/2016 provided by Z11 (Emergency System Services System Coordinator) document that fourteen residents (R1-R6, R11-R15, R19, R23, R24) from four wings were ultimately transferred to four area hospitals due to fire related conditions. Centers for Medicare and Medicaid form 672 provided by facility notes that at the time of the fire, eleven residents (R1, R2, and R16 who resided on the 500 Hall, as well as R5, R6, and R35-R40) had tube feedings; ten residents received hospice services (R1, R2, R24, R25 who resided on the 500 Hall, and R3, R48, R53-56); four residents received [MEDICAL TREATMENT] (R14 and R32 who resided on the 500 Hall in addition to R41 and R42); and eighteen residents who received respiratory services (R2, R16, and R33 who resided on the 500 Hall, as well as R3, R5, R6, R9, R15, R43-R52.) Face sheet dated 9/01/2015 documents that R2's (500 Hall) date of birth is 05/27/27 with [DIAGNOSES REDACTED]. The Hospital physician's orders [REDACTED]. Hospital Physical Exam dated 5/31/2016 noted that R2 was coughing up thick black phlegm and subsequently had some emesis in the emergency room as well as decreased breath sounds. The Hospital Assessment Plan Sheet dated 5/31/2016 indicates that R2 had fever, maybe due to exposure to heat exposure and possible [MEDICAL CONDITION], will treat .and monitor closely. The Hospital Transfer Summary noted dated 6/01/2016 states R2 is an [AGE] year old woman admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. There is notation she is a hospice patient, but we do not have confirmation of which agency is involved. R1's (500 Hall) Hospital Inpatient Record face Sheet dated 5/31/2016 lists R1's birthdate as 2/02/1929. Prehospital Care Report Summary for R1 notes Due to patient upper extremities being contracted ambulance crew was unable to obtain a blood pressure at this time. Blood glucose analysis assessed at this time with a result of 59. Patient administered oral glucose at this time. Patient unable to answer any EMS (Emergency Management Services) questions at this time. Hospital History and Physical Note dated 5/31/2016 documents This is an [AGE] year old .admitted from the emergency room with smoke inhalation. She is a resident of Cahokia Nursing and rehabilitation Center. There was a fire at the facility last evening and she was exposed to smoke. She was experiencing a cough which prompted her visit to the emergency room . Problems: Smoke inhalation injury. The Hospital Patient Discharge Instruction sheet dated 6/01/2016 states Discharge Diagnosis: [REDACTED]. R 12's (100 Hall) Hospital Face Sheet dated 5/31/2016 notes date of birth as 10/21/1933. Hospital emergency room Visit report dated 5/31/2016 indicates that R12 presents via EMS (Emergency Management Service) from nursing home. Patient ' s nursing home had a fire this evening and when patient was in a bus for transport, he reportedly had a syncopal episode while sitting in his seat .Patient with history of [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION] . An Emergency Department Progress Note dated 5/31/2016 at 9:59 pm stated, It has been reported that the bus was quite warm and nurse noted that a bottle of water the patient had with him was warm when he arrived. Other residents from the same situation have been brought in for similar complaint .spoke with (Z19) regarding patient and findings and he agreed likely situational [MEDICAL CONDITION] due to elevated temperature and hectic environment. Intervention/Assessment Treatment documentation dated 5/31/2016 noted R12 ' s temperature was 99.1 and blood pressure was 199/84. Facility census records for 5/31/2016 indicate R12 resided on 100 hall. Face sheet for R14 (500 Hall) documents that R14's date of birth is 9/19/1950. Emergency Medical Service report for 5/31/2016 notes female pt (patient) with possible low blood sugar, dizziness, and weakness .patient sitting upright and slumped to the right in her wheelchair. Nursing home staff tells EMS (Emergency Medical Service) that pt has 'seemed to be close to passing out, sweating, and is weak.' Pt has been outside in triage area for approximately 90 minutes following evacuation from building. The Hospital emergency room Visit Report dated 5/31/2016 notes [AGE] year old female presents to Emergency Department .status [REDACTED]. Patient was in an unaffected wing. She was evacuated and sat outside for nearly 1.5 hours in the heat when she started feeling dizzy and lightheaded. She feels better now .has a history of stroke and her right side is affected. The Hospital Emergency Department Progress note dated 5/31/2016 documents that R14 presents for lightheadedness after being outside .in mid 80 weather status [REDACTED]. A Hospital Face Sheet dated 5/31/2016 notes R13 (600 Hall) date of birth as 6/8/1969. Hospital emergency room Visit Report dated 5/31/2016 states [AGE] year old female with history of dementia presents to Emergency Department by EMS (Emergency Medical System) status [REDACTED].shortness of breath resolved once in ambulance. Past medical history-[MEDICAL CONDITION]/Dementia, [MEDICAL CONDITIONS], Depression. Prehospital Care Report Summary for R6 (300 Hall) documents Upon arrival pt (patient) was laying on a bed and on non-rebreather at 15 liters, and it was placed over his trach. Pt (patient) was then transferred to the stretcher and was taken to the truck and loaded in the back with other pt. The other pt was a nurse from the facility that knew the pt. Once in the back, vitals were taken .There was no info on the pt except for knowing his name per the other pt. R6's Physician's Certificate of Medical Necessity from a regional hospital dated 5/31/2016 lists [DIAGNOSES REDACTED]. R11's (500 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R11 is a [AGE] year old male with history of [MEDICAL CONDITION] due to car accident and is unable to answer any question at this time. Hospital Patient Health Summary dated 5/31/2016 lists Active Problems: Ileus, [MEDICAL CONDITION] Disorder, Smoke Inhalation . A Hospital Face Sheet dated 5/31/2016 lists R15 (600 Hall) date of birth as 9/08/44. Hospital emergency room Visit Report dated 5/31/2016 noted Patient presents .after nursing home where she was a resident had a fire. Patient states she was not in the area of the fire and did not inhale any smoke, but when they were preparing to transport her to another facility, she had increased pulse and shaking as well as feeling anxious. Patient states this has somewhat improved since coming here and son feels it was likely a panic attack R15 stated on 6/2/2016 when visited in the destination facility that she went to the hospital due to a panic attack. R15's Prehospital Care Report Summary dated 5/31/2016 notes this Emergency Services transport was dispatched to an emergency call for Cahokia Nursing and Rehab on fire with multiple pt (patients) outside in parking lot needing transported. This patient is