Every finding on record at La Bella of Woodstock

Based on interview and record review the facility failed to ensure a resident was administered their prescribed medication for 1 of 5 residents (R1) reviewed for medications in the sample of 5. The findings include:R1's face sheet shows diagnoses including chronic pain syndrome, depression, anxiety, post-traumatic stress disorder and hypertension. On 8/11/26 at 9:20 AM, V5 (RN) Registered Nurse said R1 is independent, he has pain in his lower back and receives Tylenol and Voltaren gel. R1 is compliant with taking his medications. Medications should be administered as ordered. If medication is not administered nursing should document the reason why. On 8/11/26 at 1:05 PM, V3 (ADON) said R1 is alert and oriented, he does not refuse his medications. If the nurse is not administering a medication, they should document the reason for not giving the medication. R1's Medication Administration Record (MAR) dated August 2026 shows orders including Voltaren external gel 1% apply to bilateral lower back topically two times a day for chronic lower back pain. R1's MAR shows 8 out of 21 missed opportunities and the medication was not administered. R1's MAR shows 7 out of 8 missed opportunities as see nurse notes however there was no documentation in the nurses note. The facility's Medication Administration Policy states, Ensure that the six rights of medication administration are as follows: right resident, right drug, right time, right route, right time and right documentation. Review MAR to identify medications to be administered.

Based on observation, interview, and record review the facility failed to ensure a resident's package wasn't open without their consent and did not ensure the package was signed for delivery for 1 of 3 residents (R2) reviewed for resident rights in the sample of 8.The findings include:On 8/1/26 at 11:05 AM, V4 (Receptionist) stated a box was delivered for R2. V4 stated the box was opened on the corner like it had been damaged. V4 stated he gave R2 the package and did not have him sign anything that it was given to him. V4 stated they normally have residents sign for mail/packages. V4 stated activities are the ones that normally have the residents sign for mail/packages.On 8/1/26 at 12:41 PM, V3 (Activity Director) stated, The mail gets delivered to the reception desk and they let me know it has been delivered. Mail is put in my mailbox here and it is checked every day. There is a form that the resident signs when mail/package is delivered. If they can't sign the form, V3 stated she will ask if she can sign and/or mark it's delivered for the resident. V3 stated R2 is one of the residents that she delivers mail to personally and doesn't let the activity staff deliver. V3 stated she does this because he has had problems with his mail before. V3 stated R2 should have signed the form that he received his mail/package. V3 stated she was unaware that the person at the reception desk would give residents packages/mail instead of giving it to use to deliver and sign for. V3 stated she saw R2's package and there was something wrong with the top corner, but she did not think it had been opened. V3 stated she tells everyone that signing is just so they know and we know that they got their mail.On 8/1/26 at 2:20 PM R2 stated, he had a package that was delivered last week that had been opened. R2 stated the tape was pulled over and messed up and the box had been opened. R2 stated the package looked like someone had tried to put the tape back in place and lined up but was unable to. He stated he took a picture of the package. R2 pulled the picture up and it showed one area of the box looked like it had been lifted and the tape was messed up on the package. The box looked like it had been opened and resealed. R2 stated he was out in the facility when V4 told him he had a package and gave it to him. R2 stated V4 did not have his sign for the package and should have. R2 stated there wasn't anything missing from his package. R2 stated the reason he called the state is because this has happened before. He said he has had his mail tampered with 4 times before and has reported it to the post office. R2 after this mail problem that happened last year; they put in place that you must sign for the mail. R2 stated if they are going to put something in place then they should follow it.On 8/1/26 at 2:49 PM, V5 (Ombudsman) stated, [R2] called me a week to 10 days ago stating he received a box that had been tampered with and was filing a complaint with the post office. V5 stated he came into the facility the next day and with R2's permission, he took the box to V1 (Administrator) to look at. V5 stated the box looked like it had been pulled open and in an inexpert way it was closed. V5 said the box looked like it had been tampered with. The box looked like it had been opened. V5 stated it looked like the tape had been moved from one corner, the corner of the box looked like it had been folded over and wrinkled. The tape on the box was messed up in the corner and in the middle of the box. V5 said it did not have a sticker of notice from the post office that the box had been damaged in delivery. V5 stated there has been an issue at the facility with the packages in the past.The Minimum Data Set (MDS) dated [DATE] for R2 showed no cognitive impairment.The Illinois Long-tern Care Ombudsman program, Resident Rights for People in Long Term Care Facilities booklet was being used as the facilities resident rights policy. It showed you have the right to safety and good care. The facility must provide services to keep your physical and mental health, and sense of satisfaction. Your facility must make reasonable arrangements to meet your needs and choices. You have the right to privacy.The facility's Resident Mail Delivery policy (10/1/25) showed the purpose is to ensure that all residents receive mail unopened and in a timely manner upon delivery of the mail form the United States Postal Service to the facility. Policy: Upon delivery of the mail from the United States Postal Service to the facility, the mail will be forwarded to the receptionist for sorting. Any mail designated for residents will be forwarded to the activity department for delivery. The activity department will deliver the mail to the residents of which the mails is addressed, and residents will sign or give verbal consent that they have received or refused the mail.

