Every finding on record at La Bella of Freeburg

Based on interview, observation, and record review, the facility failed to provide complete and timely incontinent care for 2 of 3 residents (R9 and R14); reviewed for Bowel/Bladder Incontinence in a sample of 16. This failure resulted in R14 expressing feelings of embarrassment and displaying dissatisfaction with care.Findings include:1.R14's Facesheet with a print date of 8/13/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute cystitis, chronic obstructive pulmonary disease, chronic kidney disease and difficulty walking.R14's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene and was dependent on staff for toileting transfers. R14's MDS further documented she was frequently incontinent of urine and bowels.R14's Care Plan dated 9/2/24 documented she is incontinent of bladder with interventions for staff to change disposable briefs per schedule and as needed and also to clean peri-area with each incontinent episode.On 8/13/26 at 9:51 AM, R14 was waiting in her wheelchair outside the restroom in front of the nurse's station. R14's head was down, she did not have a smile on her face and stated angrily she had been waiting for the restroom too long.On 8/13/26 at 10:00 AM, R13 was wheeled in line with two residents behind R14. At 10:02 AM, V17 (certified nursing assistant/CNA) wheeled R13 from behind R14 into the restroom. R14 was left waiting still.On 8/13/26 at 10:05 AM, V19 (CNA) and V20 (CNA) assisted R14 into the restroom. V19 and V20 assisted R14 on to the toilet after pulling down her brief that was soiled with urine. R14 had a bowel movement on the toilet. V20 wiped R14's midline peri region from front to back with a peri wipe, folded the same soiled wipe and wiped R14's stool that remained and then removed her gloves and put new gloves on without completing hand hygiene. V19 assisted R14's new brief on and V20 came to apply the right side, and both pulled her pants up.On 8/13/26 at 10:15 AM, R14 stated she has to wait for the restroom a long time often and it makes her feel bad and embarrassed when she needs to be changed when she soils herself. R14 stated, It shouldn't take that long, it should be more timely.On 8/13/26 at 10:24 AM, V2 (director of nursing/DON) and V15 (assistant DON/ADON) watched video surveillance of the hallway where R14 was waiting for the restroom. V15 stated, That is R14 at 9:35 AM, rolling up to the restroom. R14 was visualized waiting to use the restroom on the camera outside the nurse's station on 8/13/26 at 9:35 AM. V2 and V15 stated R14 should not have waited 35 minutes for the restroom. V15 stated she sees R13 getting pushed into the restroom before R14 also and not sure why. 2. R9's Facesheet with a print date of 8/13/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic kidney disease, weakness, and Alzheimer's disease.R9's MDS dated [DATE] documented she is severely cognitively impaired and was dependent on staff for toileting hygiene and transfers, always incontinent of both bowel and bladder.R9's Care Plan revised on 3/23/25 documented R9 has ADL self-care needs with interventions revised on 5/7/26 that she is dependent on toileting hygiene and to toilet every two hours while awake.R9's Care Plan revised on 2/4/25 documented she is incontinent of bladder with intervention revised on 5/7/26 for staff to change disposable brief per schedule and as needed and on 2/4/25 for staff to clean peri-area with each incontinence episode.On 8/12/26 at 10:20 AM, R9 was sitting in her wheelchair in a line in front of the nurse's station for the restroom. Under R9's wheelchair was a wet solution on the floor piling up. R9's pants around her groin region were saturated as she sat seemingly asleep.On 8/12/26 at 10:35 V11 (CNA) and V12 (CNA) assisted R9 to the restroom. V12 stated R9 is typically incontinent, known as a heavy wetter and she has soiled herself already. V11 and V12 used a partial body mechanical lift to transfer R9 to the toilet. V12 removed R9's saturated brief with urine and her wet pants. V11 returned with a new brief and new pants for R9. As R9 was standing with the partial body lift, V12 used his gloved hands to wipe R9's midline peri region with one wipe of wrapped toilet paper with peri spray, threw it in the toilet and then took another wrapped bundle of toilet paper with peri spray and wiped the same region then threw it in the toilet. V12 did not wipe R9's front peri region/buttocks that were saturated with urine from her brief and applied her new brief with pants.On 8/13/26 at 8:19 AM, V2 stated, Peri care should be provided to any resident that is visibly soiled right away; they shouldn't be waiting 15-20 minutes. V2 stated, All areas of the skin that were soiled should be cleaned during incontinent care.On 8/13/26 at 8:50 AM, V15 stated, Staff are supposed to perform peri care from front to back and clean all soiled areas of the skin. V15 noted in the situation that a resident has a puddle of urine and saturated pants waiting in front of the nurse's station, the resident should have been cleaned before 15-20 minutes passed. V15 noted hand hygiene and glove changes should be done from dirty to clean. V15 noted hand hygiene should be done after wiping a resident's peri region and a change of gloves before touching anything clean to prevent the spread of germs. V15 noted she expects staff to be following the infection control policy and completing timely incontinent care.On 8/18/26 at 9:35 AM, V1 (administrator) noted she expects staff to clean all soiled regions of the skin for peri care, and she expects staff to provide incontinent care for a resident who is visibly soiled as soon as possible when they notice. V1 noted she does not expect residents to have feelings of embarrassment for being incontinent from waiting for the restroom. V1 stated, It is disappointing to hear R14 felt that way and we are always looking for ways of improvement.The facility's Incontinence Policy, undated, documented the facility must ensure residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. The policy continued to document residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on interview, observation, and record review the facility failed to complete hand hygiene and glove changes during incontinence care for 2 (R9, R14) of 3 residents reviewed for Infection Prevention and Control in a sample of 16.Findings include:1.R14's Facesheet with a print date of 8/13/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute cystitis, chronic obstructive pulmonary disease, chronic kidney disease and difficulty walking.R14's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene and was dependent on staff for toileting transfers. R14's MDS further documented she was frequently incontinent of urine and bowels.R14's Care Plan dated 9/2/24 documented she is incontinent of bladder with interventions for staff to change disposable briefs per schedule and as needed and also to clean peri-area with each incontinent episode.On 8/13/26 at 10:05 AM, V19 (certified nursing assistant/CNA) and V20 (CNA) assisted R14 into the restroom. V19 and V20 assisted R14 on to the toilet after pulling down her brief that was soiled with urine. R14 had a bowel movement on the toilet. V20 wiped R14's midline peri region from front to back with a peri wipe, folded the same soiled wipe and wiped R14's stool that remained and then removed her gloves and put new gloves on without completing hand hygiene. V19 assisted R14's new brief on and V20 came to apply the right side, and both pull her pants up. V19 removed the gait belt from R14 without removing her gloves or performing hand hygiene prior. V20 removed her gloves and gave R14 a high five and wheeled R14 out of the restroom touching the wheelchair handles and door.2. R9's Facesheet with a print date of 8/13/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic kidney disease, weakness, and Alzheimer's disease.R9's MDS dated [DATE] documented she is severely cognitively impaired and was dependent on staff for toileting hygiene and transfers, always incontinent of both bowel and bladder.R9's Care Plan revised on 3/23/25 documented R9 has ADL (activity of daily living) self-care needs with interventions revised on 5/7/26 that she is dependent on toileting hygiene and to toilet every two hours while awake.R9's Care Plan revised on 2/4/25 documented she is incontinent of bladder with intervention revised on 5/7/26 for staff to change disposable brief per schedule and as needed and on 2/4/25 for staff to clean peri-area with each incontinence episode.R9's Lab Result resulted 7/3/26 documented urine culture was positive for Escherichia coli.R9's Order's dated 7/3/26 documented levofloxacin to be given for a UTI (urinary tract infection).On 8/12/26 at 10:35 V11 (CNA) and V12 (CNA) assisted R9 to the restroom. V12 stated R9 is typically incontinent, known as a heavy wetter and she has soiled herself already. V11 and V12 used a partial body mechanical lift to transfer R9 to the toilet. V12 removed R9's saturated brief with urine and her wet pants. V11 returned with a new brief and new pants for R9. As R9 was standing with the partial body lift, V12 used his gloved hands to wipe R9's midline peri region with one wipe of wrapped toilet paper with peri spray, threw it in the toilet and then took another wrapped bundle of toilet paper with peri spray and wiped the same region then threw it in the toilet. V12 did not remove his gloves, complete hand hygiene or wipe R9's front peri region/buttocks that were with urine from her brief and applied her new brief with pants. V12 with the same dirty gloves on, operated the partial body mechanical lift and adjusted R9's sling before removing them and completing hand hygiene and leaving the restroom did not wipe down the lift after leaving.On 8/13/26 at 8:19 AM, V2 (director of nursing/DON) stated staff should be completing hand hygiene before entering and leaving the room, after going from dirty to clean surfaces and glove changes from dirty to clean. V2 stated staff should complete hand hygiene prior to touching equipment after providing care such as a mechanical lift because that spreads nasty germs if you don't.On 8/13/26 at 8:50 AM, V15 (assistant DON/ADON) stated hand hygiene and glove changes should be done from dirty to clean. V15 stated hand hygiene should be done after wiping a resident's peri region and a change of gloves before touching anything clean to prevent the spread of germs. V15 stated she expects staff to be following the infection control policy and completing timely incontinent care.On 8/18/26 at 9:35 AM, V1 (administrator) stated staff should be completing hand hygiene before and after glove use. V1 stated staff should be completing hand hygiene and glove changes when coming in contact with anything dirty to clean.The facility's Hand Hygiene Policy last revised on 10/13/25 documented staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The policy continued to document the use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on interview and record review the facility failed to safely transfer a resident via mechanical lift for 1 of 3 residents (R1) reviewed for falls in a sample of 5. This failure resulted in R1 falling and sustaining a laceration to her head which required an emergency transfer and treatment at local hospital. This past noncompliance occurred from 4/28/26-4/29/26. Findings Include:R1's admission Record documents an admission date of 9/16/2019 with the following diagnoses in part; unspecified dementia, mild with psychotic disturbance, dementia in other diseases classified elsewhere, severe with agitation, Generalized anxiety disorder, postural kyphosis, cervicothoracic region, polyosteoarthritis, unspecified.R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 00, indicating that an interview was unable to be completed and documents short- and long-term memory problems.R1's care plan documents the following focus area R1 is at high risk for falls /contractures R/T (related to) muscle weakness.R1's progress notes document on 4/28/26 at 11:07am, CNA (Certified Nurse Aide) summoned this nurse to room, upon entering room resident was laying supine on bed. Blood was visible coming from middle of forehead. Light pressure was applied and bleeding stopped. Noted 3.3 cm laceration to middle of forehead. Order obtained to send resident to Memorial East ER for eval and tx (evaluation and treatment).R1's fall investigation dated 4/28/26 documents the following witness statement from V4 (Certified Nursing Assistant/CNA). Me and another CNA was getting ready to check and change R1. We hooked her up to the (mechanical lift). We made sure everything was attached and open the legs of the (mechanical Lift), then started lifting her up. As we were lifting her she started to rock. She was already a little shaky before lifting her. Once we were in the air she rocked forward and fell and hit the leg of the (mechanical lift). It then created a gash on her forehead.A document titled After Visit Summary located in R1's medical record dated 4/28/26 documents R1 was seen at the local emergency department for a head injury and laceration. This summary further documents that R1 received 1 absorbable running stitch.On 6/15/26 at 9:35am, V9, Registered Nurse, stated she was the nurse assigned to R1's hall on 4/28. V9 stated a CNA came and got her and stated that R1 had fallen out of the mechanical Sling and hit her head on leg of the lift. V9 stated when she went into R1's room she was already in bed. V9 stated a resident should not be moved after a fall in case there are other injuries, moving them could make it worse. V9 stated R1 was sent to the ER and came back with a stitch to the laceration on her head. V9 stated R1 had no other injuries.On 6/15/26 at 1:34pm, V2 (Director of Nursing) stated she was called to R1's room on 4/28 after she had fallen. V2 stated the way staff explained it to her, they were attempting to transfer R1 from her chair to her bed via mechanical lift. V2 stated that R1 started rocking, she stated R1 has behaviors of rocking. V2 stated the mechanical lift got off balance and R1 fell and received a laceration to her forehead. V2 stated the CNA's moved R1 back into her bed before she was assessed by the nurse. V2 stated R1 did not have any other injuries besides the laceration to the head but residents should not be moved after a fall until the nurse assesses them in case there are other injuries. V2 stated R1 was evaluated at the local hospital and received one stitch on the laceration to her forehead.On 6/15/26 at 2:26pm, V4 stated on 4/28 that she and V5 were transferring R1 from her chair to her bed by a mechanical lift when R1 started rocking while up in the air. V4 stated she had a hold of the sling, but she was rocking hard. V4 stated R1 fell out of the sling and hit the leg of the lift and that was what caused the injury to her head. V4 stated it all happened so fast and R1 was lying across the leg of the lift in a very uncomfortable position so they quickly put her in bed so the nurse could take a look at her. V4 stated at the time they did not think about not moving her, she was face down and bleeding and they knew she needed help.On 6/15/26 at 3:01pm, V1 (Administrator) stated they knew there was an issue as soon as the incident happened and immediately started educating and coming up with a plan of correction. V1 stated that R1 had a history of rocking behavior, it was an infrequent behavior but had happened before. V1 stated R1 also was sort of leaning forward all the time. V1 stated part of educating staff was educating the staff about things you may see and not realize they are a behavior. V1 stated her expectation would be for staff to not transfer a resident that is rocking or having any kind of behavior that would make transferring unsafe. V1 stated if staff started transferring a resident and if they started exhibiting a behavior, she would expect staff to quickly and safely lower the resident instead of trying to continue to transfer the resident. V1 stated staff should never move a resident after falling until a nurse is able to assess them and make sure there are no other injuries.Facility Document titled, Safe Resident Handling/Transfers with an implementation date of 4/1/26 and a revision date of 4/28/26 was reviewed. This document states under Policy It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 4/28/26 with V1 (Administrator), V2 (DON), V10 (Licensed Practical Nurse), in attendance. The QAPI Ad Hoc form notes under #1 Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice it states The affected resident was immediately assessed, provided first aid, and transferred to the emergency room for evaluation and treatment of a facial laceration. Upon return to the facility, neuro checks were initiated and completed for 72 hours with no adverse findings. The resident's safe patient handling assessment was updated, and the care plan was revised to clearly instruct staff to immediately halt mechanical lift transfers and safely lower the resident to a stable surface if rocking, agitation, or unsafe movement occurs during transfer. Under #2 How will you identify other residents having the potential to be affected by the same deficient practice? it states The Director of Nursing (DON) completed a 100% audit of all residents requiring mechanical lift transfers to identify those with behavioral risks, agitation, or unpredictable movements. All applicable care plans and Kardexes were reviewed and updated to ensure individualized safety interventions are in place. The Maintenance Director completed inspections of all mechanical lifts and slings to verify proper functioning and safety. Under #3 What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? It states The involved CNAs were suspended and required to successfully complete one-on-one competency evaluations on mechanical lift operations prior to returning to duty. The leadership team provided mandatory education to all nursing staff regarding safe patient handling and mechanical lift use. Education emphasized immediate interventions during unsafe resident behavior, including stopping the lift, safely lowering the resident to the nearest stable surface (bed, chair, or floor), and promptly notifying licensed nursing staff for assistance. Under #4 How will you monitor the corrective actions to ensure the deficient practice will not occur? It states The DON or designee will conduct direct observational audits of mechanical lift transfers on all shifts according to the following schedule: Five (5) transfers weekly for four (4) weeks. Three (3) transfers weekly for four (4) weeks. One (1) transfer weekly for four (4) week. Audit results will be reviewed monthly by the QAPI committee for a minimum of three (3) months. Any concerns identified will be addressed immediately with re-education and corrective action as needed to ensure ongoing compliance. The Facility Administrator will monitor compliance with this Plan of Correction and all State and Federal requirements.2. All audits of residents requiring use of mechanical lifts, and updates made to applicable care plans and Kardex's were completed by 4/29/26. The maintenance director completed inspection of all mechanical lifts and slings by 4/29/26.3. Suspension and reeducation documents were reviewed for V4 and V5 the CNAs involved in R1's transfer was completed by 4/29/26. Nursing staff education/in-service documents show that all staff were provided education regarding safe patient handling and mechanical lift use. Completion date was 4/29/26.4. Direct observational audits of mechanical lift transfers on all shifts were completed beginning 4/28/26 and were ongoing through survey exit date of 6/16/26.