complaining of severe anxiety problems at this time .The patient told EMS (Emergency Management Service) 'I just can't calm down. I was so scared that I wasn't going to make it out of the building in time and I would be burned alive.' The triage team advised EMS that this pt (patient) was not in the area of the fire and was evacuated well before she was in any harm. A staff member of the SNF (Skilled Nursing Facility) advised EMS that this pt (patient) has a severe anxiety problem and is normally very nervous as it is and this situation has made her very nervous. Upon arrival patient found sitting outside in the triage area .The pt (patient) over all has very high levels of anxiety and is having severe difficulty in calming down and relaxing . This same report documents that R15 was transported from the fire scene at 5:47 pm. Prehospital Care Report Summary for R4 (500 Hall) dated 5/31/2016 documents that R4 was having chest pain .Pt (patient) believes that he has swallowed some smoke and that is giving him chest pain. Pt states that the pain is on the right side just below the nipple line and is a constant pain which he rates it at 10/10 pain scale .pt then stated that he was becoming short of breath so 4L of 02 via a NC was established and pt states that he feels better . R3's (600 Hall) Prehospital Care Report Summary dated 5/31/2016 notes that R3 is [AGE] years old. Under Comments in this document is listed Dementia with Alzheimer's. The report states that R3 is conscious, alert, to person only, sitting in a chair and staff states that she isn't acting right. Pt (patient) has a history of dementia and Alzheimer's and is unable to tell us if anything is wrong or if she is in pain. Staff states that before EMS (Emergency Management System) arrived she wasn't acting right but now she is in her normal state. Staff states that the pt (patient) is on 4L (liters) of O2 (oxygen) at all times. Report titled Cahokia Nursing and Rehab Patient List with Destination with date of 5/31/2016 indicates R5, R19, R23, and R24 were also transported to area hospitals on the date of the fire, they were from 300, 500, 500, 500 halls respectively. All training records related to fire, fire drills, and disaster preparedness were requested from the facility. Based on all available information provided at the time of the survey there is no system in place to effectively track training efforts. Training records are incomplete and in many cases contain illegible signatures making verification of training difficult. E1 (Maintenance Supervisor) provided documents titled REPORT OF FIRE DRILL on 6/16/2016, indicating that these were all the documents available. E3 (Administrator) verified on 6/17/2016 at 1:45 pm that the training records as presented were complete. Monthly Report of Fire Drill documents were provided for June 2015 through November 2015 and January through March 2016. The Fire Drill Sign In Sheets which would show who participated in the drill were only available for 6/14/2015 and 7/25/2015. Ten signatures were present on the document dated 6/14/2015 and 17 signatures were present on the document dated 7/25/2015. The Monthly Report of Fire Drill reports have a series of nine questions with the words YES and NO after them. These questions are: 1. Was signal received by ADT? 2. What time was signal received? 3. Was all staff aware of their responsibilities? 4. Were any problems noted? 5. Did the fire alarm sound? 6. Were the strobe lights operational? 7. Were the hall fire door closers operational? 9. Were the delayed egress locks released? At the bottom of this report, it states: List any problems, corrective actions, and/or teaching required as a result of this drill. Monthly Report of Fire Drill reports for 8/18/2015, 9/30/2015, 10/13/2015, 11/10/2015, 1/19/2016, 2/21/2016, and 3/18/2016 did not contain specific locations for the fire or fire drill. Reports for September 2015, October 2015, November 2015, January 2016, February 2016, and March 2016 all have YES circled for question 4 Were any problems noted? However, the area where facility staff is to identify the problems with corrective action is blank in all cases. The Monthly Report of Fire Drill Form for August 2015 is not signed. Forms dated September through November 2015 and January through March 2016 are signed and dated by E1 (Maintenance Supervisor). There was no d

Based on interview and record review, the facility failed to maintain a functioning Quality Assurance Committee which develops and implements appropriate plans of action to correct identified quality deficiencies and to monitor the effects of these corrective actions. This has the potential to affect all 106 residents living at the facility. Findings include: On 06/14/16 at 11:12am, E1, Maintenance Director, stated he does not participate in the QA(Quality Assurance) Committee. On 07/01/16 at 11am, E36, Laundry/Housekeeping Supervisor, stated she does not participate in QA. On 07/01/16 10:40am, E35, Dietary Manager, stated she does not participate in QA. On 07/01/16 at 12:25, E33, Housekeeper, stated she did not know how to access the QA committee and stated she was unaware the facility had a QA committee. On 07/01/16 at 11:30am, E34, Certified Nursing Assistant, when asked how to access the QA committee, stated she was not sure, I guess I would ask the Quality Assurance Nurse? On 07/01/16 at 1:45pm, E13, Quality Assurance Nurse, stated QA has not met since early April 2016 when E41 was Administrator. E13 stated when E41 was Administrator, the QA committee met monthly, but has not met under E3,the current Administrator, and E13 stated there are currently no future meetings scheduled. On 07/01/16 at 12:20pm, E23, Director of Nurses(DON), stated QA has not met since she took the position of DON on 06/02/16 and there are no future meetings scheduled at this time. On 07/01/16, E3, Administrator stated she took the position of Administrator on 04/25/16, and she stated she plans to implement a QA program but has not yet done so. E3 stated there has been no QA committee meeting following the 05/31/16 fire at the facility and no future meetings are scheduled at this time. An undated Quality Assurance Process Improvement and Compliance Policy stated , This organization will implement and maintain an active quality assurance process and improvement(QA) program collect relevant information and data necessary to identify areas of risk, to detect potential opportunities for improvement and to evaluate ongoing systems and processes to evaluate and prioritize activities to address areas of risk and opportunities for improvement focusing on areas of high risk, high volume, and problem prone areas. A 672 Census and Condition of Residents dated 06/02/16 showed the facility has a census of 106. The facility could not provide any documentation, such as attendance sign in sheets, that QA meetings had occurred in 2015 or 2016.