Based on Interview and record review the facility failed to safely transfer a resident. This failure resulted in R3 sustaining an ankle fracture that required surgical repair. This applies to one of three residents (R3) reviewed for safety in the sample of three.The findings include:The facility face sheet for R3 shows she was admitted to the facility with diagnoses to include but not limited to Stage 5 kidney disease, Type 2 Diabetes, and other specified disorders of bone density. The facility assessment dated [DATE] shows R3 to be cognitively intact and requires maximum assistance from staff with transfers from bed to chair.A facility reported incident report dated 6/4/26 shows R3 was being assisted out of bed by a staff CNA (Certified Nursing Assistant) and when R3 stood up from her bed her legs became weak, and she twisted her left ankle, and the CNA lowered her to the floor. The report shows R3 was sent to the local hospital where it was discovered she had sustained a fracture on her left ankle. R3 was returned to the facility on 6/7/26 after having surgery to repair the broken ankle.On 6/23/26 at 10:01 AM, R3 said V2 CNA was helping her get ready for her dialysis treatment and she was sitting on the edge of the bed when she told V2 she was feeling weak and to not let her fall. R3 said V2 never put a gait belt on her before she began to transfer to the wheelchair. R3 said V2 put her arms under her arms and helped her to stand up. R3 said she began to feel her leg give out and remembers screaming don't let me fall. R3 said V2 attempted to hold her up but she couldn't, and she fell to the floor.On 6/23/26 at 10:14 AM, V2 CNA said she was assisting R3 out of bed to get ready for her dialysis. V2 said R3 was usually independent with her transfers but just needed supervision. V2 said she put a gait belt on R3 and then put her arms under R3's arms and helped her to stand up. V2 said R3's legs gave out and she lowered R3 to the floor. When asked why she was putting her arms under the residents' arms she said, I always do this as a precaution.On 6/23/26 at 9:27 AM, V3 CNA said he responded to V2's calls for help after R3 was lowered to the floor. V3 said he helped get R3 off the floor after she was assessed by the nurse. V3 said he believed R3 had a gait belt on but could not be sure.On 6/23/26 at 10:38 AM, V4 LPN (Licensed Practical Nurse) said she was the nurse assigned to R3 the day she fell in her room. V4 said she had told V2 that day to take extra precautions with R3 that day because she often gets weak because of her dialysis treatments. V4 said extra precautions would include using another staff person and using a gait belt. V4 said when she walked into the room, she saw R3 on her bottom next to her bed. V4 said she could not recall if a gait belt was on R3. V4 said R3 was complaining of mild pain to her ankle, but after a few minutes she began to complain of more pain. V4 said she gave R3 something for the pain and then called the provider for instructions. V4 said the Administrator came to the room and said R3 needed to be transferred to the hospital and that is what she did.On 6/23/26 at 1:26 PM, V1 Administrator said a resident who is a one person stand by assist should have a staff member at the side of the residents and have their hands gently on the gait belt as the resident is moving between bed and chair.The hospital records for R3 show she was admitted to the hospital on [DATE] with a left trimalleolar (a break to the ankle joint) fracture. The record shows R3 had an ORIF (Open reduction internal fixation) surgery on her left ankle on 6/5/26.The care plan with a revision date of 4/7/25 for ambulation shows interventions to include adaptive equipment such as a walker and gait belt. Instruct on proper use for safety. The care plan does not show any directions for transfers prior to the fall on 6/3/26.The facility policy dated 10/2025 for safe resident handling/transfers shows 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.