Based on interview and record review the facility failed to prevent falls by failing to maintain working status of chair pad alarms for 1 (R2) of three residents reviewed for accidents.Findings include:R2's admission record documents an admission date of 03/10/25 with diagnoses including: chronic kidney disease, shortness of breath, anxiety disorder, torsades de pointes, sepsis, atrial fibrillation, heart failure, acute respiratory failure with hypoxia, restlessness and agitation, muscle weakness, unsteadiness on feet, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and osteoarthritis. R2's MDS dated [DATE] documents a BIMS score of 04 indicating severely impaired.R2's care plan documents a focus area of: R2 is at risk for falls relating to history of falls upon admit, weakness with an intervention of: chair pad alarm, bed pad alarm dated 04/07/25 and re-education to staff to check alarm and that functioning properly before exit room dated 08/08/25.R2's incident note dated 11/16/25 documents: incident: Resident, R2 found ambulating to the bathroom unassisted. Bed pad alarm in place but not sounding. R2 became unsteady, turned and hit the back of her head on the closed bathroom door. R2 then slid down on the floor landing on her back. V6 (Licensed Practical Nurse-LPN) assessed R2 immediately. ROM WNL (range of motion) (within normal limit). R2 is alert with usual confusion. Neuro checks were initiated. Raised area beginning to develop posterior head and ice was applied.On 01/10/26 at 3:45 PM R2 was sitting in her wheelchair in the dining room with a pad alarm present and active.On 01/10/26 at 3:45 PM R2 stated, she does not remember falling.On 01/10/26 at 2:20 PM V1 (Administrator) stated, when R2 fell her pad alarm was not sounding and it should have been. R2 stood up from her wheelchair and was attempting to walk.On 01/12/26 at 8:24 PM V3 (LPN) stated, the bed and chair alarms are to be checked for working status every shift.The undated facility policy titled, Fall Prevention & Management Policy documents: purpose: to prevent resident falls, reduce injuries, and ensure timely assessment, response, and documentation. Prevention strategies with confirm bed/chair alarms are functioning when ordered.

Based on interview and record review the Facility failed to provide proper supervision to prevent a fall for 1 of 15 (R1) residents reviewed for supervision of falls in the sample of 42.This failure resulted in R1 being sent to the hospital on [DATE] for a fall which resulted in a facial laceration on her scalp and required her to have her scalp glued back together. Findings include:R1's Physician Order Sheet (POS) for November 2025 documents a diagnosis of anxiety, restlessness, and agitation, unsteadiness on feet, a history of falling and weakness.R1's Facesheet documents she was admitted to the facility on [DATE] for therapy then transitioned to a long-term resident.R1's Minimum Data Set (MDS) dated [DATE] documents she is severely impaired. Toileting hygiene, Substantial assist: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort.R1's Care Plan under intervention task dated 4/3/2025, Resident has a history of falls. Applied chair and bed pad alarm. 5/29/2025, Moved resident to a room that is closer to the nurse's station. 11/13/2025. Bed against the wall and floor mat x 1. 11/18/2025 fall off toilet re-educated staff on not leaving resident unsupervised.R1's Care Plan documents, Resident at risk for falls 5/29/25 Fall in room out of bed 11/13/25 Fall out of bed.R1's Progress Notes dated Late Entry:11/18/2025 at 7:50 PM, Note Text: CNA (certified nursing assistant) notified this writer that resident had fell while sitting on the toilet in her bathroom. CNA reported that she heard resident yelling and stating that she needed to poop. CNA states they assisted resident to her bathroom. CNA states resident was weak and had another CNA assist her with transferring resident to the restroom. CNA states that after assisting resident to her restroom both CNA's stood in resident's bathroom doorway. CNA reports resident leaned forward and fell forward while sitting on the toilet. CNA states they tried to rush and catch resident but were unable. Resident noted with a one-inch laceration to her mid to left forehead. Pressure/cloth applied to forehead. No other injuries noted. ROM (range of motion) and neuro checks are within normal limits.On 11/26/2026 at 11:23 AM, V11, Certified Nurse Assistant (CNA), stated, I was assisting another resident when I got called by (V12, CNA) asking for help because (R1) was screaming that she had to go poop and she is weak and needs two assistance. We used a gait belt and safely transferred (R1) to the toilet and waited outside the door but the door was open but (R1) leaned forward and fell. She went out to the hospital. I did get written up for it for not being closer to her.R1's Incident Report dated 11/18/2025 documents, Incident: CNA's who witnessed fall states that resident, (R1) leaned forward while sitting on the toilet, lost balance, and fell forward off toilet, lost balance, and fell forward off toilet. (sic) (V7, Licensed Practical Nurse - LPN) assessed resident immediately. Noted lacerations to forehead, above left eyelid. (V8), Physician and V9, Nurse Practitioner made aware of fall. Orders obtained to send (R1) to the emergency room for evaluation and treatment. Staff stated with (R1), applying pressure to laceration until EMS (Emergency Medical services) arrived. V11's (CNA, Certified Nursing Assistant) Employee Warning Notice dated 11/18/2025 at 7:50 PM, This aid with assist of other aid (V12) transferred resident to toilet. Resident wears personal safety alarm. Resident not watched at full attention resulting in resident falling off toilet and hitting head face on floor. V12's CNA Employee Warning Notice dated 11/18/2025 at 7:50 PM, This aid with assist of other aid (V12) transferred resident to toilet. Resident wears personal safety alarm. Resident not watched at full attention resulting in resident falling off toilet and hitting head face on floor.On 11/26/2025 at 11:42 AM, V12, CNA stated, I heard (R1) yelling out and she said she had to go to the bathroom and when I went to put the gait belt around her, I could tell she was weak. I called out for help (V11) came and help me and we stood her up with the gait belt and we placed her on the toilet, and she was sitting on the toilet, and it happened so fast she fell. I did get written up they said I was not close enough to her. I was in the doorway of the bathroom, and they said I was too far away.On 11/26/2025 at 11:50 AM, V2, Director of Nursing (DON) stated, We did write up (V11) and (V12) for (R1's) fall because we felt because R1 has alarms and a history of falls they should have been closer to her and not in the doorway with her history. R1's Hospital Report dated 11/19/2025 documents R1 was seen at the ED (Emergency Department) for a facial laceration on her scalp. The hospital glued back together and did CT scans which showed no brain bleeds or skull fracture. The Facility Fall Policy undated documents, Purpose: To prevent resident falls, reduce injuries, and ensure timely assessment, response, and documentation.

Based on interview and record review the facility failed to provide the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all residents in the facility.Findings include:Facility's Nurses Schedule 8/22/25 through 11/27/25 does not document that a Registered Nurse worked consecutive 8 hours on 8/30/25, 9/10/25, 10/12/25, 11/5/25, and 11/22/25.Facility assessment dated [DATE] documents that the facility requires the services of Licensed nurses providing direct care for day shift - 4, Evening shift - 3 or 4, Night shift - 2-3. The Facility Assessment documents that the facility requires Licensed Nurses (LN): RN (Registered Nurse), LPN (Licensed Practical Nurse), LVN (Licensed Vocational Nurse) providing direct care of 1 - DON, 1 - ADON, 2-3 - RNs, 8-10 - LPN daily.On 11/25/2025 at 12:34 PM, V6, Human Resources (HR) stated they could not find any RN coverage for the dates 8/30/25, 9/10/25, 11/15/25, and 11/22/25.CMS form 671 dated 9/30/25 documents a census of 95 residents in the facility.

Based on observation, interview, and record review the facility failed to prevent abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 6. This failure resulted in R2 being cut on his face by a butter knife, falling from his wheelchair, subsequently requiring transfer to the local hospital for evaluation and treatment.Findings include:R2's face sheet documents an admission date of 4/7/2022. Diagnosis include Sepsis due to Streptococcus Pneumoniae, Dementia, Contracture of Left and Right Knees, Acute Respiratory Failure, Cerebral Infarction, Chronic Pain Syndrome.R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2's care plan updated 9/14/2025 documents R2 has a behavior problem: Attempting to make others feel sorry for him. Pretending to be sick related to diagnosis of Major Depressive Disorder. Attention Seeking. Upset about diagnosis of Dementia and fixates due to diagnosis of General Anxiety Disorder.R3's face sheet documents an admission date of 9/25/2025. Diagnosis include Anxiety Disorder, Dementia, Chronic Atrial Fibrillation, Benign Prostatic Hypertrophy.R3's MDS dated [DATE] documents R3 has no cognitive deficits. R3's care plan dated 9/26/2025 The resident has an alteration in neurological status. Interventions include cueing, reorientation as needed.Facility provided incident report dated 10/15/2025 Incident: At approximately 12:30PM residents R2 and R3 were sitting in the dining room at separate tables eating lunch. Per camera footage R3 grabbed a butter knife off the table and stood from wheelchair and moved it towards R2's face, contacting R2's cheek and creating a laceration approximately 2 cm (centimeters) long. R3's and R2's altercation continued for about 35 to 40 seconds. R2 slid from wheelchair during the altercation landing on his bottom. R3 walked from the dining room immediately following. Staff made V8 (LPN-Licensed Practical Nurse), V2 (DON-Director of Nursing), and V1 (Administrator) aware immediately. Immediate assessment was given to R2. Vitals obtained; neuro checks initiated. POA (Power of Attorney) and V9 (Nurse Practitioner) made aware as soon as possible. V8 did full body assessment and first aid given to R2. New order to send to hospital for evaluation and treatment given. Staff stayed with R2 until Emergency Medical Services, EMS, arrived and transported to local hospital. POA did not express desire to make police report.R3 was under 1 on 1 supervision immediately following incident and until leaving facility. V2 and V4 (SSD-Social Services Director) present. First aid was attempted, and R3 refused all care. Attempting to strike staff when attempting to give care. POA and ombudsman made aware of the order to send R3 out to hospital for psychological evaluation. R3 left facility with EMS and was transported to hospital.On 10/21/2025 at 8:45AM facility provided video surveillance of incident with R2 and R3. Video dated 10/13/2025 showed R2 and R3 sitting at dining tables next to each other. R3 stood up, took a step over to R2 and stabbed a butter knife into R2's right cheek below the right eye. R2 began struggling and trying to grab knife and then fell out of wheelchair. R3 then dropped the knife and walked out of frame of video. Staff members came into frame and began assisting R2.On 10/21/2025 at 9:00AM R2 sitting up at dining room table in wheelchair. Surveyor asked R2 about incident with R3. R2 stated I was sitting here and this guy I didn't know clocked me. I thought he punched me, but he used a knife. I only saw his fist. I fell out of my chair. He's gone now. Surveyor asked R2 if he felt safe and R2 stated I guess so.On 10/21/2025 at 9:15AM V6, CNA (Certified Nurse's Assistant), stated I was at a table close by R2's table assisting another resident and heard R2 scream My eye my eye. I ran over and R3 was walking away with a glazed look in his eyes. He said, Get out of my face #####. I started helping R2 and getting his vitals. R3 left the dining room with other staff. R3 had never acted this way before.On 10/21/2025 at 8:10AM V5, RN (Registered Nurse) stated I was in V2's office when I heard someone yell Help me Help me. I saw R3 walking away out of the dining room. Staff members that were in the dining room were already there and walking with R3 and staff were already assisting R2. R2 was on the floor. R2 thought he had gotten hit. We laid R2 on the ground flat. R2 had a very small laceration under his right eye on his cheekbone area. There was a very small amount of blood. We started neuro checks and vitals on R2 and helped him up. R3 was sent out to the hospital first and then R2. R2's vitals and neuro checks were all fine.On 10/21/2025 at 8:33AM V2, DON, stated I was in my office the time of the incident with R2 and R3. I heard Ouch, Ouch and went running out of office. I saw R2 on the floor and his head was on the foot pedals of his wheelchair. I asked R2 what happened, and he said, That guy clocked me. We then laid R2 flat and started getting vitals and neuro checks. One of the CNAs had walked out of the dining room with R3. I went to see about R3, and he was away from all other residents. He was talking crazy. He was saying his wife was cheating on him and his son was stealing from him. He was irate. We stayed with him and kept him away from residents until EMS came.On 10/21/2025 at 10:40AM V8, LPN, stated I was walking back into the dining room on 10/13/2025 during lunch and heard R2 yelling help and that his eye hurt. V2 was already there by R2 and some other staff were with R3 keeping him away from other residents. We started vitals and neuro checks. I then called and got orders to send both residents out. Facility abuse policy updated 12/13/2023 states This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident-sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within our control to prevent occurrences of mistreatment, neglect or abuse of our residents.

Based on interview and record review, the facility failed to honor care directives for 1 of 5 (R2) residents reviewed for quality of care in the sample of 8. This failure resulted in R2 being sent out to the hospital and having unnecessary diagnostic testing initiated before discovering (R2) was not the intended resident. This failure also puts R2 at risk for incurring unnecessary medical bills. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admitted [DATE] with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Care Plan dated 12/31/24 documents a focus of Advanced Directives. The goal of the facility initiated 1/16/25 was to honor R2's Advanced Directives. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents Comfort -focused Treatment as the desired end of life treatment selected by R2 or her family representative. Comfort treatment primary goal is maximizing comfort through symptom management. Allow natural death. Use medication by any rate, as needed. Use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective treatment unless consistent with comfort goal. Transfer to hospital only if, comfort cannot be achieved in current setting. R2's Electronic medical records do not document vital signs for 5/10/2025. R2's Nurse's Progress dated 5/10/25 do not contain an entry documenting any medical symptoms or concerns. R2's Nurse's Progress notes dated 5/10/25 documents a late entry: (R2) mistakenly sent to emergency room (ER) due to low blood pressure and low O2 sats. On 5/28/25 at 2:40 PM V2 Director of Nursing stated these were the signs and symptoms of the resident (R3) intended to be sent to the emergency room for further evaluation, not resident (R2). V2 could not explain how (R2) was taken out of the facility by the Emergency Medical Technicians without the duty nurses' knowledge. On 5/27/2025 at 4:00 AM V10 Registered Nurse (RN) stated she is familiar with R2 and any medical signs and symptoms exhibited by R2 could be managed inside the facility. (R2) did not warrant or require any outside intervention. On 5/27/2025 at 1:42 PM V18 Licensed Practical Nurse (LPN) stated she would transfer a hospice resident to the hospital depending on family and hospice. V18 states she would not transfer a hospice resident unless it was medically necessary and would do a head-to-toe assessment prior to calling doctor and obtain an order to transfer. R2's medical records dated 5/10/25 documents R2 was seen in an area hospital for a complaint of Shortness of breath (SOB). Diagnostic testing was initiated before discovering (R2) was not the intended resident. The facility policy Resident Rights undated documents the facility must provide services to keep your physical and mental health and sense of satisfaction. The resident roster provided by the facility on 5/27/25 documented 100 residents currently resided in the facility. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. 52557