Based on observation, interview, and record review, the Facility failed to provide timely assessessment and monitor for changes in condition for one of 4 residents (R10) reviewed for possible aspiration and pain in the sample of 28. This failure resulted (R10) having a delay in hospitalization and treatment. R10 was admitted to a local emergency and subsequently to the Intensive Care Unit, with [DIAGNOSES REDACTED]. Findings include: R10's Admission Sheet documents [DIAGNOSES REDACTED]. R10's Care Plan, dated 2/9/15, documents a Problem of "at risk or altered nutrition and dehydration, related to a [DIAGNOSES REDACTED]. Diet as ordered, Water flushes, monitor for signs of dehydration, R10 is at risk for nutrition and dehydration [DIAGNOSES REDACTED]." The Care Plan - Pain, dated 2/9/15, documents; R10 is at risk for pain... Signs/ Symptoms of pain will be identified and pain interventions will be implemented immediately. The Facility's Pain Management Monthly Flow Record documents on 4/13/2015 Day shift Pain Intensity = 8, Very Severe. Non - Verbal signs are #2, Tightly Closed, wide open, blinking eyes, #3, crying moaning, and #6, guarding an area of the body. Interventions included giving [MEDICATION NAME] 5/325, at 1:44 AM for "complaints of pain". Other interventions of turning and repositioning were documented as ineffective. For the day shift when pain was documented to be Very Severe, no other interventions drug or non-drug were documented. There is no documentation the Z3, (Physician) was notified of R10's pain. On 4/14/2015 the Facility's Pain Management Monthly Flow Record documents Score = 6, Severe Pain. Non verbal signs of pain are #9, Irritability and #1, facial wrinkling, grimacing. Interventions included [MEDICATION NAME] 0.5mg (milligrams) given for "constant yelling out / increased agitation." Non-drug interventions included turning and repositioning. There is no documentation of interventions on the day shift where it is documented R10 is in pain. There is no documentation Z3, (Physician), was notified of R10's pain. On 4/16/2015, during multiple observations from 11:04 AM through 1:30 PM, R10 was observed lying crumpled down in her bed and moaning off and on. Throughout this time R10 had dried green pasty material, which appeared to be vomitus, crusted around her mouth, down her chin and neck, and on the front of R10's gown. The green vomitus was on her bed linens, extending from R10's shoulder to her hip. During this time R10 smelled of feces. At 12:15pm, R10 remained in bed with the dried vomitus on her face/neck and a small hand towel had been placed over the vomitus on her gown and she continued to smell of urine and stool. At 1:30pm, E6 (Certified Nurses Aide) was in her room and had just rolled her over and placed a mechanical lift sling under her for a shower. The sheet was soaked with brown urine and smelled strongly of bowel movement. On 4/16/15 the The Medication Administration Record [REDACTED]"hurts". The pain management record does not document R10's having pain or the interventions. Pain Management record and Nurse's notes for the day shift failed to document any information on R10's moaning / pain, or vomiting. The 4/16/15 Medication Administration Record [REDACTED]. On 4/16/15, at 1:30 PM, a 1000 cubic centimeter (cc) bottle of Glucerna 1.2 was attached to R10's feeding tube. The bottle was labeled "4/16/15, 2:30 AM, amount 5." R10's tube feeding pump was turned off until 5:05 PM with 850 cc remained in the bottle. Physicians orders dated 3/27/15 documented rate of 50 cc's per hour for 23 hours. Calculation of the flow rate from time of hanging at 2:30 AM, indicates there should have only been 300 cc's remaining in the bottle at 5:05 PM . At 5:05 PM, E18 turned on R10's tube feeding pump at a rate of 75 cc's per hour. On 4/16/15 at 18:25 (6:25 PM), E3 (Assistant Director of Nursing) documented the discrepancy in the [DEVICE] rates in her Nurses Notes. At this time she called Z3, to clarify orders, and documented "informed Z3, resident weight stable, no Nausea and Vomiting", orders received to resume tube feeding at rate prior to hospitalization , "that there is no harm done," will continue to monitor resident." In a telephone interview on 4/28/15 at 3:22 PM, E36, Certified Nurses Assistant (CNA) stated "I did work with R10 on 4/16/15. R10 did have several, 2 -3 emesis of large amounts. I told E32, (Licensed Practical Nurse, LPN), about R10's emesis. I was told to keep the head of her bed elevated. At 1:30 I took R10 to the shower and cleaned her up. In a telephone interview on 4/28/15 at 3:50 PM, E32, (LPN0, stated " I worked on day shift (6:30 Am to 2:30 PM) on 4/16/15, R10 did have 2 emesis. R10 has a history of vomiting (previously when she ate), and sometimes now with her [DEVICE]. I gave her the PRN (as needed) medication as ordered on her Medication Administration Record. No, I did not chart on this, as it was a busy day and I did not do it." A review of R10's PRN-Medication sign off record found no documentation that E32 on 4/16/15, had given any medication to R10 for her 2 episodes of vomiting. E32 also stated, "I did not tell anyone that R10 had vomited that day." In a previous interview on 4/24/2015 at 11:00 AM, E3, Assistant Director of Nursing (ADON) stated R10's typical demeanor is she usually chats a sort of singing sound but no moaning nor groaning. E3 stated that on 4/16/15, she