Based on interview and record review the facility failed to identify a resident's pressure injury prior to an advanced stage. This failure resulted in R1 being identified with a DTI (Deep Tissue Injury) to his bilateral buttocks on 5/20/26. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in a sample of 9. The findings include: R1's EMR (Electronic Medical Record) shows that he was admitted to the facility on [DATE] with diagnoses including Hypertension, Muscle Weakness, Chronic Kidney Disease Stage 3, Acute Cystitis with Hematuria and Metabolic Encephalopathy. R1's Skin and Wound Note dated 5/13/26 written by V9 (Wound Nurse Practitioner) states, No wounds. On 6/9/26 at 9:44AM V2 (Assistant Director of Nursing) stated, He is not here anymore. It started with a DTI (Deep Tissue Injury) to his left buttocks. I put an assessment in wound rounds. He was not eating or drinking. Had a low air loss mattress. It was added the day we found the DTI. He was agitated and resistant to care. R1's Facility Skin Issues assessment dated [DATE] shows R1 has a new wound, unstageable pressure injuries presenting as deep tissue injury to the buttocks, present on admission, onset- unknown. The wound measures 14 x 13 x 0.1 cm (centimeter) and is comprised of 70% epithelial tissue, 10% granulation tissue and 20% eschar. The Wound Assessment Report done by V9 on 5/20/26 shows the wound measuring 14 x 13 x 0.1 cm to the bilateral buttocks, acquired in house on 5/18/26. The wounds are described as 100% intact epithelium with evidence of deeper tissue injury (maroon or darkened purplish discoloration) epithelial. R1's Facility Skin Issues assessment dated [DATE] shows that R1's wound to his buttocks is now in-house acquired, measures 11.80 x 11.20 x 0.2 cm and consists of 20% epithelial tissue, 20% slough and 60% eschar The Wound Assessment Report dated 5/27/26 done by V9 shows the wound measures 11.80 x 11.20 x 0.2 cm to the bilateral buttocks. It is unstageable and consists of 30% epithelial, 10% granulation, 30% slough and 30% eschar. On 6/10/26 at 8:40AM V9 stated, On 5/13 yes, he had no wounds on that visit. On 5/20, the wound was brought to my attention by the facility. It was a purple discoloration; it was a DTI. There was epithelial tissue and a small opening but no necrosis. It was kind of a maroon colored on both buttocks. On 5/27- He had eschar, slough and epithelial tissue. It was a DTI that had opened up. He had a lot of co-morbidities, impaired functional mobility, incontinence. I had him at moderate risk for pressure development. He had altered mental status, but he was able to turn without assistance. He was cooperative for me during the assessments. I guess when they saw it, they would have thought it was bruising or something. He was on a blood thinner. He was not eating much, and I know he was a possible candidate for hospice. R1's EMR show no mention of a skin assessment or identification of R1's wounds prior to 5/20/26.