Based on interview and record review the facility failed to follow physician orders to send a resident (R3) to the emergency room for further evaluation and failed to follow hospice agreements that a resident (R2) is not to be transferred to the hospital for treatment without first notifying hospice for 2 of 4 residents (R2, R3) reviewed for quality of care in the sample of 8. This failure resulted in R2 being sent out to the hospital and having unnecessary diagnostic testing initiated before discovering (R2) was not the intended resident and R3 not being sent out to the hospital as ordered. This failure also puts R2 at risk to incur unnecessary medical bills. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: 1. R2's Face sheet undated documents that resident was admitted to the facility on [DATE]. R2's Physician Order Summary (POS) dated 12/31/2024 documents diagnosis of Cerebral infarction, unspecified and Facial weakness following cerebral infarction. R2's MDS (Minimum Data Set) dated 4/7/2025 documents a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R2's MDS dated [DATE] documents that resident is dependent with toileting hygiene, putting on/taking off footwear and lower body dressing and needs substantial/maximal assistance with shower/bathe self and upper body dressing. R2's MDS dated [DATE] document resident needs substantial/maximal assistance with mobility. R2's Nurse Progress Note dated 5/10/2025 at 11:47 PM documents resident mistakenly sent to ER for eval and treat of low BP and low 02 sats. When the hospital noticed the mistake, POA and MD made aware. Resident returned to facility with no further incident. R2's Hospital medical records dated 5/10/25 documents Patient arrives per EMS, wrong patient sent from facility. Pt being sent back to nursing home, emergency room Charge RN attempted to call pt family with no answer. emergency room Physician notes dated 5/11/24 at 12:26 AM documents Wrong patient sent by nursing home, patient is hospice, Do Not Resuscitate (DNR), Do Not Intubate (DNI), comfort care, and family did not want this patient seen. I did (?) evaluate or treat the patient. No facility physician order documented for R2 to be sent to hospital as of 5/27/2025. On 5/28/2025 at 11:22 AM, V1 Administrator states we dodged a whole lot of bullets with this one, so many things could have gone wrong. V1 states V19, Licensed Practical Nurse (LPN) was terminated the following Monday after incident. On 5/27/2025 at 1:46 AM V9, daughter of (R2), stated the emergency medical technicians (EMT's) went to the wrong room. She states her mother (R2) was in room [ROOM NUMBER] and the other resident was 06. She states the EMT's took the patient in room [ROOM NUMBER] as the patient needing to be transported to the hospital. She states no one notified the family that (R2) had been taken to the hospital and they had no idea that it had happened. She states the hospital called at 11:58 PM to advise that our mother (R2) was at the hospital. She states (R2) had a series of strokes and was not alert. She states (R2) was receiving hospice services and had only been with hospice for 1 week. She states she did speak with a nurse and [NAME] in admissions who admitted that her mother (R2) had been sent to the hospital by mistake and the nurse had been fired. She states she has hospital records but not the ambulance records, mother (R2) did not receive any treatment but if they had provided treatment, it would have been for the wrong person. She states the patient they were supposed to transfer to the hospital had diabetes and questions what if they would have given (R2) insulin. She states anything that the hospital would have done would been unnecessary treatment and that her mother was not supposed to be transported. R2's medical records dated 5/10/25 documents R2 was seen in an area hospital for a complaint of Shortness of breath (SOB). Diagnostic testing was initiated before discovering (R2) was not the intended resident. On 5/28/2025 at 10:12 AM, V27, Hospice Nurse, states she was notified on 5/12/2025 at 9:00 am by V19, Licensed Practical Nurse (LPN), (R2) was having difficulties that day. V19 mentioned to V27 that (R2) had been sent to theER on [DATE] by ambulance and they had taken the wrong resident. V27 states V19 told her emergency medical service (EMS) grabbed the wrong resident and not sure how this happened. V27 notified Hospice both clinical coordinator and medical director. V27 states she did not receive medical records from the hospital and had prepared a report of the incident. V27 states the Case Manager followed up with (R2's) family. V27 states she has not filed a report but would do so today. V27 states the nursing home told her that no care was provided at the hospital. V27 states her expectation is the facility will call before sending (R2) out to hospital. On 5/28/2028 at 4:48 AM, V15, certified nurse assistant, (CNA) stated she works nights but was not here at that time of the incident. V15 states she has been trained to accompany EMT's to the resident's room, stay with the resident and get the resident ready for transport. V15 states the nurse provides the information to the Emergency Medical Technicians (EMT). On 5/28/2025 at 5:00 AM, V16, CNA, states she work both evening and night shifts and has received in-service training on transferring a resident to the hospital and to notify the family representative. V16 states the CNA's duties are to stay with the resident and get the resident ready for transport. On 5/28/2025 at 4:00 AM, V10, Registered Nurse (RN) stated she works the evening and night shift and did relieve the evening shift nurse. V10 does not recall the events surrounding the wrong resident being sent out. V10 states CNAs that worked that evening were all agency CNA's and did not know names. Have no idea how the wrong person was sent out. Hospice organization dated December 1, 2008, documents regarding Patient Transfer. The Nursing Facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of Hospice. If the Nursing Facility fails to obtain the necessary prior approval, Hospice bears no financial responsibility for the costs of transfer and the costs of care provided in another setting. Facility Policy for Hospice Services undated documents Purpose: Provide and promote collaboration and coordination of care and services for the resident receiving hospice care. This facility will immediately notify the hospice provider of the following: Significant change in resident's physical, mental, social, or emotional status; Clinical complications that suggest a need to alter the plan of care; Need to transfer the resident from this facility for any condition and the resident's death. 2. R3's Face Sheet undated documents R3 was admitted [DATE] with pertinent medical diagnoses of Human Metapneumovirus as the causes of diseases classified elsewhere, Systemic Inflammatory of Response Syndrome (SIRS) of Non-infectious origin without Acute Organ Dysfunction. R3's Nurse's Progress notes dated 5/10/25 documents R3 was experiencing a temperature of 100.2 degrees, abnormal lung sounds and a decrease in blood pressure of 102/64 to 88/46. R3's Nurse Progress notes dated 5/10/25 documents R3 was experiencing a temperature of 100.2 degrees. The Medical Director ordered (R3) to be transferred to area hospital for further evaluation. R3's Nurse's Progress notes dated 5/10/25 documents by error resident was not sent to hospital. MD was made aware when error was noticed. Resident re assessed and not sent out to ER and resident family made aware. On 5/27/25 at 4:00 AM V10 Registered Nurse stated she work nights and was the on-coming nurse and was made aware that R3 had not been sent out to the hospital. V10 was familiar with R3, re-assessed her and believed her symptoms could be addressed at the facility. V10 did not contact the medial director with that information and did not send R3 as ordered. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. 52557

Based on interview and record review the facility failed to notify 1 (R2) of 5 resident representatives of significant changes in status which were reviewed for change in status in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admitted [DATE] with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely cognitively impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare, R2's Nurse's Progress notes dated 5/10/25 documents a late entry: (R2) mistakenly sent to emergency room (ER) due to low blood pressure and low O2 sats. (V25) Medical Director (MD) and (V9) Power of Attorney (POA) were notified. On 5/27/25 at 11:46 AM V9, R2's daughter and power of attorney stated she was unaware of her mother being sent to the hospital until 5/12/25. V9 stated she was informed by the hospice nurse (V27). On 5/27/25 at 3:24 PM V25 medical director stated he had not been notified that (R2) had been sent out mistakenly to the hospital. On 5/28/25 at 10:12 AM V27 Hospice nurse stated she had not been notified until 5/12/25 that R2 had mistakenly been sent to the hospital. On 5/27/25 at 12:37 PM V1 Administrator stated that she was led to believe the assigned nurse (V19) had contacted R2's family. (V19) left things in a mess and we dodged a bullet, we followed policy and it was human error. On 5/28/25 at 11:14 AM V2 Director of Nursing stated she entered the documentation that R2's family had been notified because she thought the nurse (V19) had done so but had not completed her documentation before leaving the facility. R3's undated Face Sheet documents R3 was admitted [DATE] with pertinent medical diagnoses of Human Metapneumovirus as the causes of diseases classified elsewhere, Systemic Inflammatory of Response Syndrome (SIRS) of Non-infectious origin without Acute Organ Dysfunction. R3's Minimum Data Set, dated dated dated [DATE] documents she is cognitively intact. On 5/29/25 at 9:35 AM V28 R3's daughter stated she had not been notified on 5/10/25 by the facility that her mother was being transferred to the hospital for further evaluation. According to V28 she was contacted by the hospital for insurance information and during that conversation she discovered that it was not her mother (R3) in the hospital. The facility did not notify her that (R3) did not go to the hospital. On 5/28/25 at 3:24 PM V25 Medical Director stated he was not informed that the resident (R3) had not been sent out. He discovered 5/12/25 when he arrived at the facility for regular visits with residents that (R3) had not been sent out as ordered. V25 stated his expectations are that his orders are carried out and he be notified of any changes that warrant intervention. The facility policy Resident Rights undated documents the facility must provide services to keep your physical and mental health and sense of satisfaction. The facility policy on Transfers and Discharges undated documents A thorough assessment by the attending physician or healthcare provider will determine whether a transfer is medically necessary. This assessment will be documented in the resident's care plan. Notification: The resident and their family (or legal representative) will be notified of the transfer, including the reasons for the transfer and the expected timeline. The family will be given sufficient notice to make appropriate arrangements. Physician will be involved in and informed of resident's transfer. Detailed documentation of the transfer request, reasons, and any family discussions or approvals must be kept in the resident's record. The transfer process will be documented, including the physician's assessment, transfer arrangements, and communication with the resident and family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. 52557

Based interview and record review the facility failed to ensure that 1 of 3 (R2) residents or their representative reviewed for hospital transfer received sufficient preparation for transfer to the hospital in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admitted [DATE] with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare. On 5/27/25 at 11:46 AM V9, daughter of R2 stated she was not made aware her mother (R2) had mistakenly been sent to the hospital. (R2) cannot speak for herself and is not cognizant, therefore the facility did not have (R2's) or her (V9) consent to send (R2) to the hospital. R2's Nurse Progress notes dated 5/10/25 do not provide documentation the neither (R2) or (V9) received preparation for the transfer to the hospital. The active facility policy on Transfers, Discharges All discharge decisions, including reasons for discharge, discussions with the resident and family, and discharge plans, will be documented in the resident's record. The facility will ensure that all discharge paperwork, including any required notices and appeals information, is provided to the resident and their family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months.

Based on interview and record review the Facility failed to seek medical interventions in a timely manner for 1 of 5 residents (R48) reviewed for medical interventions in the sample of 49. This failure resulted in R48 sustaining a fracture and not being sent out to the hospital for two days and sustaining a fracture of her left ankle. Findings include: R48's Skin/Wound Note dated 5/18/2024 (Saturday) at 1:28 PM, Note Text: 11 x 6 cm (centimeters) bruise noted to left shin during routine care. Staff reported to this nurse. Leg elevated on pillow and V13, Nurse Practitioner notified and aware. Will monitor until healed. Author of this note was documented as V12, Licensed Practical Nurse (LPN). R48's Health Status Note dated 5/19/2024 (Sunday) at 7:49 AM, Note Text: Resident moaning with pain to left leg, +2 plus edema with warmth to touch. 11 x 6cm purple bruise to left shin, increased edema and bruising today. Notified NP. Called POA, notified of change at this time and voiced understanding stated she is out of town today and keep her updated. R48's Health Status Note dated 5/20/2024 at 9:34 AM, Note Text: Received a new order to obtain x-ray of left tib/fib 2 views. Author of this note was V12. (This was two days later after the incident). R48's Health Status Note dated 5/20/2024 at 10:45 AM, Note, Text: (Company) x-ray here obtained 2 views of tib/fib at this time. R48's Health Status Note dated 5/20/2024 at 11:39 AM, Note Text: NP (V13) here received new order to send resident to ER (emergency room for evaluation and treatment related to left shin x-ray results. R48's Health Status Note dated 5/20/2024 at 11:51 AM, Note Text: Called POA (Power of Attorney), notified of resident fracture left leg and new order to send to (hospital) for evaluation and treatment. Resident transferred out to ER (emergency room ) at this time. On 8/29/2024 at 10:41 AM, V12, Licensed Practical Nurse stated, (V11) and (V10) came and got me and told me they had found a bruise on (R48's) leg while they were doing care. I went and looked at it and I did an incident report. I was watching the bruise and they did an investigation on her. (R48) did not walk and was unable to propel herself in the wheelchair. At the time of the incident (R48) was in a manual wheelchair with foot pedals. We think that at mealtime they accidently hit her foot with the other resident. I do not know who the other resident was, or who the staff member was that was caring for (R48) while they were pushing the other resident under the table, and then they collided. (R48's) bruise was progressively getting worse and I called the Nurse Practitioner and she had me get an x-ray, and when the x-ray came back, we learned she had fractured her leg. I was in shock and blown away because I did not expect (R48's) foot to be fractured from colliding with another resident. On 8/29/2024 at 2:02 PM, (V11), Certified Nursing Assistant stated, Me and (V10, CNA) were taking care of (R48). We got her up and took her to breakfast. (R48) was in a regular wheelchair with foot pedals. She was not able to propel herself. After breakfast the nursing aid, I do not know her name, she was agency, told me that she had bumped (R48's) leg at the dining room table that morning. When we took (R48) back to her room and laid her down, she winced and even though she could not talk she was grimacing, and you could tell her leg hurt her and she had a red/purple bruise. I went and got the nurse (V12) and had her look at it. (V12) was monitoring it and contacted the doctor and got an x-ray and later we found out she had a fracture. We were all in shock. On 8/30/2024 at 2:40 PM, V13, Nurse Practitioner stated, The documentation on this case was poor and what we know is that (R48) had a fracture, and we were not sure how she got that fracture. There was a late entry and I have many issues with that because staff should have documented immediately if she was hit by accident or with other residents and at the end, we can only go by what is documented. It is hard to say and an unusual case. In the beginning I just thought it was a bruise because there was no fall. No staff told me when she was in pain until the next day. When I first got the call, I was out of town, but then on Monday I was in the facility and when I saw her I sent her out immediately when I learned she had a fracture. The Facility Change of Condition MD/NP Policy updated 5/20/2023 docuemnts, Immediate notification: Any symptom, sign or apparent discomfort, that is: acute, or sudden onset, and a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. This would include abnormal vital signs, labs, respiratory distress, significant weight loss/gain, pain, fall, pain with wound care, changes in wound appearance, food/liquid intake reduced, abnormal x-rays. A full list is located at nurse station. The nurse would notify the MD/NP by phone of any condition that needs immediate attention. Resident POA or resident representative will be notified immediately. Non-Immediate Notification: New or worsening symptoms that do not meet the above criteria. Example vital signs normal, labs normal. This would allow the nurse to update the MD/NP by Mediprocity or phone call. Documentation will be done for the resident and the situation as well as the Administrator, DON or ADON being notified of any changes.