had not been told by E32 that R10 had vomited earlier on the day shift. Also, she (E3) had not assessed R10 when she wrote her Nurses Note that R10 "had not" vomited that day. E3, did not know if E18, (LPN/evening shift), had assessed R10, prior to her (E3's) calling Z3 on 4/16/15 and telling him E3 was "stable with no nausea/vomiting." E3, stated she would have expected the staff nurse to complete a physical assessment of the resident before calling the doctor, especially if vomiting was reported, but no nausea and vomiting had been reported from either day or evening shift. On 4/24/2015 at 2:12 PM, E34, (RN) stated "I was the RN caring for R10 the night of 4/16/2015 - 4/17/15. E34 stated it had been reported to her at 5:00-5:15 AM, by E35, (CNA) that R10 had two emesis. I documented it at "06:25 AM, two emesis". E34, (RN), said she noticed the vomitus was brown and had assessed R10's bowel sounds and skin. E34, (RN) stated R10 didn't respond or make eye contact, which R10 usually did respond to others and did make eye contact. E34, RN then felt her abdomen "it was firm and that is enough to call the doctor." The tube feeding had been running throughout the night at the same rate set by the second shift. E34 could not recall the rate. On 4/29/15 at 2:45 PM, Z3, (Physician on Call), stated; on 416/15, stated that he had been called for orders for R10's [DEVICE] feeding. At that time he had not been told R10 had vomited during the day. He stated that although she does have a history of periodic vomiting, he feels the staff should have told him, he would want to know. Z3, stated if he does not know if sending R10 to the hospital sooner would have changed her outcome, due to her multiple medical problems, but had he known of the nausea and vomiting, he would have admitted R10 to the hospital for fluids and evaluation, earlier that day. As it was, Z3 stated he was not called until 4/17/14 and told R10 had vomited. On 4/29/15 at 3:35 PM, a telephone interview was conducted with E1- (Administrator), E2 - (Director of Nursing), and E30, (Regional Nurse). E30 stated, "it was normal for R10 to have emesis, and staff would not have called the physician as it was not seen as a change in R10's condition. E1 stated, Z5 (Primary Physician), "would not" have wanted to be called for vomiting as it was normal for her to vomit at times. When informed of R10's observed condition on 4/16/15 of moaning, and laying in vomit, E1, E2 and E30 stated they were not aware of this, and would check with their staff. E1, E2, and E30 stated they were not aware of R10 having documented pain for 2 days prior to 4/16/15. E1, E2, E30 stated they were not aware E32 had not documented R10's episodes of vomiting or that she had given R10 PRN medications for vomiting. They stated that they were also not aware that on 4/16/15, E32 had not told any staff either verbally or in writing of R10's vomiting and moaning multiple times that day. E2 stated "we will have to address that internally." E1, E2, and E3 stated "they would review R10's record and talk to staff to find out why, (if R10 routinely vomited), there was no record of nursing staff giving PRN-anti-nausea medications documented in the Medication Administration Record [REDACTED]." On 4/29/15 at 4:20 PM, Z5, (Primary Physician of R10), stated "R10 did have a history of Nausea and Vomiting, but R10 also has a history of vomiting when she has a UTI (urinary tract infection) that is becoming septic. Z5, stated, the facility should have been aware of the history of R10's UTI's and vomiting. As R10 does have PRN (as needed) medications for vomiting, but it would only be normal if it was a one time spontaneous event. However, if she had vomited two or three times already I (Z5) would want to know she had vomitied to rule out possible issues of being septic or other problems due to her history of gastroparesis." Z5, stated, "because R10 had multiple medical issues, it is better if staff called the physician and informed them of the nausea, vomiting, and pain, and let the physician determine if this was something that needed to be addressed or not. If R10 was having nausea, vomiting, and pain, it would indicated something was wrong and probably needed to be seen by the physician. In the case of R10 on 4/16/15, she could have been sent to the hospital sooner, and treatments, surgical options or Hospice could have been discussed and offered to the family." The Facility policy Change in Condition / Notification dated 2/23/09, documented; It is the responsibility of licensed staff to contact the physician and resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status. Definition: 1. A change in condition is any assessment finding, observance, or event that deviates or has the potential to cause a deviation in the resident's usual or expected physical, mental or psychosocial status. Policy: Upon identification of a change in condition licensed nursing personnel will contact the resident's physician to notify him / her of the change. All notifications should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions. Examples of Changes in Condition: (include but not limited to) Emesis or Diarrhea, Symptoms of an Infectious Process with or without fever, Abnormal reports of Pain, Subjective reports made by the resident "I don't feel good, something is wrong", contact physician after thorough physical and mental assessment.