Based on interview and record review the facility failed to ensure a psychotropic medication order was transcribed to the medication administration record. This failure resulted in R1 not receiving the medication for the purpose of managing R1's behaviors and improving his quality of life. This applies to 1 of 1 resident (R1) reviewed for significant medication errors in the sample of 9. The findings include: R1's EMR (Electronic Medical Record) shows that he was admitted to the facility on [DATE] with diagnoses including Hypertension, Muscle Weakness, Chronic Kidney Disease Stage 3, Acute Cystitis with Hematuria and Metabolic Encephalopathy.R1's Progress Note written by the Psychiatric Nurse Practitioner dated 5/22/26 states, Patient is noncompliant with oral medications, limiting effectiveness of current PO regimen. Initiate ZyPREXA (olanzapine- an antipsychotic) 5 mg (milligrams) IM (intramuscularly) every 8 hours PRN (as needed) for anxiety/agitation for 7 days. Continue behavioral interventions including redirection, reassurance, low-stimulation environment, and consistent caregiving approach. Encourage continued attempts at oral medication administration when safe and feasible .R1's Progress Notes dated 5/23/26, 5/24/26, 5/25/26, 5/26/26, 5/27/26 and 5/28/26 all shows that R1 was having aggressive, combative behaviors, spitting out his food and oral medications. R1's Medication Administration Record for May 2026 shows no order for Zyprexa. This same document shows that R1 has no documented behaviors in the month of May. (Inconsistent with R1's Progress Notes.)R1's Care Plan dated 5/22/26 does not address R1's aggressive behaviors or refusal of food, fluids or medications. On 6/10/26 at 10:30AM V1 (Administrator/Action Director of Nursing) stated, The nurse practitioner usually sends us a separate email after she sees the resident. I will look into this and see what happened. At 11:25AM V1 presented Surveyor with a copy of the email addressed to V1 and V2 (Assistant Director of Nursing) showing the order for the Zyprexa (Antipsychotic). V1 stated, It was never given- that medication is for schizophrenia which he did not have. That is the regulation. He already had all of these other medications on board and that was not something he needed. It never got ordered. The son would have had to have to agree to that also. The facility policy dated 10/2025 states, Psychotropic medications are to be used only when the practitioner determines that the medication is appropriate to treat a resident's specific diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated be monitoring and documentation of the resident's response to the medication.

Based on observation, interview and record review the facility failed to ensure that dietary staff change their gloves during food service after coming in contact with potentially dirty objects/areas to prevent cross contamination. This has the potential to affect all 73 residents in the facility. The findings include: On 6/9/26 at 11:40AM V5 (Head Cook) was checking food temps with a thermometer at the steam table in the kitchen. V5 was wearing gloves. V5 reached up and touched his glasses with his gloved hand and then continued to check temperatures. V5 then rubbed the side of his nose, opened the service window door, and rubbed his eye wearing the same gloves. Without changing his gloves V5 then started stacking plates and bowls onto the counter getting ready for service. V5 was speaking to Surveyor and resting his gloved hand on the top plate. V5 picked up his notebook used for collecting food temperatures and put his notebook back in the pocket of his apron. V5 then touched his glasses again. Without removing the gloves V5 began serving the noon meal. V4(Dietary Manager) asked V5 for a chopped chicken piece. V4 removed the chicken from the steam table pan and placed it on the counter in front of him. V5 Cut the chicken and then scooped it with his gloved hand onto a plate. We do sanitize the counter before we start. V4 wore the same pair of gloves throughout the entire meal service. On 6/9/26 and 12:17PM V4 stated, We should be changing gloves between everything we do when we are serving the food. The servers do not wear gloves, but we do wear them when serving from the steam table and they should be changed between everything that we do. On 6/9/26 at 1:30PM R9 stated, (V4) in the kitchen is always touching his face with his gloves on and then serving the food.The Facility Data Sheet dated 6/9/26 shows that there are 73 residents residing in the facility. The facility policy entitled Gloves for Food Handling dated 2025 states, The gloves should be discarded when damaged, torn, soiled, or when interruptions occur or when handling something beyond the scope of food prep.