Based on interview and record review the Facility failed to ensure a resident was not injured while being pushed in their wheelchair during meal service for 1 of 4 residents (R48) reviewed for accidents in the sample of 41. This failure resulted in R48 sustaining a fracture to her left leg while being pushed by staff in her wheelchair. Findings include: R48's Physician Order Sheet (POS for August 2024) documents a diagnosis of Major Depression disorder, severe with psychotic symptoms, pressure ulcer of left heel, Alzheimer disease, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbances, psychotic disorder with delusions due to known physiological condition, and anxiety and bilateral primary osteoarthritis of hip. R48's Minimum Data Set (MDS) dated [DATE] documents she is severely impaired for cognition for activities of daily living, she has impairments on both sides, she uses a manual wheelchair. She is dependent on staff for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene, Rolling from left to right, sit to stand, chair to bed, toilet transfer tub/shower transfer, and she does not walk and is always incontinent of urine and bowel. R48's Care Plan: (R48) at risk for falls; due to poor safety awareness. Maintain safe environment to room/facility to prevent injuries, well lite environment. Observe resident for any unassisted transfers/ambulation status. Remind to wait for assist and assist residents as needed. B & B (bowel and bladder) before meals/after and as needed. Keep resident clean and dry. Resident to use call lights when assist needed. Report any unsteady balance/gait to Nurse. Report any decline in safety awareness to Nurse (PRN). Use of 1/4 side rails times 2, check every two hours and as needed. R48's Skin/Wound Note dated 5/18/2024 at 1:28 PM, Note Text: 11 x 6 cm (centimeters) bruise noted to left shin during routine care. Staff reported to this nurse. Leg elevated on pillow and V13, Nurse Practitioner notified and aware. Will monitor until healed. R48's Incident/Accident report date of incident 5/18/2024, Staff noticed a 11 x 6 cm light purple bruise to left shin during routine care. Staff reported resident leg was bumped by another resident's wheelchair. R48's Health Status Note dated 5/19/2024 (Sunday) at 7:49 AM, Note Text: Resident moaning with pain to left leg, +2 plus edema with warmth to touch. 11 x 6 cm purple bruise to left shin, increased edema and bruising today. Notified NP. Called POA, notified of change at this time and voiced understanding stated she is out of town today and keep her updated. R48's Health Status Note dated 5/20/2024 at 9:34 AM, Note Text: Received a new order to obtain x-ray of left tib/fib 2 views. R48's Health Status Note dated 5/20/2024 at 10:45 AM, Note, Text: (Company) x-ray here obtained 2 views of tib/fib at this time. R48's Health Status Note dated 5/20/2024 at 11:39 AM, Note Text: NP (V13) here received new order to send resident to ER (emergency room for evaluation and treatment related to left shin x-ray results.) R48's Health Status Note dated 5/20/2024 at 11:51 AM, Note Text: Called POA (Power of Attorney) notified of resident fracture left leg and new order to send to (hospital) for evaluation and treatment. Resident transfer out to ER (emergency room ) at this time. R48's Skin Wound Note Late Entry, created date 5/21/2024 at 10:36 AM, Staff reported resident sliding down in wheelchair, left lower leg bumped by another resident's wheelchair pedal while in dining room for lunch. Light red/purple abrasion noted. Resident assessed by this nurse, no acute distress noted. R48's Skin Investigation Report dated 5/18/2024 documents, On 5/18 resident wheeled to lunch by CNA when wheeled up to table left leg bumped a wheelchair, a light red/purple bruise noted by nurse. On 5/19/2024 bruises are now 11 cm x 6 cm. Resident shows signs and symptoms of pain with transfers, NP notified, order for x-ray leg received on 5/20/2024, after x-ray transferred to ER (emergency room ). Findings: Resident was transferred with gait belt of assist of 2. CNA's Interviews with (V12), (V11) (V26) all agree. Resident did walk with restorative staff on 5/18. Verified on camera. Resident returned to facility with order to follow up with ortho. Interventions: Resident was provided care until EMS (emergency medical services) arrived to transport to ER (emergency room ) upon return resident transfer status was updated. Ortho f/u (follow up) to be made. R48's Orthopedic Paperwork documents, R48 was admitted to the hospital on 5/28/2024 and discharged on [DATE], Procedure performed, 'left tibia closed reduction and intramedullary nailing'. This patient is a [AGE] year-old female with unknown mechanism of injury, presenting with a left tibia fracture. Chief complaint: Left leg pain and swelling. R48's Skin Injury Investigation Checklist undated with no name documents, Type of skin injury: 'bruise', staff assigned to resident (V10), certified nursing assistant (CNA) and (V11), CNA. How was skin injury found? During routine care. Resident's activity at the time of the skin injury; sitting in wheelchair. What the resident said happened: Unable to voice. Does the resident self-ambulate or self-propel wheelchair around the facility; 'No'. Was there a prior injury to this area recently? 'No' R48's Initial Incident Report dated 5/20/2024, Staff reported that (R48) resident had a bruise noted to lower left leg. Nurse V12, Licensed Practical Nurse (LPN)) reported to (V13) Nurse Practitioner that bruise had gotten larger, so NP ordered x-ray of lower leg. The x-ray report came back and shows a fracture. (R48) was sent to (hospital) for evaluation and treatment. (R48) later that same day returned to this facility with an order to follow up with an orthopedic doctor. R48's Final Incident Report, Resident (R48) was admitted to (Facility), March 21, 2019 and has been a long term care resident since then. Her admitting diagnosis for care was dementia. On 5/18/2024 the assigned staff to (R48), (V12, LPN), (V10, CNA), (V11, CNA) and (V10, CNA) reported to (V12, LPN) after meal that (R48) was sliding down in her wheelchair at meal so they repositioned her while in the dining room. While repositioning her (R48) (bumped the shin of her left leg on another resident's wheelchair pedal). Nurse assessed resident at the time. Noted a small, light bruise that measured approximately 11 cm x 6 cm and small abrasion. Nurse monitored the bruise and filled out incident report as per policy. (State), NP, Administrator, DON and all notified in a timely manner. On 5/19/2024 staff noted bruise had grown in size and notified nurse (V12). V12 informed (V13, NP) of bruise as well as POA. R48's Accident/Incident Report reported to State on 5/20/2024 documents, Staff reported that (R48) had a bruise noted to lower left leg. Nurse (V12) reported to (V13) that bruise had gotten larger, so NP ordered an x-ray of left lower leg. The x-ray report came back and shows a fracture. (R48) was then sent to the hospital for evaluation and treatment, (R48) later that same day returned to this facility with an order for follow up with an orthopedic doctor. (R48) was admitted to (Facility) on 3/21/2019 and has been a long-term care resident since then. Her admitting diagnosis for care was dementia. On 5/18/2024 the staff assigned to (R48) were (V12, LPN), (V10, CNA), (V11, CNA), and (V14, CNA), who reported to (V12) that (R48) was sliding down in her wheelchair at meal, so they repositioned her while in dining room. While repositioning her (R48) bumped her shin of her left leg on another resident's wheelchair pedal. Nurse assessed leg at that time. Noted a small, light purple bruise that measured approximately 11 cm x 6 cm and small abrasion. Nurse monitored the bruise and filled out incident report as per policy. R48's Radiology Report with a report date of 5/20/2024 at 10:55 AM, Findings: Proximal tibia/fibula fractures with mild displacement. Mild soft tissue swelling. Conclusion: Acute appearing proximal tibia/fibula fractures as noted. On 8/29/2024 at 10:41 AM, V12, Licensed Practical Nurse stated, (V11) and (V10) came and got me and told me they had found a bruise on (R48's) leg while they were doing care. I went and looked at it and I did an incident report. I was watching the bruise and they did an investigation on her. (R48) did not walk and was unable to propel herself in the wheelchair. At the time of the incident (R48) was in a manual wheelchair with foot pedals. We think that at mealtime they accidentally hit her foot with the other resident. I do not know who the other resident was, that was while they were pushing the other resident under the table, and then they collided. (R48's) bruise was progressively getting worse and I called the Nurse Practitioner and she had me get an x-ray, and when the x-ray came back we learned she had fractured her leg. I was in shock and blown away because I did not expect (R48's) foot to be fractured from colliding with another resident. On 8/29/2024 at 2:02 PM, V11, Certified Nursing Assistant stated, Me and (V10, CNA) were taking care of (R48). We got her up and took her to breakfast. (R48) was in a regular wheelchair with foot pedals. She was not able to propel herself. After breakfast the nursing aid, I do not know her name, she was agency, told me that she had bumped (R48's) leg at the dining room table that morning. When we took (R48) back to her room and laid her down, she winced and even though she could not talk she was grimacing, and you could tell her leg hurt her and she had a red/purple bruise. I went and got the nurse (V12) and had her look at it. (V12) was monitoring it and contacted the doctor and got an x-ray and later we found out she had a fracture. We were all in shock. On 8/30/2024 at 9:33 AM, V26, Registered Nurse (RN) stated, I was working the Medicaid Hall that day. When I saw the bruise on R48's leg for the first time I was not sure what or why it had happened. She could not propel herself in the chair or move her legs and she could not tell you what happened. She could not talk. She had a history of sliding down in her chair that is why she is now in a geriatric chair. I heard something about a staff member bumping her leg but I am not sure who the staff member was. I remember sending a message to the Nurse Practitioner. We were all in shock when we learned her leg was fractured. On 8/30/2024 at 11:03 AM, V10, Certified Nursing Assistant (CNA) stated, I remember taking (R48) back to her room after lunch and when laying her down we, (me and (V11, CNA) noticed a bruise on her leg. We immediately notified the nurse (V12, LPN). Before laying her down she had no prior pain or symptoms. After laying her down she would grimace when we touched the bruise. She cannot talk or tell you what had happened. No staff told me that there was any accident and or injury to (R48). I was working the night shift and I was very surprised to learn that she had a fracture. I am no longer employed at the facility. On 8/30/2024 at 2:40 PM, V13, Nurse Practitioner stated, The documentation on this case was poor and what we know is that (R48) had a fracture, and we were not sure how she got that fracture. There was a late entry and I have many issues with that because staff should have documented immediately if she was hit by accident or with other residents and at the end, we can only go by what is documented. It is hard to say and an unusual case. Without names and dates I just have issues. I would not expect a resident to be injured while being pushed in a wheelchair. The Facility Abuse Policy updated 9/26/2023 documents, Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Timely and thorough investigations of all reports of allegations of abuse. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. The Director and/or Assistant Director of nursing is responsible for reviewing the incident report and reporting any findings to the facility administrator. If the resident complaints of physical injuries or physical injuries are noted, the resident's physician and representative will be contacted for further instructions. The Accident/Incident Policy revised 12/2023 documents, All accidents or incidents that result in an injury or illness must be reported to the Administration, DON (Director of Nursing), or ADON (Assistant Director of Nursing). The DON will make an initial report of the incident and report it to (State) through facility Reported Incdient. The following data, as it may apply, must be included in the Accident/Incident Report form: Date and time accident/ incident occurred circumstances surrounding accident/incident. Where the incident/accident occurred. Name (s) of any witness (es) and his/her account of the accident or incident.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 99 residents living in the facility. Findings include: On 8/27/2024 at 9:13 AM, tour of the facility was conducted. In the kitchen in the sink were 5 large industrial clear bags of frozen chicken. Water was running over one bag, but the other four bags did not have any water running on them. The temperature of the water was taken with a calibrated metal thermometer and the water was 100.0 degrees Fahrenheit (F). There was not a stopper in the sink and the water was running straight down into the drain. The frozen chicken was not submerged in the water. There was about 1/2 of water in the sink with the water running. Not all of the chicken was in water. On 8/27/2024 at 9:22 AM, in the walk-in refrigerator was a moving tray and on the tray on the top shelves were small clear plastic cups with an orange substance inside of the cups. The orange cups were not covered and were exposed in the air of the refrigerator. There was no date and or label and there were 4 trays with a total of 92 cups. On the next to bottom shelf of the cart was a large industrial box labeled 8 piece cut glazed chicken. The box was leaking, and the entire tray was covered with a bloody liquid that was leaking from the cardboard box. On 8/27/2024 at 9:24 AM, there was a clear container of pineapple with the use by date of 8/11/2024 that was still in the walk-in fridge. On 8/27/2024 at 9:25 AM, there was a clear, large industrial container of corn kernels with no date and/or label. On 8/27/2024 at 9:28 AM, above the stove the hoods were shiny and greasy and in need of a cleaning. On 8/27/2024 at 9:29 AM, V25, [NAME] stated, The menu calls for chicken and I am not sure what happened but the chicken was spoiled and so we are trying to thaw new chicken so we can follow the menu. I am not sure how or why the chicken was spoiled. Our Dietary Manger is not working today, she does not normally work on Tuesdays. We were just trying to get the chicken thawed. On 8/27/2024 at 10:32 AM, V24, Dietary Manager stated, I would expect all food to be dated and labeled. I am not sure what happened with the chicken, but the staff should not have tried to defrost the chicken in the sink without taking into consideration the water temperatures and ensuring they were doing it the correct way. On 8/29/2024 at 8:51 AM, V24 stated, I am not sure when the hoods were last cleaned. I would expect the hoods to always be clean and free of grease. The Meat and Vegetable Cookery Policy undated documents, Meat is defrosted using safe thawing methods (never at room temperature): In the sink, under clean running water <70 F (Fahrenheit). The Labeling and Dating Foods 2020 documents, All food stored will be properly labeled according to the following guidelines. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the 'first in- first out' method of rotation. Once the package is opened, it will be redated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Prepared food or opened food items should be discarded when: The food item is older than the expiration date. The US FDA (Food and Drug Administration) 2022 code documents, 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41oF) Pf. 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. The Long Term Care Facility for Application Form for Medicare and Medicaid Form (CMS 671) dated 8/27/2024 documents there were 99 residents living in the facility.