Based on observation, interview, and record review, the Facility failed to provide timely monitoring and ensure food intake met the required amount as ordered by the physician for 4 of 4 residents (R3, R10, R12, & R19) with Gastrostomy Tubes ([DEVICE]s) observed for adequate hydration, nutrition and weight loss in the sample of 28. This failure resulted in significant weight losses for R3, R19, and R10 and R19 being admitted to the hospital with [REDACTED]. Findings include: 1. The MDS dated [DATE] documents R19 was readmitted to the facility on [DATE] following a hospitalization for Dehydration, Dysphasia, Constipation and Urinary Tract infection in part. The MDS documents R19 to have moderate cognitive impairment and requires total assistance of staff for all activities of daily living. The care plan dated 3/3/15 identifies the tube feeding and includes interventions that all R19's calories and fluid needs will be met by 6/3/15 and staff are to monitor for signs/symptoms of dehydration, report problems to nurse. The monthly weight record, documents R19's January 2015 weight was 157.6 pounds. Registered Dietician (RD) notes dated 2/24/15 document that R19 went from an oral feed and tube feeding to NPO (nothing by mouth.) R19 was totally dependent on his tube feeding to supply all his fluid and nutritional needs prior to his hospitalization in March. An RD note dated 3/24/15 document for the month 3/2015 R19's weight was 148.2 pounds. This is 5% decrease in 1 month, 7% decrease in 3 months, 9% in 6 months. An order was given for Glucerna 1.2 to be given at 70cc/hour for 21 hours per day, at total of 1470cc/day. The Nurses Notes of 4/09/15 at 2:15pm, document R19 weighed 142.4 pounds. This is a 5.2% weight loss despite the fact that he receives all his nutritional needs from his tube feeding. The Nurses Notes dated 4/9/15 document that the RD was called due to weight loss and the tube feeding was increased to Glucerna 1.5 70cc/hour with 200cc every 4 hours water flush. The April physician's orders [REDACTED]. The POS also documents [REDACTED]. The Nurses Notes on 4/17/15 at 9:18 AM documents; R19 is up in the reclining chair with tube feeding infusing well. On 4/18/15 at 2:15PM, the nurse documents R19 to have an elevated temperature of 100.5 axillary with clear urine draining from his urinary catheter. At 3:55PM, the physician's office calls and a U/A (urinalysis) was ordered with a culture and sensitivity. At 5:50pm, the nurses notes document R19 having "no eye focusing, mouth breathing. Skin cool to touch. Facial perspirations noted. Moans out at intervals at this time" Blood pressure 102/58, Temperatures 101.4 axillary, pulse 116, and respirations 16. The physician was called again and R19 was sent to the emergency room . The Nurses Notes documents At 6:58PM, R19 was sent to the hospital. At 10:35PM, the hospital called and R19 was admitted to the Intensive Care Unit. emergency room hospital records dated 4/19/15 document R19 to have "pale and dry mucosa" with current problems listed as "Septic Shock, Acute Urinary Tract Infection, Dehydration, Acute/[MEDICAL CONDITIONS], and Acute [MEDICAL CONDITION]." The April 2015 Medication Administration Record (MAR) shows all flushes and feedings initialed by nursing staff for all three shifts. However, the Fluid Intake and Output Record which documents the [DEVICE] feeding amounts actually administered are incomplete for the month of April, 2015. No 24 hour amount was calculated to ensure that R19 is receiving the ordered amount of feeding. Based on 70cc/hour for 21 hours, R19 should be receiving 490cc per shift or 1470cc per 21 hours. The Intake records document on 4/18/15 for day shift (6:30am-2:30pm) that R19 received 477 cc of tube feeding and on 2nd shift (2:30pm to 10:30pm), he was documented as receiving 376cc. Nothing is recorded for the night shift, for a total of 853cc/24 hours. On 4/17/15, day shift is blank, 2nd shift - 417, and 3rd shift, 329cc, totaling 746cc/24 hours. On 4/15, 1st shift is documented as 560cc, 2nd as 420, and 3rd 914cc for a total of 1894cc. The facility was unable to provide the week prior to 4/15/15 and only three weeks of intake records for March were provided and those were incomplete. There is no evidence that the facility assessed R19 to determine a causative factor as to why R19 would present to the hospital with dehydration on his readmission to the hospital in April. There is no documentation in regards to any assessments being done or evidence that nurses closely monitored R19's feeding to ensure his nutritional and hydration needs were met. On 4/22/15 at 11am, E20, (RD), stated she does not routinely look at the intake records when she evaluates residents on [DEVICE]s, but asks the nurses how the residents are doing. E20 stated she would expect the nurses to follow physician's orders [REDACTED]. E20 stated she thinks the nurses are doing the feedings and flushes but has not considered that a factor. E2 stated she was unable to determine why R19 would have dehydration if he received all his feedings and flushes. E20 when asked if she expected the nurses to follow orders and administer the amount prescribed stated "you and I both know orders are orders and everyone should follow them." 2. The MDS dated [DATE] identifies R3, as being admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R3 requires extensive assist of one staff for most activities of daily living and