Based on interview and record review the facility failed to administer medications as ordered, at ordered times for 2 of 3 residents (R1, R3) reviewed for medication administration in the sample of 6.The findings include:1. On 5/27/26 at 11:42 AM, R1 said he can recall receiving his meds very late last week. It was after 12PM when he finally got his morning medications. R1 said the nurse that was working was not on time giving his meds. Review of R1's Physician Order Sheet (POS) shows an order of: Valproic Acid Oral Capsule 250 mg (milligrams), Give 500 mg by mouth three times a day for seizures Take 2 capsules (250 x2=500mg) to be given at 9AM, 1PM and 2100 (9PM); Clonazepam Oral Tablet 0.5 mg, Give 0.5 mg by mouth two times a day for anxiety/ aggression to be given at 8AM and 4PM.Review of R1's Medication Administration Audit report shows that on 5/18/26, the morning dose of Valproic Acid that was supposed to be given at 9AM was given to R1 at 12:42 PM (more than 3 hours late).R1's morning dose of Clonazepam that was supposed to be given at 8AM, was given to R1 at 12:44 PM (more than 4 hours late). 2. On 5/15/26 at 8:45 AM, R3 said he did not receive his morning medications until approximately 1PM. R3 said he missed his lunch while waiting for his morning meds. R3 said he refused his noon medications because they would have been given too close together.Review of R1's POS shows an order for:Alprazolam 1 mg gives 1 tablet three times a day (TID) for anxiety to be given at 8AM, 2PM and 8PM.Dicyclomine 10 mg 1 capsule TID for abdominal discomfort cramping to be given at 8AM, 1PM and 6PM.Review of R1's Medication Administration Audit report show:On 5/18/26, the morning dose of alprazolam that was supposed to be given at 8AM was given at 12:58 PM (more than 4 hours late), the morning dose of dicyclomine that was supposed to be given was given at 12:53 PM (more than 4 hours late).On 5/27/26 at 12:20 PM, V3 (Licensed Practical Nurse-LPN) said she was an agency nurse, she worked last 5/18/26 day shift. V3 said she cannot recall the specific events that day. V3 said meds should be given at the prescribed time as ordered.On 5/27/26 at 10 AM, V6 Licensed Practical Nurse (LPN) said in this wing (100), residents were when they received their meds. Residents should be administered their medications an hour before or an hour after the scheduled time.The Facility Policy entitled Medication Administration dated 10/2025 showed Medications are administered by Licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physicians and in accordance with professional standards of practice in a manner to prevent contamination or infection. Administer medications within 60 minutes (1 hour) prior to or after scheduled time unless otherwise ordered by the physician.

Based on interview and record review the facility failed to administer medications as ordered, at ordered times for 4 of 7 residents (R4, R5, R6 and R2) reviewed for medication administration in the sample of 7.The findings include:1.On 5/15/26 at 8:55 AM, R4 was in her room sitting in her wheelchair. R4 said she wants to take her medications on time. Review of R4's Medication Administration Audit report show an order of:Duloxetine delayed release 30 mg two times a day for depression, with the morning dose to be given at 8AM. On 5/11/26 the morning dose was given at 11:42 AM.Furosemide 20 mg two times a day (diuretic) with the morning dose to be given at 8AM. On 5/11/26, the morning dose was given at 11:42 AM.Midodrine 5 mg BID for hypotension with the morning dose to be given at 8AM. On 5/11/26 the morning dose was given at 13:28 (1:28 PM)Eliquis 5 mg two times a day for a fib (abnormal heart rate) with morning dose to be given at 9AM. On 5/11/26 the morning dose was given at 11:42 AM.Azelastine nasal spray 2 spray in both nostrils two times a day, with morning dose to be given 9 AM. On 5/11/26, it was given at 11:42 AM.2. On 5/15/26 at 8:45 AM, R5 was sitting in her wheelchair in her room. R5 nodded when asked if she had received her morning medications today.Review of R5's Medication Administration Audit report shows an order of:Levetiracetam 500 mg two times a day for antiseizure/epilepsy, to be given at 9AM. On 5/11/26 it was given at 11:36 AM. Depakote ER tablet extended release 500 mg two times a day for antiseizure/epilepsy