Based on observation, interview and record review the Facility failed to ensure proper infection control guidelines were being followed for 6 of 22 residents (R20, R48, R28, R38, R42 and R60) reviewed for infection control in the sample of 41. Findings include: 1. On 8/27/2024 at 12:11 PM, V39, Certified Nursing Assistant (CNA) was feeding (R42). V39 was wearing a mask and was resting her elbows on the dining room table and both of her hands were on her cheeks. She then proceeded to feed R42 without disinfecting and/or washing her hands. On 8/27/2024 at 12:15 PM, V39, reached over the table and touched R42's bib and then proceeded to feed another resident without disinfecting and/or washing her hands. Then after touching her face again she proceeded to feed R42 without disinfection and /or washing her hands. 2. On 8/30/2024 at 10:33 AM, wound care was provided by V35, Licensed Practical Nurse (LPN). R48's door had a sign on the door documenting EBP (Enhanced Barrier Precautions) and instructed staff to wear PPE (Personal Protective Equipment) including mask, gloves and gowns. V35 was not wearing any gown while providing wound care. On 8/30/2024 at 10:55 AM, V2, Director of Nursing stated, (R48) was on EBP (Enhanced Barrier Precautions) and she would expect for all staff to wear gloves, mask and gowns for all treatments. 42834 3. On 8/27/2024 at 12:00PM, V32 Certified Nursing Assistant (CNA), was sitting at a table providing feeding assistance to R20 and R60. V32 began feeding R20 a spoonful of food and immediately began feeding R60 a spoonful of food. No hand hygiene was completed between feedings. V32 wiped R20's mouth with a cloth. V32 was handling multiple cups and utensils. No hand hygiene completed before V32 began feeding R60. No hand sanitizer on table or nearby. On 8/27/2024 at 12:05PM, V33, Certified Nursing Assistant, CNA, was sitting at a table providing feeding assistance to R28 and R38. V33 began feeding R28 with a spoon and immediately began feeding R38 with a spoon. No hand hygiene was completed between feedings. V33 touched R38's clothing protector and face, with no hand hygiene completed prior to feeding R28. No hand sanitizer on table or nearby. On 8/30/2024 at 8:45AM, V27, Certified Nursing Assistant, CNA, stated We are taught to use hand sanitizer between feeding residents. On 8/30/2024 at 8:40AM, V2, Director of Nursing, DON, stated The CNAs feeding residents are to use hand sanitizer between feeding residents or touching residents. They are to use the same hand to feed a resident and the other hand to feed the other resident. Facility's undated Hand Hygiene policy states Handwashing will be regarded by this facility as the single most important means of preventing the spread of infection. Staff will follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents, and visitors. Hands should be washed for at least 20 seconds using soap and water under the following conditions: Before having direct contact with a resident. After having direct contact with a resident. After handling items potentially contaminated with blood, body fluids, excretions, or secretions. Hand sanitizers containing at least 60% alcohol may be used when soap and water is not readily available. Facility's undated Resident Feeding policy states Residents who are unable to feed themselves will be fed by approved personnel with attention to safety, comfort, and dignity. Staff will sit when feeding residents. Facility's Infection Control Policy updated 7/31/2024 states The facility must establish an infection prevention and control program that must include, at a minimum, the following elements: Written standards, policies, and procedures, for the program, which must include, but are not limited to: The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food if direct contact will transmit the disease, The hand hygiene procedures are to be followed by staff involved in direct resident contact. The Enhanced Barrier Precautions (EBP) Policy and Procedure undated documents, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs), CMS notes that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Enhanced barrier precautions (EBP) are an infection control measure designed to reduce transmission of multidrug-resistant organisms (MDROs) in the nursing homes. Enhanced Barrier Precautions involve gown and gloves use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices. High-contact resident activities include Wound care: any skin opening requiring a dressing. Gowns and gloves will be available immediately near or outside of the resident's room. Enhanced barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on interview and record review, the facility failed to report an injury of unknown origin for 1 of 2 residents (R23) reviewed for abuse in the sample of 41. Findings include: On 8/27/24 at 11:00 AM, V1, Administrator stated she does not have any investigations of injuries of unknown origin or abuse investigations. R23's Face Sheet documents her diagnoses as Generalized Anxiety, Major Depressive Disorder, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavioral Disturbances, Unsteadiness on Feet, and Muscle Weakness. R23's Minimum Data Set (MDS) dated [DATE] documents she is severely cognitively impaired and is dependent on staff for toileting, dressing, turning and positioning, and transfers. R23's undated Care Plan documents, Skin Integrity with goal of, The skin will remain intact. Interventions include, Continue with A&D Ointment or zinc oxide daily and as needed for protection, encourage good nutrition and hydration in order to promote healthier skin, monitor for signs and symptoms of infection, weekly skin checks, staff to observe skin daily. R23's Progress Note dated 6/15/24 at 10:22 PM document, Incident Note: Note Text: This resident complained of pain to her right arm when staff was trying to get her ready for a transfer from wc (wheel chair) to bed this eve after supper. The CNAs (Certified Nursing Assistants) x 2 used a gait belt as per the resident's Kardex in her room and transferred her to her bed. Resident was able to bear weight to assist with the transfer. Once the CNAs undressed the resident to put her night gown on they noted a bruise to resident's right upper arm humerus area. This nurse assessed resident arm and right upper arm is noted with a 10 centimeter (cm) X 9 cm dark purple bruise. Resident is uncooperative as this is her normal behavior and will not cooperate in showing me if she has ROM (Range of Motion) to that right arm. Resident is able to move fingers on her right arm. (Medical Doctor (MD)) was notified and order received to get an x-ray stat of the area. This nurse did report to MD that resident does take Pradaxa 75 milligram (mg) twice a day as well. This nurse called (x-ray company) to order a stat xray of the right humerous and the order was put in as stat but the operator placing the order stated that no further test could be placed for tonight and reason was unavailable to this nurse. This nurse placed a call to (x-ray company management) and left a message to find out why no further testing could be done and I was not given a reason or a time frame on when I could expect it to be performed tomorrow. Resident resting now with eyes closed and no signs or distress noted. On 8/28/24 at 3:40 PM, V2, Director of Nursing (DON) and V3, Assistant Director of Nursing (ADON) came in to discuss R23's bruise she had on 6/15/24. V2 stated the bruise was first observed when staff were providing care for R23 on 6/15/24 and R23 was complaining of pain to her arm. V2 stated this was the first time any staff were aware that R23 had the bruise. V2 was agreeable that initially R23's bruise was an injury of unknown origin. She stated after an investigation they determined R23's bruise on her arm was most likely due to her being combative with care. She stated this was a common behavior by R23 when care was being provided. V2, DON provided the investigation/incident report on R23's bruise. R23's untitled report dated 6/15/24 documents (R23) Injury: Bruise to right upper arm 10 cm x 9 cm. DON Notified: (V2) Comment: Resident complained of pain-as her norm. CNAs x 2 transferred resident from w/c to bed for HS care. CNAs transferred x2 with gait belt and resident was able to bear weight. Once resident was undressed the CNAs noted bruise to right upper arm. This nurse assessed the area to find 10 cm x 9 cm dark purple bruise. Resident not cooperative on assessing ROM. Call place to (V36 Medical Doctor) and order received for stat x-ray to right upper arm. A statement at the bottom of this report documented, This is immediate notification of injury and a full investigation will follow within five days. There was no documentation that the Administrator was notified. This report was signed by V3, ADON who was working that day. R23's Skin Investigation Report dated 6/16/24 and documented: Situation: Resident complained of pain to right arm. Nurse investigated arm. Bruise 10 cm x 9 cm found. Resident recently transferred with gait belt and assist x 2 CNAs. MD notified and x-ray orders received. X-ray not available so sent to ER. Findings: Spoke with CNAs, (V10) on 6/17/24. Confirmed resident was combative with care and transfer. Interventions: Resident transfer status updated. Therapy initiated. A hand written note dated 6/15/24 but untimed documented (V10 CNA) get up toileted x 3 on days. Per (V10) and (unknown CNA) noted after supper with HS (bed time) care. Bruise right upper arm by (V37, CNA) and (V38, CNA). Sent to (local hospital) for xray. On 8/30/24 at 8:55 AM ,V2, DON stated she talked to the CNAs who worked on 6/15/24 the next day about the bruise on (R23's) arm. V2 stated the CNAs reported that they had gotten (R23) up in the morning and she did not have a bruise on her arm . V2 stated (V10), CNA, described how (R23) was resistive to care and combative to the staff and he described how (R23) had swung her right arm back and hit him and she determined that the probable cause of (R23's) bruise was due to her hitting her arm on him. V2 stated she did not write down exactly what (V10) stated but immediately did the report. V2 stated she felt the investigation showed how (R23) sustained her bruise while being combative with care. On 8/30/24 at 10:10 AM, V1 stated (V3) told her about the bruise on (R23's) right arm and told her staff were constantly pulling (R23) up when she slid down in her wheel chair and that (R23) was on blood thinners and that is probably how she got the bruise. V1 stated that was a good enough explanation for her as to how (R23) got the bruise. On 8/30/24 at 10:20 AM, V3 stated the CNAs who were putting (R23) to bed on 6/15/24 came and got her and told her (R23) had a bruise on her right arm. She stated she went down and looked at it and it was a big purple bruise on (R23's) right upper arm. V3 stated she had not had any other staff report anything out of the ordinary related to (R23) during the shift and she did not know what caused the bruise. She stated she immediately notified the Medical Doctor, Administrator, (R23's) family and the Director of Nursing. V3 stated there was a problem with their x-ray company coming out so the MD gave orders to send to the emergency room because (R23) is on blood thinners. On 8/30/24 at 11:10 AM, V10, CNA stated he took care of (R23) on day shift on 6/15/24 and was informed they found a bruise on (R23's) right arm on that night. He stated he never observed a bruise on (R23's) right arm while he was taking care of her on that day. V10 stated he does not remember (R23) having any abnormal behaviors that day. He stated her normal behaviors was yelling out for no reason. V10 stated (R23) was not combative or resistive to care with him that day. He stated someone did call him the next day to ask if he knew anything about her bruise but he could not recall who called him. The facility's policy, Abuse Prevention Program Policy and Procedure updated 9/26/23 documents, Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. An initial written report shall be sent to the Illinois Department of Public Health (IDPH) immediately. The written report should contain the following information if known at the time of the report: Any obvious injuries or complaints of injuries.

The facility failed to ensure all bruises of unknown origin were thoroughly investigated for 1 of 3 residents (R48) reviewed for bruises of unknown origin in the sample of 41. Findings include: R48's Physician Order Sheet (POS for August 2024) documents a diagnosis of Major Depression disorder, severe with psychotic symptoms, pressure ulcer of left heel, Alzheimer disease, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbances, psychotic disorder with delusions due to known physiological condition, and anxiety and bilateral primary osteoarthritis of hip. R48's Minimum Data Set (MDS) dated [DATE] documents she is severely impaired for cognition for activities of daily living, she has impairments on both sides, she uses a manual wheelchair. She is dependent on staff for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene, Rolling from left to right, sit to stand, chair to bed, toilet transfer tub/shower transfer, and she does not walk and is always incontinent of urine and bowel. R48's Care Plan: (R48) at risk for falls; due to poor safety awareness. Maintain safe environment to room/facility to prevent injuries, well lite environment. Observe resident for any unassisted transfers/ambulation status. Remind to wait assist and assists residents as needed. B & B (bowel and bladder) before meals/after and as needed. Keep resident clean and dry. Resident to use call lights when assist needed. Report any unsteady balance/gait to Nurse. Report any decline in safety awareness to Nurse (PRN). Use of 1/4 side rails times 2, check every two hours and as needed. R48's Skin/Wound Note dated 5/18/2024 at 1:28 PM, Note Text: 11 x 6 cm (centimeters) bruise noted to left shin during routine care. Staff reported to this nurse. Leg evaluated on pillow and V13, Nurse Practitioner notified and aware. Will monitor until healed. Author of this note was documented as V12, Licensed Practical Nurse (LPN). R48's Incident/Accident report date of incident 5/18/2024, Staff noticed a 11 x 6 cm light purple bruise to left skin during routine care. Staff reported resident leg was bumped by another resident's wheelchair. The incident report does not document who the staff member was when the injury occurred and or who the other resident was involved in the injury. R48's Incident/Accident report date of incident 5/18/2024 does not document the time or when the physician was notified, and the form was not completely filled out. The Skin Injury Investigation Checklist undated does not document the name of the resident. There was no name, the form documents, Type of skin injury: 'bruise', staff assigned to resident (V10), certified nursing assistant (CNA) and (V11), CNA. How was skin injury found? During routine care. Resident's activity at the time of the skin injury; sitting in wheelchair. What the resident said happened: Unable to voice. Does the resident self-ambulate or self-propel wheelchair around the facility; 'No'. Was there a prior injury to this area recently? 'No'. Does the resident have any behaviors? No. The checklist does not documents which staff member told the other staff an incident had occurred or who the other resident involved was. On 8/29/2024 at 10:41 AM, V12, Licensed Practical Nurse stated, (V11) and (V10) came and got me and told me they had found a bruise on (R48's) leg while they were doing care. I went and looked at it and I did an incident report. I was watching the bruise and they did an investigation on her. (R48) did not walk and was unable to propel herself in the wheelchair. At the time of the incident (R48) was in a manual wheelchair with foot pedals. We think that at mealtime they accidentally hit her foot with the other resident. I do not know who the other resident was, or who the staff member was that was caring for (R48) while they were pushing the other resident under the table, and then they collided. (R48's) bruise was progressively getting worse and I called the Nurse Practitioner and she had me get an x-ray, and when the x-ray came back, we learned she had fractured her leg. I was in shock and blown away because I did not expect (R48's) foot to be fractured from colliding with another resident. On 8/29/2024 at 10:02 AM, all investigations for the bruise of unknown origin were requested. On 8/29/2024 at 2:02 PM, (V11), Certified Nursing Assistant stated, Me and (V10, CNA) were taking care of (R48). We got her up and took her to breakfast. (R48) was in a regular wheelchair with foot pedals. She was not able to propel herself. After breakfast the nursing aid, I do not know her name, she was agency, told me that she had bumped (R48's) leg at the dining room table that morning. When we took (R48) back to her room and laid her down, she winced and even though she could not talk she was grimacing, and you could tell her leg hurt her and she had a red/purple bruise. I went and got the nurse (V12) and had her look at it. (V12) was monitoring it and contacted the doctor and got an x-ray and later we found out she had a fracture. We were all in shock. On 8/29/2024 at 3:32 PM, V2, Director of Nursing stated, I do not have any interviews documented for (R48's) fracture. I did not get any statements from anyone, I did not realize I was supposed to do that as I am new to this position. On 8/30/2024 at 11:03 AM, V10, certified nursing assistant (CNA) stated, I remember taking (R48) back to her room after lunch and when laying her down we, (me and (V11, CNA) noticed a bruise on her leg. We immediately notified the nurse (V12, LPN). Before laying her down she had no prior pain or symptoms. After laying her down she would grimace when we touched the bruise. She cannot talk or tell you what had happened. No staff told me that there was any accident and or injury to (R48). I was working the night shift and I was very surprised to learn that she had a fracture. I am no longer employed at the facility. On 8/29/2024 at 3:42 PM, V1, Administrator stated, I remember the case, but I did not do the investigation, (V2) was in charge of the investigation. On 8/30/2024 at 2:40 PM, V13, Nurse Practitioner stated, The documentation on this case was poor and what we know is that (R48) had a fracture, and we were not sure how she got that fracture. There was a late entry and I have many issues with that because staff should have documented immediately if she was hit by accident or with other residents and at the end, we can only go by what is documented. It is hard to say and an unusual case. Without names and dates I just have issues. The Facility Abuse Policy updated 9/26/2023 documents, The facility affirms the right of our residents to be free from abuse, neglect, misappropriations of property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect, or abuse of residents and has attempted to establish a resident-sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within our control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Timely and thorough investigations of all reports of allegations of abuse. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. The Director and/or Assistant Director of nursing is responsible for reviewing the incident report and reporting any findings to the facility administrator. If the resident complaints of physical injuries or physical injuries are noted, the resident's physician and representative will be contacted for further instructions.

Based on observation, interview and record review the facility failed to prevent staff to resident abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 17. This failure resulted in V8, Certified Nurse's Assistant, CNA, being rough with R2 and verbally abusing R2. A reasonable person would not want to be treated roughly during care and verbally abused. Findings include: R2's Admission Record Form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of another specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set (MDS) dated [DATE], documented R2 as being severely cognitively impaired. R2's Care Plan, dated 6/8/23, documented, Requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:30 AM, V14, R2's sister/Power of Attorney (POA) stated, Some of these young kids do not have compassion and some of the CNAs are rough. I have video of a (Certified Nurse Assistant) named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated she went to V7, Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, was observed by surveyors. Observations made were R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, showed V8 pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand. V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. On 12/4/23 at 12:10 PM V1, Administrator, stated We didn't report the video concerns because we cleared it on the spot when the sister (V14) brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. On 12/4/23 at 12:30 PM, V7, Social Worker, stated, When the family showed me the video, I was adamant that we had to report it to the Administrator. V7 stated that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to (V14). On 12/5/23 at 4:40 AM V17, Registered Nurse (RN) stated that she feels that some of the staff speak to residents in a rough tone especially if it is a resident who was being resistive to care. V17 stated that she thinks that some of the staff need more education regarding dementia care. She continued to state that she would report them to (V1, Administrator) or to (V23, ADON) who was over the CNAs. On 12/5/23 at 1:20 PM V8, CNA, stated, On 11/26/23, I went to get (R2) dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 stated, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 continued to state The ADON (Assistant Director of Nursing) came to me later that day and said (R2's) sister showed me the video. V8 stated (V23) knows how her sister is and (V23) didn't want me to get in to trouble. V8 stated, (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated They did not send me home, they just put me on another hall. R2's Progress Note, dated 11/26/23 at 3:31 PM, documented, Bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. R2's Facility's incident report form, dated 11/26/23, documented, Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility could not provide documentation of investigation, including witness statements and root cause analysis. It also could not provide documentation that the state agency was notified. An electronic mail (email) dated 12/06/2023 at 11:23 AM, from V1, Administrator, documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire and sign a form they received it. (V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbals, physical or mental abuse in our policy was met by (V8, CNA) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she will not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility Abuse Prevention Program Policy and Procedure, dated 9/26/23, documented, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident-sensitive and secure environment.