has severe cognitive impairment. According to the February 2015 POS, R3's tube feeding was [MEDICATION NAME] 1.5, given Bolus 300cc every 4 hours via enteral syringe, with a 120cc water flush every 6 hours. At that time, R3 was also receiving an oral diet of puree food. The 2015 March Medication Administration Record, MAR, show nursing staff initials documented the tube feeding being given every 4 hours around the clock with the water flushes every 6 hours. Dietary History and Initial Screening dated 1/30/15 have R3's weight as 152.8 pounds. The RD documents R3 consumes approximately 25-50% of his meals and that the tube feeding provided 51% or more of Kcal and greater than 51% of fluid needs per day. Rd note dated 3/23/15, documents R3's March 2015, weight was 145 pounds, a 7.8 pound weight loss with the tube feeding every four hours and an oral tray. R3's weight on 4/2/15 was recorded as 136.6 pounds, an additional 9 pound weight loss. R3 has lost a total of 9.43% of her body weight in 63 days (from 1/30/15 to 4/2/15). There is no indication the facility staff assessed R3's weight loss to determine what could be contributing to R3's weight loss, although feedings were recorded as given. E33's, (Dietary Manager), note, dated 4/14/15 documents "resident is now NPO (nothing by mouth) status as of 4/13/15. Will update order when received. Weight for April is 136.6 and March 145, resident has had a 9 # (pound) weight loss in 30 days (5.8%). RD will assess upon next visit. E33's note did not document the total overall weight decline of 9.43% since 1/30/15. On 4/20/15, R3's tube feeding was changed due to weight loss with an order for [REDACTED]. There is no corresponding RD note with this change. The MAR documents the every three hour feeding and shows that on average, R3 gets his feeding 7 times a day or approximately 2100cc of feeding with some days recorded as little as 4 times/day, and some as much as 8 times/day. The information on the MAR conflicts with the Intake and Output records. Examples include: On 4/20 and 4/21/15, the 3rd shift nurses initialed R3 getting 300cc at 12am, 3am and 6am (900cc) but on the intake record, wrote in only 600cc. On 4/19/15, day shift initialed R3 getting 300cc at 9:00AM, 12:00pm and 3:00pm but only documented 600cc on the intake record. On 4/17/15 at 2:30pm, (R3's wife), Z1 stated she always questioned whether R3 was getting enough feeding when he was first admitted because she donated cases of [MEDICATION NAME] and with the order being 300cc, nurses would have to use one whole can and about 60cc from a second can. Z1 stated she observed the nurses giving just one can and then in the most recent past, observed a nurse "shooting his feeding in using a syringe" because she said she was in a "hurry." Z1 stated she also felt staff didn't spend enough time feeding him when he could eat. Z1 stated she talked to facility staff about it but was unable to give names of who she spoke with. Z1 stated R3 has lost a great deal of weight since admission and she was concerned that he wasn't getting enough. On 4/21/15 at 12:00 noon, E16 Licensed Practical Nurse (LPN) checked placement and flushed R3's [DEVICE] before giving him 300 cc of [MEDICATION NAME] per gravity with a syringe. On 4/22/15 at 11:40am, E20 (RD) was asked about the discrepancies between the MAR and the intake record and R3's overall weight loss while getting a [MEDICATION NAME] around the clock. E20 stated she did not routinely look at the intake records or the MAR and that she relies on the charge nurse to tell her about residents. E20 stated the order for 300cc when awake was not her order but agreed that it leaves some question as to whether or not he's getting what he needs daily in his tube feeding. E20 stated she also does not routinely observed residents eating or tube feedings but evaluates the resident monthly and is called all the time with questions. 3. The Admission Record identifies R12 as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R12 to be dependent on staff for all activities of daily living and have cognitive impairment. The April 2015, physician's orders [REDACTED].@ (at) 60cc/hour for 23 hours continuous, flush with 150cc of water every 4 hours, 30cc with medications. The 23 hour total amount for [MEDICATION NAME] should be 1380cc or approximately 460cc/shift. R12's weight record documents her weights as 4/3/15 - 134 pounds and on 4/14/15 as - 131 pounds. On 4/17/15 at 8:05am, R12 was in bed, slouched down with her tube feeding running at 60cc/hour per pump. The 1000cc bottle of [MEDICATION NAME] 1.2 had 675cc left in it and was labeled as being hung on 4/16/15 at 2200 (10pm) which is approximately 10 hours. The bottle of 1000cc had 675cc left in it at 8:05am. Calculating the feeding at 60cc an hour for 10 hours results in 600cc should have infused. R12's feeding showed a deficit of 275cc, that R10 did not receive for the 10 hours . On 4/21/15, at 4:00pm, R12's tube feeding was running at 60cc/hour per pump. The 1000cc bottle of [MEDICATION NAME] 1.2 had 400cc left in it and was labeled as being hung at 1:30am on 4/21. Calculating 14.5 hours times 60cc equals 870cc. R12's feeding was again 270cc less than should have infused since the time the bottle was hung. The Intake and Output Sheets from 4/16/15 have 3rd shift documenting 293cc, daily shift 582cc and no amount documented for 2nd shift (a total of 875cc for day). On 4/17/15, 3rd shift recorded 617cc/shift, day shift 330cc/shift and nothing recorded for 2nd shift (at total of 947cc for day). On 4/18/15, only day shift documented 854cc for 24 hours. On 4/19/15 only 3rd shift documented 483cc (no other for day). On 4/20/15, 3rd shift recorded 580cc and day shift - 321cc with nothing recorded on 2nd (a total of 901 for day). On 4/21/15, the nurses have documented an intake of 305cc/night shift and 405cc per day shift and again, none recorded for 2nd shift (a total of 710cc). All of the above days documentation indicated R12 failed to meet her required intake of 1480cc/day. On 4/22/15 at 8:15am, E30, (Corporate Nurse) stated the facility had identified an issue with tube feedings and weight loss and had been working on it recently the past couple months. E30 agreed that nurses should be aware of what feeding amount is to be given during their shift and a 24 hour amount should be calculated especially if weight loss is occurring. The Facility's Policies, Standards, Protocols, and Procedures Manual Enteral Feeding Delivery Policy dated 12/06/12, documents; "Adequate nutritional support through enteral feeding will be provided to residents that are unable to meet their dietary needs through the oral intake of food. Enteral feedings will be administered in a manner that promotes resident dignity, safety and function.." Policy Guidelines and Interpretation #2, A physicians's order specifying type of solution, rate and frequency is required. #4, The nurse will confirm that there are appropriate, by mouth (PO) or nothing by mouth (NPO), orders for all residents with tube feedings. The decision to allow or disallow PO will be made in conjunction with the physician, Registered Dietitian and the Speech Therapist, as appropriate, given resident [DIAGNOSES REDACTED].#8, The following procedure is contraindicated if the resident's tube is obstructed, improperly positioned, the resident is vomiting, bowel sound are absent, or if the resident appears to be in respiratory distress. Procedures / Pump #4, Monitor resident for signs and symptoms of aspiration and/or feeding intolerance." #5, On the formula label document resident's name, date and time formula was hung/administered, formula type, if using a feeding bag, and rate/amount to be infused and initials of person performing procedure. #6, Flush tube as ordered by physician. 4. R10's Admission Sheet documents [DIAGNOSES REDACTED]. R10's Care Plan, dated 2/9/15, documents a Problem of "at risk or altered nutrition and dehydration, related to a [DIAGNOSES REDACTED]. Diet as ordered, Water flushes, monitor for signs of dehydration, R10 is at risk for nutrition and dehydration [DIAGNOSES REDACTED]." Monitor for incontinence frequently. Monitor and document bowel movements (BM), report diarrhea, constipation or no BM in 3 days. [DEVICE] Flushes and care as ordered. Diet as ordered water flushes. R10's Physician order [REDACTED]. Flush PEG (Percutaneous Endoscopic Gastrostomy) tube with 150 cc's Q-4 hours (every) via enteral syringe. Flush 150 cc every 4 hours (with water)." From 3/27/15 through 4/7/15 the Interdisciplinary Progress notes indicate R10 received Glucerna 1.2 at 50cc/hr X 23 hours. However, on 4/8/15 the nurses notes document [DEVICE] patent infusing at 75 cc per hour flushed without difficulty. Per physician's orders [REDACTED]. Review of R10's Fluid Intake and Output record from 4/1/15 to 4/16/15, documented multiple inconsistencies in the amount of [DEVICE] feeding R10 was given. Nursing staff failed to calculate and document the 24 hour total intake for R10 during this time. R10's intake per shift was totaled by the surveyor and found for 24 hours the following amounts infused: 4/1/15 - 1236cc, 4/3/15 -790cc, 4/4/15 - 1390cc, 4/5/15 - 1662cc, 4/7/15 - 960cc, 4/9/15 - 1511cc, 4/10/15 - 1632cc, 4/11/15 - 1660cc, 4/12/15 - 1700cc, 4/14/15 - 904cc, and 4/15/15 - 1872cc. On 4/2/15, 4/6/15, 4/8/15, and 4/13/15, no amounts were recorded. During this time for three days R10 received 200cc to 400cc less feeding than required. And the rest of the days received between 100cc and 900cc more per day than ordered by the physician. No information was given for these discrepancies in R10's intake. On 4/16/2015, during multiple observations from 11:04 AM through 1:30 PM, R10 was observed lying crumpled down in her bed and moaning off and on. Throughout this time R10 had dried green pasty material, which appeared to be vomitus, crusted around her mouth, down her chin and neck, and on the front of R10's gown. The green vomitus was on her bed linens, extending from R10's shoulder to her hip. R10 smelled strongly of feces. On 4/16/15, at 1:30 PM, a 1000 cubic centimeter (cc) bottle of Glucerna 1.2 was attached to R10's feeding tube. The bottle was labeled "4/16/15, 2:30 AM, amount 5 (?)