Based on interview and record review, the facility failed to implement a system in which staff immediately report allegations of abuse and injuries of unknown origin to the Administrator and State Agency. This has the potential to affect all 96 residents residing in the facility. Findings include: 1.R2's Admission Record Form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of another specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set, MDS, dated [DATE], documented R2 as being severely cognitively impaired. R2's care plan, dated 6/8/23, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her (R2's) leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to (V14) that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture. V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, was reviewed by the surveyor and showed R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAs interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in (R2's) case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with (V1, Administrator), and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1 stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V1 continued to state, On abuse we decide if it is a reportable or not reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24, LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. 2. R16's Admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder, and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at (R16's) chart when I sent it to you and the nurse probably assumed it was from picking. The facility had no documentation that nurse reported this to V1 for investigation and was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead, purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL (within normal limits). No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's Progress Note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There were not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's Admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was reported to V1 for investigation and was reported to the state agency. 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurse's station. Staff was assisting with putting her hearing aid back in her right ear. R17 stated she was good and asked writers name but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non-adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was reported to the Administrator and state agency and investigated as an injury of unknown origin. An electronic mail dated 12/06/2023 at 11:23 AM, from V1 documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CNA) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c. Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriate. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility.

Based on interview and record review, the facility failed to properly investigate allegations of verbal and physical abuse and injuries of unknown origins for 4 of 4 (R1, R2, R16, R17) residents reviewed for accidents and abuse in a sample of 17. This failure has the potential to affect all 96 residents residing in the facility. Findings include: 1. R2's admission record form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of other specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set), dated 11/6/23, documented R2 as being severely cognitively impaired. R2's care plan, dated, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her R2's leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to V14 that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture.' V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, documented, R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAS interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, DON, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in R2's case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with V1, Administrator, and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1, Administrator, stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V 1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V 1 continued to state, On abuse we decide if it is a reportable or not a reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24 LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/11/23 at 2:04 PM, V29, CNA stated that at one point we when R2 was getting therapy we used a pivot disc and 2 CNAS to transfer. On 12/11/23 at 2:17 PM, V30, CNA, stated that he always used a hoyer lift when transferring R2. He continued to state that therapy mentioning the pivot disc but he never attempted it with R2. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. 2. R16's Admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at R16's chart when I sent it to you and the nurse probably assumed it was from picking. The facility was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's progress note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There was not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's Admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. R1's Care Plan, dated 11/25/2023, documented, Floor mat x2. Neuro checks, re arrange furniture. On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurses station. Staff was assisting with putting her hearing aide back in her right ear. R17 stated she was good and asked writers name, but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. An electronic mail, dated 12/06/2023 at 11:23 AM, from V1, Administrator, documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire, and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CAN) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c.Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriatei. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility.

Based on observation, interview, and record review, the facility failed to implement progressive fall interventions, in 1 (R87) of 9 residents in the sample of 42. This failure resulted in R87 falling and sustaining a femur fracture and head laceration and being sent out to local hospital. Findings include: R87's Face sheet documents, an admitted [DATE]. Diagnosis include Dementia, Displaced Fracture of Lesser Trochanter of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing, Unsteadiness, Weakness. R87's Minimum Data Set, MDS, dated [DATE] documents, R87 is severely cognitively impaired. MDS dated [DATE] documents, R87 requires limited assist of 1 person for transfers and ambulation. R87's Care Plan dated 3/9/2023 documents, Physical mobility needs related to Right arm fracture and muscle weakness. Interventions include: Ambulation: R87 requires limited assistance by (1) staff to walk. Locomotion: R87 requires limited assistance by (1) staff for locomotion. The resident is weight-bearing, splint/sling to right upper extremity. R87's Fall assessment dated [DATE] documents, high risk for falls with a score of 90. Unsteady gait and history of falls. R87's fall investigation documents, on 6/6/2023 at 6:15 PM, R87 was in hallway near nurses' station in wheelchair. This nurse heard V16, Certified Nursing Assistant, CNA yell out hey what are you doing at that time this nurse heard a smack. This nurse got up from nurses' station and saw R87 laying on floor in hallway with head at employee breakroom door frame and legs extended outward towards hallway. R87 attempted to get up and was instructed to not move. Upon immediate assessment, this nurse had vitals obtained 132/82, 98.1, 20, 60, 98%, room air. R87 alert and oriented, noted profuse bleeding from crown of head, immediately applied pressure with cool cloths, noted decreased range of motion to left leg. R87 complained of pain to left hip. On palpation R87 unable to move leg at hip joint. R87 leg made comfortable to position. During time R87 states, What did I do wrong, what happened My sons are going to be so mad. R87 given care and continued to be made comfortable. Encouraging R87 to stay awake and keep eyes open. Noted Oxygen sats started to fall in low 90's, and R87 was placed on 2L Oxygen per NC, (nasal cannula), and Oxygen sats brought back up to 98%. R87 was able to follow questions, continued to answer her name and birth date, today's date, answered questions appropriately. Emergency Medical Services, (EMS), arrived and R87 was transferred from floor to stretcher via 2 EMS and this Nurse. Power of Attorney, (POA), Director of Nursing, (DON), made aware of fall. R87's History & Physical dated 6/6/2023 documents, Nursing Home resident. fell out of wheelchair. Hit head on the back and developed a laceration. Brought to the emergency room . Work up for intracranial abnormality. Head laceration stapled. Acute comminuted moderately displaced left proximal femoral intertrochanteric fracture found. Ortho consulted. R87 complaining of leg pain. Otherwise, unable to provide history due to dementia. On 9/21/2023 at 3:00 PM, V1 stated, I know falls are a problem. For a while we had a lot of agency and agency staff don't know the residents as well. We are slowly reducing our number of agency and hiring our own staff again. On 9/21/2023 at 1:10 PM, V13, LPN, stated, I was working the evening R87 fell . She was out of her wheelchair, and I heard the CNA, say (R87) what are you doing? Then I heard the worst sound I have ever heard in my life. She hit her head and it was bleeding profusely. We started treating her head wound and talking to her. She complained of pain in her left hip. She had seemed off that day and we found out later, she had a Urinary Tract Infection, (UTI). Unsure if R87 had a history of falls. On 9/21/2023 at 2:25 PM, V16, CNA, stated, I was in the hallway helping another resident and R87 was propelling in the hallway. I saw her get up and I said, What are you doing? and she fell and hit her head on the railing. Everyone ran to help her and get towels for the blood. R87 was one to get up on her own. On 9/22/2023 at 8:10 AM, V17, Nurse Practitioner, (NP), stated, she would've expected progressive fall interventions to be in place, regarding a resident with a history of falls. Fall policy undated states (Facility name), will make a good faith effort to fulfill regulatory and person-centered standards to reduce risk factors for falling. The process of reducing fall risks incudes the creation of an individualized care plan. For purpose of this policy and protocol, fall is defined as an unintentional change of plane from a higher to a lower position that is not the result of an external force.

Based on interview and record review, the facility failed to perform a safe transfer for 1 of 5 residents (R3) reviewed for resident injury in the sample of 6. This failure resulted in R3 sustaining a left tibial and fibular fracture which required hospitalization for surgical intervention. Findings include: R3's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of Type 2 Diabetes Mellitus, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity, Unspecified Protein-Calorie Malnutrition, Muscle Weakness, Other Abnormalities of Gait and Balance, and Other Age-Related Physical Debility. R3's Physician Order dated 8/27/23 documents the order: Send to (local hospital) to eval and treat left lower leg abnormality. R3's Minimum Data Set (MDS) dated [DATE] documents she is moderately cognitively impaired and requires extensive assist of one staff to transfer. It further documents R3 is not steady, and is only able to stabilize balance with staff assistance during surface to surface transfer (transfer between bed and chair or wheelchair). R3's Care Plan dated 6/16/23 documents, Resident at risk for falls/contractures related to need for assistance with personal care, weakness. The intervention for this care plan is, Maintain a safe environment to room/facility to prevent injuries, well lit environment. Observe resident for any unassisted transfers/ambulation status. Remind to wait for assist and assist resident prn (as needed). B&B (bowel and bladder) before meals/after and prn. Keep resident clean and dry. Instruct/remind resident to use call lights when assist needed. Report any unsteady balance/gait to nurse/physician prn. Report any decline in safety awareness to nurse prn. Use of side rails times___ checked every two hours and prn. R3's Kardex dated 6/16/23 documents, under transferring, Transfer: The resident requires extensive assistance by (1) staff to move between surfaces. The Facility's document, Incident Report, documents the date of R3's incident at 8/27/23 at 3:15 PM in her room. It documents, Incident: CNA (Certified Nursing Assistant) (V10) alerted nurses (V5, Licensed Practical Nurse (LPN) and (V4, Registered Nurse (RN) ) that (R3) complained of left lower extremity pain. (V5) went to her room and observed (R3) sitting up in wheelchair (w/c) with left lower extremity appearing hyperextended and appeared abnormal. (V10) statement indicated that after transferring (R3) as indicated on Kardex with gait belt, once she was in her wheelchair, she complained of pain then (V10) notified the nurse. Per (R3) she told the nurse that her leg was caught beneath her. (V4) assessed leg also and order was given to send to (local hospital) for evaluation and treatment. POA (Power of Attorney) was aware. DON (Director of Nursing) notified and Administrator notified. V10's handwritten statement was included in the incident investigation provided by V1, Administrator, on 8/29/23 and in this statement V10 documented, On 8/27/23 I was assisgned B hall which included (R3). During first rounds I went into check on (R3) to see if she needed anything at that time. She asked if she could get up to go to Bingo. I told he that it would be no problem and proceeded to get her up for Bingo. (R3) did not complain of any pains prior to getting her up. Before transferring (R3) from her bed to her chair I explained to her step by step what I was doing. She agreed with things and seemed to be okay. I counted to 3 before lifting (R3) up and proceeded to put her into her chair. Once (R3) was in the chair she complained of leg pains. I told (R3) to give me a minute while I get the nurse. I got the nurse and notified the nurse of (R3's) complaints. I was not aware of (R3's) leg before putting her into her chair. V10's statement did not document that she used a gait belt when transferring R3 from her bed to the wheelchair. R3's x-ray report dated 8/27/23 at 5:44 PM documents R3 has acute proximal tibial and fibular diaphyseal fractures with slight displacement and angulation. On 8/29/23 at 9:00 AM, V1 Administrator stated she is aware of R3's left leg fracture from her Power of Attorney (POA) yesterday. She stated V2 DON, had called him to inform him of R3's injury that occurred during transfer. V1 stated she has sent the initial report and V2 DON is still investigating the incident. V2 DON, was also present during this interview and stated the only thing she can think may have happened is that R3's leg got tangled up in the blankets during the transfer or her foot may have gotten tangled up in the chair. She stated she is only guessing because she really does not know what happened. V2 stated the nurses noted swelling to R3's leg and sent her to (local hospital) and she has been transferred to outlying hospital for an ortho consult. V2 stated they had the choice to do a mobile x-ray or send her to the emergency room (ER) and they sent her to the ER for a quicker assessment. V2 stated the CNA who transferred R3 is an agency CNA and she thinks it may have been her first time working in the facility. V2 stated R3 is alert and oriented x 2-3; she has good days and bad days. V2 stated R3 yelled out with everything, if she wanted something or wanted to know what was going on with her brother. On 8/29/23 at 9:55 AM, R6, R3's brother and roommate, stated R3 did not fall; the CNA was transferring her from the bed to the wheelchair and right away she (R3) hollered, but he didn't think anything of it because she hollers every time they transfer her. He stated R3 stated, It hurts so much and when he looked at her, her foot was out at an angle. He stated R3 stated when the CNA transferred her, her leg was underneath of her, but he didn't know if she meant it was under her or under the wheelchair. R6 stated he was in the room when R3 was transferred, but he didn't look up until she was already in the wheelchair. R6 stated he did not see what happened. R6 stated the CNA was a little stunned and had the nurse in there checking her out about 30 seconds later. R6 stated the nurse came right in and checked her out and gave her Tylenol while the other nurse called the ambulance. R6 stated again that he didn't see what happened but maybe her (R3's) foot got caught. R6 stated his other brother called him to ask what happened because the hospital said both of the bones in her lower leg are broke. R6 stated it happened when the CNA was getting her out of bed and into her chair to go down to the dining room. R6 stated after the nurse checked R3 out, she transferred her back to bed and the ambulance came and got R3 about 4:00 PM. R6 stated his brother told him R3 is going to have surgery. On 8/29/23 at 10:10 AM, V4 RN stated, at about 2:55 PM on 8/27/23 (V10) CNA had transferred R3 from bed to her wheelchair. V4 stated you could see the deformity right away when looking at R3's left leg. V4 stated R3 told her at first that this happened when the girl laid her down, but then said it happened when they got her up. V4 stated R3's leg is contracted and thinks it may have gotten tangled up in the blankets. V4 stated the CNA called the nurses in immediately when R3 said she was hurt. V4 said the CNA said when she was transferring R3, she said, Oh my foot's caught. V4 stated V10, the agency CNA, transferred her on her own because R3 only weighed about 90 pounds. V4 stated when she went into R3's room, the CNA had R3 sitting up in her wheelchair. V4 stated she asked R3 if she was able to move her left leg and R3 lifted it up some and V4 was able to see the protrusion. She stated this happened on Sunday night and they sent her to the local hospital and she heard they were transferring her to (an outlying hospital) to determine if they were going to repair it. V4 stated R3 had said her foot was caught but she (V4) didn't know what it was caught on. V4 stated R3 hadn't had any falls and didn't try to get up by herself . On 8/29/23 at 10:23 AM, V7 CNA stated, R3 usually transferred just fine with one assist, but if they were transferring her to the shower chair they would use 2 staff just because of floor being wet, to make sure she was safe. V7 stated she was able to transfer R3 on her own but often used another staff just because R3 sometimes freaked out because she was scared she would fall. V7 stated R3 was able to follow directions when they transferred her . V7 stated she uses a gait belt when transferring R3 because she is unsteady. On 8/29/23 at 10:20 AM, V8 CNA stated, R3 required one assist and a gait belt for transfers. V8 stated R3 could stand pretty good and followed simple commands and was cooperative with staff. On 8/29/23 at 10:22 AM, V9 CNA stated, R3 was not combative or resistive. V9 stated R3's legs are contracted and hyperextended but she is still able to stand with assist. V9 stated she doesn't ever know R3 to get tangled in her blankets. V9 stated if R3 had a problem during a transfer, she was able to let you know. V9 stated R3 would be able to stand or could easily be transfered to the bed or wheelchair, but you have to use a gait belt because she was unsteady. On 8/29/23 at 10:41 AM, during phone interview, V10, Agency CNA stated she was working evenings on 8/27/23 when incident with R3 occurred. V10 stated it was right at the start of her shift and she was doing her rounds and R3 asked to be gotten up so she could go to Bingo. V10 stated she talked to R3 about how they were going to transfer and counted 1-2-3 and then transferred R3 to her wheelchair. V10 stated the other staff told her R3 was a one person assist for transfers. V10 stated she transferred R3 to her wheelchair and as soon as she sat down in her chair, R3 complained of her knee, stating my leg, my leg , it hurts. V10 stated she immediately went and got the nurse. V10 stated as soon as the nurse started assessing R3, she (V10) went to finish her rounds. R3 stated when she did R3's actual transfer, both of R3's feet were on the floor. V10 stated R3 did not help a lot with the transfer but her feet were not tangled in the blanket. V10 stated R3 did not complain of any pain until she was sitting in her chair. V10 stated she did not use a gait belt while transferring R3 because nobody told her R3 needed a gait belt with transfers. On 8/29/23 at 2:12 PM, V5 LPN, during phone interview, stated, I honestly don't have a clue what happened to (R3's) leg. She stated the CNA came up to her and asked her to come help with R3 because she said her leg hurts. V5 stated as soon as she walked into R3's room she was sitting in her wheelchair and her left leg was grossly abnormal. V5 stated she talked to R3 to see what had happened and R3 gave her two different stories. V5 stated at first R3 stated when they laid her down in bed she told the girl that her leg hurt. V5 stated this would have been the day shift CNA who laid her down after lunch. V5 stated R3 said she told the girl her foot was caught on me .it was under me. V5 stated she clarified this statement with R3, asking her if this was when they laid her down after lunch and R3 told her yes. V5 stated she had another nurse (V4) come in and assess R3, and she asked R3 to tell her again how it happened and R3 told her, Well when she was getting me up I told her my foot was caught. (V5 stated it was actually just below R3's knee). V5 stated R3 stated she wanted to go play Bingo and she was getting up when she said it hurt. V5 stated R3 said her brother was in the room when it happened. V5 stated R3's left lower leg just below the knee was protruding to the left and her foot was hyperextended to the left. V5 stated the foot was red but she didn't see any bruising. V5 stated R3's legs are normally discolored. V5 stated while R3 was just sitting still she did not complain of pain, but if left leg was moved she said it hurt. V5 stated V4 was calling the doctor and the ambulance and she (V5) transferred R3 back to bed and she was fine during the transfer and getting into bed until V5 positioned her leg and that was when R3 said it hurt. V5 stated she did not talk to the CNA's from day shift because they were already gone. V5 stated R3 transferred just fine with one assist and a gait belt. V5 stated R3 was a pivot transfer and she is a very tiny person. V5 stated R3 required moderate assist to help her balance during transfers. On 8/30/23 at 2:57 PM, V17 emergency room (ER) nurse from local hospital where R3 was initially sent, stated she is a night nurse and took care of R3 when she was brought to the ER with left leg fractures on 8/27/23. V17 stated R3 reported to her that she was being transferred to or from the bed or to or from the wheelchair and her leg got caught under the wheelchair and she told the staff to stop but they didn't and went ahead with transfer. V17 stated R3 is alert and oriented to self and knew she was in the hospital, and repeated the same story over and over again. V17 stated R3 had x-rays which showed a fibula/tibia fracture of the left leg. V17 stated it looked like a match stick. V17 stated the fracture was displaced and wiggling. V17 stated she was unable to reach R3's POA after several attempts and R3 was transferred to (outlying hospital) for ortho. On 8/31/23 at 10:00 AM, V1 Administrator and V2 Director of Nursing stated V10 CNA should have been using a gait belt while transferring R3 from the bed to her wheelchair on her own. V1 stated V3 Assistant Director of Nursing always educates agency staff to bring their gait belt and where to park when they are scheduled. On 8/31/23 at 4:53 PM, V18 R3's POA/brother, during phone interview, stated the facility nurse notified him on Sunday, 8/27/23 that (R3) was complaining that her leg hurt after she was transferred to her wheelchair and he was agreeable to her being sent to the hospital to have it checked out. V18 stated R3 was sent to the local hospital who then sent her to a larger hospital in the city. V18 stated this worked out well because there was a doctor there who was able to do surgery, which was done on Tuesday, and the doctor put a band on the larger bone which was connected to her knee on one end and her ankle on the other, and the doctor told him her smaller bone would heal along with the bigger bone. V18 stated R3's tibia and fibula were both broken. V18 stated R3 told him when the aide transferred her to her wheelchair, her foot got stuck and she yelled for the aide to stop but she went ahead and completed the transfer. V18 stated R3 told him it was only one girl transferring her from her bed to her wheelchair, but after she was hurt, two nurses transferred her back to bed. V18 stated he does not feel that aide had received appropriate training on how to transfer residents. V18 stated she (V10) should have gotten someone else to help her if she didn't know what she was doing. On 9/1/23 at 10:46 AM V3, RN/ADON sent the following statement via email message : I understand the agency CNA may have said that she was not aware of gait belts being required while here. I do the CNA staffing and am right now only using one agency and that is (staffing agency name). They have an information page that any aid that books a shift here is to read prior to booking shifts and on that page it clearly states that gait belts are mandatory. Agency aids also sign in on a clipboard that is located on my office door and right beside the clipboard is a page typed in all caps that also states that gait belts are mandatory. Myself, and nurses on the floor, are also always on the look out to ensure that any aid has a gait belt and reminded to locate theirs if noticed not to be on their person. On 9/1/23 at 12:28 PM, V19, Nurse Practitioner (NP) stated the facility had messaged on 8/27/23 her regarding R3's left leg swelling and she had given the order to send R3 to the emergency room for evaluation. V19 stated if the x-ray reports documented R3 had vascular calcifications, diminished osseous density and diffuse demineralization, this would have made her more susceptible to fractures. V19 stated she would expect the CNAs to use the gait belt when transferring residents who need assist for their safety. The facility's undated policy, Fall Policy and Procedure, documents, Policy: All residents have a right to be cared for within a safe environment. Each resident should be considered part of our fall prevention plan, which includes assessment of risk and initiation of appropriate interventions. The facility's undated policy, Gait Belt Policy, documents, The gait belt is a mandatory part of each aide's uniform. For the safety of the patient and the employee, aides are expected to use the gait belt whenever ambulating or transferring a patient. The gait belt will be worn around the waist of the staff member or be kept in the pocket when not in use throughout the scheduled shift. Gait belts will be used when helping the patient move from the bed, chair, or commode/toilet and to transfer and /or ambulate patients who need extra assistance. Direct care personnel will be trained in the proper use of the gait belt, primarily for safety purposes for both the staff and the patients. An employee who is injured or causes an injury to a patient as a result of failure to properly apply and use a gait belt is subject to disciplinary action, up to and including termination. The facility will supply a gait belt to any employee who does not currently own one (there may be a cost to the employee.)