." R10's tube feeding pump was turned off from 1:30 PM until 5:05 PM with 850 cc remained in the bottle. Calculation of the flow rate from time of hanging at 2:30 AM to 5:05 PM, indicates there should have only been 275 cc's remaining in the bottle (not 850cc). On 4/16/15 at 5:05 PM, E18, Licensed Practical Nurse (LPN), stated "she checked for R10's tube feeding order on the current monthly Medication Administration Record (MAR) dated 4/2015 which documents "Glucerna 1.2 at 75 cc's per hour from 7:00 PM to 7:00 AM ." (order is inconsistent with current MD order of 50cc/hour for 23 hours.) E18 stated she then turned on R10's tube feeding pump at a rate of 75 cc's per hour. On 4/22/15 at 11am, E20, (RD), stated she does not routinely look at the intake records when she evaluates residents on [DEVICE]s, but asks the nurses how the residents are doing. E20 stated she would expect the nurses to follow physician's orders [REDACTED]. E20 stated she thinks the nurses are doing the feedings and flushes but has not considered that a factor. E2 stated she was unable to determine why R19 would have dehydration if he received all his feedings and flushes. E20 when asked if she expected the nurses to follow orders and administer the amount prescribed stated "you and I both know orders are orders and everyone should follow them." E2 stated that she though R10 was doing fine, but was not aware R10 had been hospitalized . On 4/24/2015 at 11:00 AM, E3, Assistant Director of Nursing (ADON) stated "On 4/16/15 I spoke to Z3, (Physician on call). He told me to write for the Glucerna to be given per the previous admission order. I wrote the order on 4/16/15 for R10's Glucerna to run 75cc / hour for 23 hours. I was not aware the [DEVICE] feeding should be from 7:00 PM to 7:00 AM only. I did not verify the order against the original in the chart." Additionally, E3 stated she had not been told by E37 that R10 had vomited earlier on the day shift. On 4/24/2015 at 2:12 PM, E34, (RN) stated "I was the RN caring for R10 the night of 4/16/2015". She stated she had documented at "06:25 two emesis". The emesis had been reported to her at 5:00-5:15 AM when the E35, (CNA) showed her the linens with emesis. E34, (RN) noticed the vomitus was brown and had assessed R10's bowel sounds and skin. E34, (RN) stated R10 didn't respond or make eye contact, which R10 usually did respond to others and make eye contact. E34, (RN) then felt her abdomen "it was firm and that is enough to call the doctor." The tube feeding had been running throughout the night at the same rate set by the second shift. E34 could not recall the rate. R10 was transferred from the Facility to the local hospital emergency room (ER) on 04/17/15. The local hospital ER report documents R10 [DIAGNOSES REDACTED]. R10 was treated with bolus fluids and admitted to the hospital. On 4/29/15 at 2:45 PM, Z3, (Physician on Call), during interview stated; on 4/16/15, stated that he had been called for orders for R10's [DEVICE] feeding. At that time he had not been told R10 had vomited during the day. He stated that although she does have a history of periodic vomiting, he feels the staff should have told him, he would want to know and had he known of the nausea and vomiting, he would have admitted R10 to the hospital for fluids and evaluation, earlier that day.

Based on observation, interview and record review, the facility failed to provide safe bed mobility to prevent injury for one of eight (R3) reviewed for falls in the sample of 24. This failure resulted in R3 sustaining a fracture of the left tibia. Findings include: 1. R3's physician's orders [REDACTED]. R3's Minimum Data Set (MDS), date 3/18/2014, documents she has a Brief Interview of Mental Status (BIMS) Score of 14 (13-15 cognitively intact). On 4/8/2014, at 9:44 AM, during the initial tour of the facility, an interview was conducted with E6, Quality Assurance Nurse/Licensed Practical Nurse (LPN). E6 stated R3 rolled out of bed and sustained a fracture. On 4/8/2014, at 9:44 AM, R3 was lying in bed with two assist side rails on the top of each side of the bed. R3 was obese. R3 had a splint on her left arm. The Facility's Patient Comprehensive Event (PCE) Reporting Form, dated 12/08/2013, documents "0500 - Informed by CNA that Resident was on the floor - CNA stated that resident rolled out of the bed while she was providing peri care on arrival to residents room she was noted on the floor on her back between the fridge and the heating unit, was able to get her off the floor using hoyer lift. " On 4/8/2014, at 11:22 AM, R3 was lying in her bed on her back. When questioned how she fractured her ankle, R3 responded "I didn't fracture it. I had help." R3 stated a Certified Nurses Aide (CNA) came into her room and was cleaning her up. R3 stated the CNA asked her to roll over. R3 stated she rolled over and reached for her side rail which was not in the up position. R3 stated she continued to roll off the bed. R3 stated "I'm not sure why she would tell me to roll when there was nothing there to grab. I kept rolling." R3's MDS, dated [DATE], the assessment completed prior to her sustaining the fracture, documents she requires assistance of one staff person with bed mobility, transfers and toileting. The Care Plan also documented 1/2 siderails X 2. The MDS documents she is incontinent of bowel and bladder. The Facility's Record of V/S (Vital Signs) and Weights for December 2013 documents R3 weighed 317.2 pounds. On 12/16/13 R3's Care Plan documented an update indicating R3's need for 2 staff assist due to her History of CVA with Left Sided [DIAGNOSES REDACTED], History of Morbid Obesity, and recent fall. On 4/10/2014, at 1:10 PM, an interview was conducted with E7, CNA Supervisor. E7 stated she spoke to E8, CNA, because she was the CNA who cared for R3 when she rolled off the bed. E7 stated E8 usually took care of R3 by herself, and on the night R3 rolled off the bed. E7 stated E8 asked R3 to roll over and R3 rolled off the bed. E7 stated R3's legs rolled off the bed first and then she (R3) kept rolling.