Based on observation, record review and interview, the facility failed to implement progressive interventions and provide supervision to prevent falls for 3 of 7 residents (R34, R55, R138) reviewed for accidents/supervision in the sample of 39. This failure resulted in R138 falling, hitting his head, and being sent to the emergency room (ER). R138 sustained multiple intracranial hemorrhages including intraparenchymal hemorrhage in the left temporal region with subarachnoid blood that caused death. Findings include: 1. On 4/17/2020, R138 was admitted to the facility with the following diagnoses: [CONDITION(S)], COVID-19, hypertension, dementia without behavioral disturbance and major depressive disorder. R138's Morse Fall Scale, dated 7/20/2021 documents he was high risk for falls. R138's Minimum Data Set (MDS), dated [DATE], documented R138 had severely cognitive impairment. R138's MDS documented his balance was not steady, only able to stabilize with staff assistance when walking, moving from seated to standing position and turning around. The MDS documented R138 required limited assistance of one person for transfers and ambulation. The MDS documented R138 utilized a walker and had no falls. R138's Late Entry Incident Note, dated 8/8/2021 at 9:23 AM documents res (resident) was agitated this morning before breakfast. Res pacing with walker up and down C Hall. Res redirected several times and unwilling to sit down or go back to bedroom. Res was standing against the wall at the top of C Hall. This nurse heard a loud noise and noted that res was laying on the left side on the floor where res had been standing. Assessed res and no injuries noted. Vitals stable at 110/58; P60; R 16; T 96.7; O2 100%. Res denies pain and denies hitting head, but this nurse started neuro checks because fall was not witnessed and unsure if resident actually hit head. Called and left message for POA (Power of Attorney) to call facility. Res resting in bed at this time. R138's Care Plan, dated 9/1/2021 documents he was at risk for falls/contractures R/T (related to) decreased mobility, weakness, [CONDITION(S)]. The Care Plan documented that On 1/21/21, Certified Nurse's Aide (CNA) noted res (resident) up in BR (Bathroom) prior to going to next room. When CNA walked out into hall, res laying on back in BR. The Care Plan documented that on 8/8/21, R138 was agitated this am pacing C hall-redirection unsuccessful-had a fall in hallway. The Care Plan Goal documented (R138) placed in fall management, free of signs/symptoms pain. The Care Plan Intervention, dated 8/8/21 documented 1 on 1 spent with resident. R138's Care Plan Interventions, dated 9/1/21, documented Maintain safe environment to room/facility to prevent injuries, well-lit environment. Observe res (resident) for any unassisted transfers/ambulation status. Remind to wait assist and assist res PRN. B & B (Bowel and bladder) before meals/after and PRN (as needed). Instruct/remind resident to use of call lights when assist needed. Report any unsteady balance/gait to Nurse/ Phys (physician) PRN. Report any decline in safety awareness to Nurse PRN. Change of position every two hours and PRN. Non skin pad in chair as needed. Bed to low position and locked. Monitor use of eyeglasses, hearing aids. Reinforce assistive devices. Evaluate need for an adjustment in Resident's daily activity schedule. Observe res for restlessness. Assist resident to bathroom. This Care Plan did not address R138's need for increased supervision when ambulating. R138's Health Status Note, dated 9/27/21 at 10:16 AM documents Resident was taken to restroom had a large BM (bowel movement) because weak, and staring off. This nurse assessed resident elevated HOB (head of bed) and elevated feet. Resident able to grasp with upper extremities without difficulty. Able to smile without difficulty. Pushed PO (by mouth) fluids, answered questions without difficulty. Stated he felt better. V/S (vital signs) 100/60 (blood pressure), 97.3 (temperature), 88 (pulse), 20(respirations), SPO2 (oxygen saturation levels) 98% RA (room air). Placed on Mxxxxxxxxxx (secure clinical communication tool). Will monitor. R138's Incident Note dated, 9/27/2021 at 11:04 PM documents Resident leaning against dining room wall. Resident had a [CONDITION(S)] episode and fell on to the floor at 5:30 PM. Resident drooling, not responsive at first. Resident became more and more responsive after about 10 minutes. Vitals 97.1,68,20,118/88,98%. POA notified and agreed resident should be sent to ER (emergency room ) for evaluation and treat. Doctor also notified. Resident left by ambulance without any resistance at 6:28 p.m. Nurse called at 10:00 PM to check on the status of resident and was informed resident is being admitted with GI bleed. R138's Fall Information Form, dated 9/27/2021 written by V14, Licensed Practical Nurse (LPN) documented at 5:30 PM Resident was standing in dining room against the wall. Resident then fainted and fell to the floor. Resident sent to ER for evaluation. The form documented that the incident was no witnessed. The form documented R138's family was notified at 5:45 PM and his physician was notified at 6:00 PM. R138's Electronic Medical Record, dated 9/27/2022 documents no further assessment of the R38 after he fell at 5:30 PM. There were no documented neurological checks after this incident occurred. R138's Communication - with Family/NOK (Next of Kin/POA (Power of Attorney) Note dated 9/28/2022 at 3:52 PM documents Call received from POA. She states resident has been placed on hospice care for brain bleed that the hospital medical team has been unable to control. She states family wishes to have any photos or cards of resident's but donates all clothing at this time. The Facility's Final Report of Serious Incident dated 10/1/2021 documents (R138) is a [AGE] year old resident with a diagnosis of [CONDITION(S)], history of COVID-19, essential hypertension, unspecified dementia without behavioral disturbance and major depressive disorder. (R138) is alert and oriented x 2, able to make all needs known, his primary mode of transportation is wheeled walker which he can ambulate without assistance. At approximately 5:30 PM on 9/27/2021 (R138) was ambulating in the dining room when he stopped and rested against the wall. (V15. Licensed Practical Nurse/LPN) noted his appearance changed with him staring straight ahead and appeared to faint and fell to the floor landing on his right side before any staff could get to him. (V15) and (V14, LPN) responded immediately and performed assessment, neurological assessment was abnormal due to loss of consciousness, vital signs were normal for (R138.) Upper and lower extremities showed no signs of injury. Nurse noted hematoma to right forehead starting to form. (R138) became alert and more responsive after approximately 10 minutes. (V15) stayed with (R138) while (V14) contacted the medical director, his physician and received orders to transfer to hospital of choice for further evaluation and treatment. Medical director, Illinois Department of Public Health (IDPH), Administrator, DON and POA notified in timely manner. Conclusion: no abuse was suspected. (R138) was sent to a local hospital for further evaluation and treatment. Immediate intervention was staff stayed with (R138) until ambulance arrived. (R138) was admitted with a diagnosis of intracranial bleed with midline shift. CT (Computerized tomography) scan showed multiple intracranial hemorrhages. He was admitted to general in patient and POA wanted comfort measures only. (R138) passed away the next day at the hospital. R138's Hospital Paperwork, dated 9/27/22, documents diagnosis of fall with head trauma and multiple intracranial hemorrhages including intraparenchymal hemorrhage in left temporal region with subarachnoid blood. The Hospital Report documents The resident is a [AGE] year old male with past medical history significant for hypertension (high blood pressure) [CONDITION(S)], dementia, depression, mitral valve insufficiency and COVID-19 infection December 2020. Patient presented to our ED (emergency department) via EMS (emergency medical services) from the nursing home secondary to a fall, patient was witnessed falling from a chair and struck his head on the tile floor, no loss of consciousness, patient unable to provide history information obtained from records, in the ED patient was evaluated CT (cat scan) showed multiple intracranial hemorrhages including intraparenchymal hemorrhage in the left temporal region with subarachnoid blood and parenchymal contusions, neurosurgery were consulted. There was a 3 to 4 centimeter hematoma to left parietal scalp. Patient was given IV (intravenous) [MEDICATION(S)], IV [MEDICATION(S)], intensivist was consulted, and patient get admitted for further evaluation and treatment. Patient was admitted to ICU (intensive care unit.) Discharge condition: poor, discharged to inpatient Hospice. Hospice note: patient was recently admitted after a fall and was diagnosed with intracranial bleed with midline shift and is requiring total care of activities of daily living (ADLs.) The patient is lethargic, requiring IV gtt (drop) [MEDICATION(S)] (narcotic pain medication) at 2 milligrams (mg)/hr (hour.) On 7/6/2022 at 12:21 PM V28, LPN stated she was the restorative nurse and remembered R138. V28 stated He walked with a walker and was supposed to only walk with staff assistance because he had unsteady gait, but he would often walk by himself. He was a high fall risk and staff had to remind him often not to walk alone. On 7/7/2022 at 11:00 AM V13, Certified Nurse's Aide, CNA stated he works day shift and recalled R138. V13 stated R138 was a walk to dine resident. V13 stated R138 walked unsteady on his feet so staff were supposed to walk with him. On 7/7/2022 at 11:14 AM V12, LPN stated she remembered R138 and stated he walked with a walker but only with staff assistance because he was unsteady on his feet. On 7/7/2022 at 11:20 AM V14, LPN remembered R138. She stated R138 walked with a walker with staff assistance. V14 stated she didn't see R138 fall on 9/27/21, staff alerted her he fell in the dining room and her and another nurse (name unknown) assessed R138. V14 stated she didn't recall if he hit his head or not, he didn't have any injuries from the fall that she could see. V14 stated after R138 fell he initially wasn't responsive but then he opened his eyes. V14 stated she called the family and physician and got an order to send him to the hospital for further evaluation and treatment. R138 stated she called the ambulance company directly, she did not call 911 because it wasn't a medical emergency. On 7/7/2022 at 11:28 AM V15, LPN stated she works evening shift and was familiar with the resident. He was confused and ambulated with a walker with staff assistance. He was unsteady on his feet to ambulate alone. She assessed him when he fell in the dining room on 9/27/21 but wasn't assigned to her. She didn't recall a head injury. V15 stated after R138 fell he was more confused than usual and was no longer communicating verbally. She felt this was a medical emergency after he fell because he had an altered mental status. On 7/7/2022 at 2:30 PM the Director of Nurses (DON) stated when a resident falls staff are expected to document everything from what they saw and what the assessment was and to be as descriptive as possible in the nurses note. She spoke to staff after the fall and V15, LPN reported the resident had a hematoma forming on the side of his head and V14, LPN reported the resident was unresponsive for a bit after the fall which means he lost consciousness and that is considered a medical emergency and 911 should have been called. She expected staff to call the resident's family and physician immediately after a fall. She also expected staff to get neuro checks when a resident has a head injury and to apply ice to the area. On 7/7/2022 at 2:00 PM V19, R138's Physician, stated he didn't recall the specifics of R138 falling in September 2021. V19 stated he has no notes on the fall the nurse must have called after the doctor's office closed for the day because if it was during office hours, he would have notes about the fall. V19 stated when a resident falls and loses consciousness it is considered a medical emergency and 911 should be called. He also expected staff to document what occurred with the fall in the resident's medical record especially document when a resident has a head injury. If the resident fell and hit his head that could cause a brain bleed and could have been a factor in his death. The facility's undated Neurological Assessment - Head Treatment policy documents the neurological assessment form is initiated by the nurse immediately upon noting any trauma to a resident's head. The assessment lists various items that are used to indicate presence of intracranial pressure. It is important to note the resident's normal neurological signs to accurately judge changes that are noted during the use of this assessment. A weak hand clasp is not a significant if it was noted to be present before initiation of the forms for example. A 72-hour assessment is done in full according to this time scheduled: every 15 minutes x 4, every half hour x 2, every four hours x 4, then every 8 hours for the last 48 hours. Levels of consciousness nurses noted by checking whether resident is oriented, disoriented, restless or drowsy. Any change in the level of consciousness is one of the earliest and most sensitive indicators or increased intracranial pressure. Summary: altercations in consciousness provide the best guide for the nurse to estimate intracranial pressure. 2. R55's Health Status Note, dated 5/22/2022 10:09 PM documents: Res (resident) across hall put her light on. She heard resident (R55) saying help. CNA entered room and found res lying on l (left) side in front of w/c (wheelchair). ROM (range of motion) WNL (within normal limits). Not witnessed so neuros started. WNL. Res was making voluntary movement with arms. Assist x 3 to get off floor. Res body was flaccid. She refused to assist. 0 inj (injury) noted. POA, DON and Dr (doctor) aware. Res remains on ABT (antibiotic) R/T (related to) [CONDITION(S)] (urinary tract infection.) 0 ASE (adverse side effects) noted. Refused fluids. 0 signs or symptoms of pain noted. Will continue to monitor. R55's Significant Change MDS, 6/14/2022 documents wheelchair, walker, one fall since admission no injury and she was moderately cognitively impaired. R55's Late Entry Incident Note, dated 6/16/2022 at 10:46 documents Resident yelling out for help. Resident on buttocks leaned against side of bed. Resident could not explain what she was doing. states I slid down denies pain. ROM to all ext's (extremities) wnl. x 2 staff and gait belt resident back into center of low bed. call light in reach. will do 72-hour f/u per fall protocol. received order for floor mat at side of bed and initiated. 97.9-100-20-118/62-93%. R55's Health Status Note, dated 6/18/2022 at 7:05 AM documents CNA notifies nurse 'Can you come help me?' Nurse observes res r (right) side lying on floor mat, bed low position. Res Denies pain. No injury. 2 staff assist res to bed, low position. Res education provided r/t calling for help before self-transfer attempts. R55's Care Plan dated 6/20/2022 documents problem: resident is at risk for falls. Goal: free from falls. Interventions: 2/5/21 staff reeducation on proper transfer resident out of shower chair and staff to ensure shower chair is locked when transferring. Dysom placed in wc to prevent sliding from cushion. 6/20/2022: floor matt x 1 door side due to resident throwing legs out of bed. On 7/6/2022 at 10:58 AM, there was no floor mat on floor in R55's room. 3. R34's MDS date 05/04/22 documents a BIMS score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only of one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses walker and wheelchair for mobility. R34's Care Plan dated 01/19/22 documents (R34) is at risk for falls /contractures R/T muscle weakness and poor safety awareness d/t recent hospitalization for infection in blood stream. R34's Care Plan documents the following incidents: 11/7/21 self-transferred self from w/c and slipped onto floor; 11/22/21 ambulating in room alone, slipped and fell . 1/19/21 out of bed and scooting on floor; 4/15/22 observed laying on floor near bed. 4/18/22 sitting on buttock in front of wc. R34's Care Plan Interventions are as follows: 01/19/22 - Maintain safe environment to room/facility to prevent injuries, well lite environment. Observe Res. for any unassisted transfers/ambulation status. Remind to wait assist and assist Res. PRN. B & B before meals/after and PRN. Keep Res Clean and dry. Instruct/remind Resident to use of call lights when assist needed. Report any unsteady balance/gait to Nurse/Phys PRN. Report any decline in safety awareness to Nurse PRN. Use of side rails times ____ checked every two hours and PRN; 04/18/22 - UA (Urinalysis) with C/S (Culture and Sensitivity); 04/15/22 - 2 Re-educated staff to organize and declutter the room; 02/24/22 - wheelchair alarm changed to alert one; 01/19/22 - bed pad alarm; 01/22/21 - reeducated CNA to toilet resident Q 2 hours at night; 01/07/21 - chair pad alarm. R34's Incident Note dated 05/31/22 at 10:05 AM documents This nurse notified that resident had fallen in assigned bedroom during a self-transfer. CNA responded to resident's alarm and witnessed resident fall onto back in front of nightstand while attempting to self-transfer from wheelchair onto bed. Area of impact - back/head. No apparent injuries noted. Neuro checks initiated and WNL. PERRLA - brisk 3mm bilaterally. Hand grips strong bilaterally, while legs are weak bilaterally, which has been baseline for resident for a little while now. NP/DON/POA made aware of incident. Denies any pain at present time. Resident placed at nurses' station with this nurse for close monitoring. R34's Care Plan was not revised after this incident with progressive interventions to prevent her from future fall. R34's Incident Note dated 07/05/22 at 10:40 AM documents This nurse called to restorative room; resident noted to be lying on her back, legs outstretched with her head towards her wheelchair. alert one intact. Assessment done by this nurse- no injuries noted at present time. resident had no c/o pain or discomfort. resident unsure if she had hit her head, fall not witnessed. neuro checks initiated. POA AWARE, DON AWARE, (family) AWARE. will continue to monitor resident. R34's Care Plan was not revised after this incident with progressive interventions to prevent her from future falls. The facility's undated Fall Policy & Procedure, documents policy: All residents have a right to be cared for within a safe environment. Each resident should be considered part of our fall prevention plan, which includes assessment of risk and initiation of appropriate interventions. All residents are assessed for their risk of falls on admission and ongoing assessment continue on a regular basis depending on the resident status. All injuries will be promptly addressed, and post-fall interventions will be implemented. Perform verbal assessment to the cause of the fall and potential for injury. Perform physical assessment including vital signs, neurological assessments, range of motion and pain. Identify any environmental risks contributing to fall. Fall incident report filled out. Notify provider, DON, Administrator and POA. Document the fall in EMR (Electronic Medical Record). If transfer complete transfer/discharge summary.

Based on observation, record review, and interview, the facility failed to provide a safe transfer for one of three residents (R2) reviewed for mechanical lift transfers in the sample of 3. This failure resulted in R2 falling out of the mechanical lift sling / pad during a transfer, and was hospitalized with a [DIAGNOSES REDACTED]. Findings include: On 8/30/12, at 1:00 PM, the facility incident report dated 8/25/12, 5:15 PM, was reviewed. The report documented E4 and E5, Certified Nurses Aides (CNA), were using a electronic mechanical lift to transfer R2 from her bed to a geriatric chair. During the transfer R2 fell from the elevated lift the floor, landing on top of the feet of the lift. E6, Licensed Practical Nurse (LPN), documented in the incident report, that she saw and heard R2 fall from the lift, ran to check her, and called 911. In a nurses note dated 8/25/12, 5:15 PM, E6, documented "the hoyer was in a high position, roughly 3 to 4 feet in the air and R2's back had landed on the feet of the hoyer." A written statement by E4, dated 8/25/12 at 5:15 PM, documented E4 had hooked up the lift pad to the mechanical lift, and then called E5 for assistance. E4 and E5 had lifted R2 off her bed, and as they were moving through the door of her room, R2's pad came undone and she fell to the floor, landing on top of the lift legs. A written statement by E5, dated 8/25/12 at 5:15 PM, documented E5 came to assist E4 to move R2. R2 was already hooked up to the lift and E5 was operating the lift / raising R2 up and down. E5 documents she did not notice anything out of order as they worked, but "all of a sudden R2 just dropped to the ground, we made it from the bed to the doorway." On 8/30/12 at 1:45 PM, an observation of the lift involved in R2's fall was done with E4, and E7, Maintenance Supervisor. E7 stated that he found nothing wrong with the lift mechanisms, the electronics of the lift, the swivel bar or hooks of the lift. During the observation of the lift, it was observed that there were three hooks on each end of the swivel bar (six total hooks) to use for hanging the lift sling / pad. Near the end / opening of each hook were two small holes. 5 of the hooks had empty holes, 1 hook had a small rectangular white metal ring / safety latch. When the latch was in the down position, it covered the opening of the hook and would prevent the sling from sliding backwards off of the hook. E4, stated that she could not remember seeing the latches on the hooks on 8/25/12 when she moved R2. E7 stated "sometime during the last year, the latches had come loose with use and fallen off the hooks. The CNA's had told me the previous Administrator said not to replace them." E7 stated he had not been asked to replace the latches prior to this incident. On 8/30/12 at 1:45 PM, in an interview with E4, she stated, "R2 was in bed, I put the lift pad on R2 and attached it to the lift. I called E5 to come help me. When we started lifting her I did not stop to check the sling / pad to be sure it was still in place on the hooks before moving R2 off of the bed. The part of the sling / pad that came off of the hooks was by R2's left leg. I guess it just slid off the hook, and she fell out of the sling about 3 or 4 feet to the floor. I didn't think she hit her head." On 8/30/12 at 2:30 PM, the facility's Final Report of Fall, dated 8/29/12 was reviewed with E1, Administrator and E7. In the report E1, documents, "it is my conclusion that E4 failed to properly secure the sling loop to the lift, enabling the sling to slip off and cause R2 to fall." E1 stated "R4 was disciplined for not making sure the sling was secured properly. R4 was retrained on 8/27/12 on the proper use of the lift and sling. E1 provided a copy of the Mechanical Lift Performance Check list that documented E4 had been in-serviced. Additional documentation of in-service attendance was reviewed for the remaining facility staff attending the mechanical lift in-services that were held on 8/26 and through 8/30/12. E7 stated "after R2's fall I checked all the mechanical lifts, there are three of them. I found that there were two lifts where the hooks were missing safety latches." The lift used to transfer R2 was pulled from use on 08/26/12 by E2, Director of Nurses, DON, and the second lift found to not have the saftey latches was removed from use on 8/27/12. New safety latches were ordered for the lifts on 8/27/12. A review of the Owner / Operator Manual for Electric Portable Patient Lift, Reliant 450, documents on Page 20, is a picture of the lift and sway bar with 6 hooks, and all hooks have safety latches on the ends. The Owner Manual documents: Safety / Page 9, Using the Sling /Warning - Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair, commode). Safety / Page 9, Lifting the Patient / Warning - When elevated off the surface of the stationary object, and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. Section 7 - page 35, Maintenance, Check the swivel bar sling hooks for wear or deflection, initially, and monthly. Page 36, Detecting Wear or Damage - Replace any defective parts immediately and ensure that the lift is not used until repairs are made. On 9/4/12 at 9:00 AM, R2 was observed in her bed at a local hospital, with Z1, Registered Nurse. R2 did not wake when spoken to. Z1 stated R2 was not responsive and had no active movements. On the left side of her head R2 had a 2 inch by 1 inch fading dark bruise and raised area behind her left ear, a large dark purple / blue bruise from the left under arm into the chest, a lighter dark purple bruise under the left scapula, and multiple dark purple and blue fading bruises down the length of her left arm, elbow and fore arm. Z1 stated these bruises were from the time of R2's admission. Z1 stated R2 did have other bruising on her right extremities, but Z1 could not confirm this was from prior to admission. On 9/4/12 at 9:40 AM, Z2, Physician / Hospitalist, stated "I saw R2 upon admission, and R2's current condition has not improved since. R2 did have a urinary tract infection that had been treated, but this did not contribute to R2's current state. R2's fall has caused her to be in this condition, no other illness is causing this decline." A review of R2's hospital CT-Scan (computerized tomography scan) dated 8/25/12, 19:15 (7:15 PM) documents, Findings: There is a small left parietal and temporal lobe subdural hematoma measuring 4.7 x 0.5 cm in the greatest AP and Transverse Dimensions. A Left Parietal Scalp Hematoma is seen. A CT-Scan done on 8/25/12 at 23:25 (11:25 PM) documents, Findings: This exam shows increased extension and thickening of an acute left temporal, parietal and occipital hematoma which measures 7 MM in greatest thickness. A review of R2's hospital CT-Scan of the Pelvis dated 8/25/12, documents, Findings: Nondisplaced fractures of Left Superior Pubic Ramus, Left Ischium, and Left Sacra Ala are seen. On 9/4/12 at 2:00 PM, in an interview with Z3, Manufacturer Legal Representative, he stated "the latch at the end of the lift hooks is an additional safety feature to ensure the sling / lift pad is properly in place. Sometimes the latches may fall off from use, but they should be immediately replaced, so the sling does not inadvertently slide off the hook. Sometimes people find them inconvenient, but they should not be removed. The facility can and should call us at any time they have questions or concerns about the lift." On 9/5/12 at 10:00 AM, in an interview with E7, he stated " over the past years some of the latches fell off during use, and some were removed by the CNA's. The latches were not replaced because the previous Administrator told the CNA's that they didn't have to have the latches on the lift. I was not part of that conversation, but the CNA's told me this. I checked the lift each month, but did not replace the latches." E7 stated this was at least a year ago, and thought E8 and E9, CNA's might have more information. On 9/5/12 at 10:30 AM, E8, LPN, and E9, CNA, were interviewed, and they stated, "the latches kept popping off, and we were told they didn't need to be replaced. I don't remember who told us this, but all the CNA's knew about it back in 2011. A lot of the staff who knew this don't work here any more. E8 stated that she "was told by other CNA's that the previous Administrator gave permission not to replace the latches". E8 did not know for sure when this was said. On 9/5/12 at 11:00 AM, in a telephone interview with E5, she stated "I was called by E4 to come and help move R2 to her wheel chair. R2 was already in the sling when I came to the room. I raised R2 off the bed and E4 and I moved her toward her chair. I did not check the sling after E4 attached it to the arm of the lift. While we had R2 in the air, the bottom of the sling came loose and R2 fell out. She landed across and on top of the legs of the lift." On 9/5/12 at 11:30 AM, E1, stated, "I just started working here in January, 2012. This is the first I have known that the mechanical lift had parts missing. I did not give anyone permission to remove the latches, and would have told E7 to replace them if I had known of the problem. At this time, the safety latches on all three mechanical lifts have been replaced. In my interviews with E4, she stated she did not check R2's lift prior to moving her off of her bed. I believe that the sling slid off of the hook and caused R2 to fall." On 9/5/12 at 12:00 PM, all three facility mechanical lifts were observed and found to have the safety latches in place. .