with the morning dose to be given at 9AM. On 5/11/26 the morning dose was given at 11:37 AM. 3. On 5/15/26 at 11 AM, R6 was by the nurse station alert and pleasant and said he already received his morning medications and trusts the Nurses they were giving his meds on time. Review of R2s Medication Administration Audit report show an order of:Insulin Glargine Pen injector 35 units subcutaneously (SQ) two times a day for diabetes to be given at 9AM, on 5/11/26 it was given at 11:30 AM.Glucophage 1000 mg two times a day for diabetes for the morning dose to be given at 9AM. On 5/11/26 it was given at 11:25 AM.Eliquis 5 mg twice a day blood thinner for the morning dose to be given at 9AM. On 5/11/26, it was given at 11:23 AM 4. On 5/15/26 at 12 PM during lunch, R2 was in the dining room alert, calm and pleasant. R2 said he does not keep track of what time he gets his medications and would like to get them on time.Review of R2's Medication Administration Audit report shows an order of:Metoprolol 50 mg 50 mg two times a day for hypertension with the morning dose to be given at 9AM. On 5/11/26 the morning dose was given at 12:24 PMOn 5/15/26 at 9AM, V7 (Registered Nurse) said an agency nurse worked last 5/11/26. V7 said she did not know what happened, but residents had reported to her that their morning medications that day were given very late. On 5/15/26 at 12:26 PM V2 (Assistant Director of Nursing) said last 5/11/26, morning medications were given late. Medications should be given an hour before or an hour after the ordered time.The Facility Policy entitled Medication Administration dated 10/2025 show, Medications are administered by Licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physicians and in accordance with professional standards of practice in a manner to prevent contamination or infection. Administer medications within 60 minutes (1 hour) prior to or after scheduled time unless otherwise ordered by the physician.

Based on observation, interview, and record review the facility failed to follow R6's Menu Preferences for 1 of 8 residents (R6) reviewed for dietary in the sample of 8.The findings include: On 05/05/2026 at 12:30PM, R6 was eating the noon meal. R6 did not have any yogurt during the noon meal.On 05/05/2026 at 11:51AM, R6 said, I did not get any yogurt for breakfast. I was told there was no yogurt on the delivery truck. I was served yogurt last Thursday night (04/30/2026). Many excuses, the most common is, The truck comes on Monday. Yogurt was added to my diet menu a month ago during my care plan meeting. On 05/05/2026 at 12:43PM, V8 Dietary Manager said, we are out of yogurt. Yogurt was added to R6's Menu Preference during the Care Plan meeting a month ago. I ordered the yogurt for R6; the yogurt is gone within one day. This is the second time R6 has not gotten yogurt. R6's Dietary Card dated 05/05/2026 at Lunch shows, Regular Diet, Regular texture, yogurt at all meals.

Based on observation, interview and record review the facility failed to ensure resident's environmental noise was at a comfortable level. This applies to 3 of 3 residents (R5-R7) reviewed for resident rights in the sample of 11. The findings include: On 4/27/26 at 10:48 AM, R5's TV sound was heard loudly from the nurse's station. At 1:49 PM, R5's door was open, a sign posted on the door, Do Not Shut Door. R5's TV volume was excessively loud it was heard from the end of the hallway. On 4/27/26 at 1:50 PM, R6 was in her room with the door closed. R5's TV was heard across the hall with the door closed. R6 said R5 always has her TV on loud. They say it's her right to have it loud. R6 said R5's loud is disruptive at night when she is trying to sleep. R6 said it's been an issue for a while and affects other residents on this hall. On 4/27/26 at 2:09 PM, R7's room was located one door down from R5. R5's TV was heard loudly from R7's room with her door shut. R7 said the lady next door (R5) has her TV really loud at night especially. R5 turns it down for a little bit and then turns the volume back up. R7 tells the staff to tell R5 to turn down the volume. The staff can't tell her to turn it down because R5 gets upset and has a bad temper. R5's TV is loud all day long; it's been going on for a while. R5 said she has to put on her headphones to cancel off the noise. On 4/27/26 at 1:44 PM, V4 (Licensed Practical Nurse-LPN) said resident's complaint about the volume of R5's TV. R5 likes the TV volume loud. R5 is non-compliant with turning down her TV. R5 has behaviors, she gets agitated and verbal with staff when they ask her to lower the volume. V4 said she is not aware of R5 having a set TV volume. On 4/28/26 at 9:57 AM, V8 (Certified Nursing Assistant-CNA) said residents complain about R5's TV being too loud. Sometimes they can't sleep because it's too loud. We try to talk to R5 and ask her to turn it down. R5 gets upset if you ask her to turn down the TV. She likes her door open and you can't turn her TV down because she gets very upset and mad. R5 holds her remote in her hand and there is no way you can turn down the volume. You can tell her to turn down it down, but she won't listen. You can hear her loud TV from the of the hallway. R5's face sheet shows she has diagnoses including unspecified dementia with other behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and restlessness and agitation. R5's nurses note dated 3/26/26 documents (R5) was asked to lower her TV volume. The TV volume was elevated at level 70.(R5) was informed the volume was disturbing other residents who were sleeping. (R5) became verbally aggressive towards staff. R5's progress note dated 4/18/26 by V1 (Administrator) documents she met with (R5) to discuss some concerns last night. (R5) said her TV was on loud and she was asked to turn down the volume (R5 would not turn down the volume). Nursing shut the door after several attempts to lower the volume. (R5) stated, she does not like her door shut. R5's current care plan shows she has a problem related to turning the volume up excessively, in the evening or when she is out of her room with the apparent intent to provoke to taunt others. Interventions include (R5) agreed to turn the volume to 40, staff should remind her of the agreed TV volume.

Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 4 residents (R1,R2,R3,R4) reviewed for abuse in the sample of 4. Findings include:1. On 04/16/2026 R1's at 9:30AM, R1 was lying in his bed in his room. At 1:05PM, R2 was lying in his bed in his room. On 04/16/2026 at 9:30AM, R1 said, on 03/28/2026 I was sitting in my wheelchair in the hallway when R2 said, get out of my way, I am going to kick your ass. He threatened me and there was a scuffle. We threw some punches; I was hit with a coffee cup. A couple days later (03/30/2026) I went down to a community area to sit with my buddies. V3 RN-Registered Nurse started making a fuss. R2 heard V3. R2 came out of his room and started another fight with me. R2 was in his room; R2 came out when the nurse started a big commotion asking me to leave.On 04/16/2026 at 10:09AM, V1 Administrator said, R2 pushed R1's wheelchair with his foot. R2 was attempting to move R1's wheelchair out of the way. R2 had an empty plastic cup. R1 and R2's arms were swinging, maybe the cup touched R1. R1 said R2 kicked him. R2 said, he pushed R1 with his foot. R2 wanted to get through an opening, R1 said, you can't tell me what to do.On 04/16/2026 at 1:05PM, R2 said, I have had an altercation a couple of weekends ago (03/28/2026). There is a lot of traffic at the nurse's station. I ended up shoving R1. The police told me; I should not do that. R1 started swearing, came at me, spit at me. I had a coffee cup in my hand; I hit him in the face with it.On 04/16/2026 at 3:58PM, V3 RN said, on 03/30/2026 R1 and R2 were yelling and screaming at each other. I assessed R1; R1 claimed to be assaulted. R1's personality was not normal. R1 and R2 were sent out at the request of the psychiatric doctor.R2's Progress Notes dated 3/30/2026 at 5:11AM, shows R2 tried to take another resident's phone from him.R2's Progress Notes dated 3/30/2026 at 5:47PM, R2 started verbalizing profanity and instigating trouble towards other residents during lunch in the main lunchroom.R2's Progress Note date 3/31/2026 at 11:12AM, shows, hospital states R1 was admitted for Aggressive behavior psychiatry has already seen R1 and are planning treatment or transfer.R1/R2's Abuse Report dated 03/28/2026 shows R2 was attempting to go to room. R1 was blocking the hall. R2 used leg to move R1's wheelchair, a cup R2 hit R1's head.R2's Abuse Report statement dated 03/28/2026 shows, I was trying to get by in the hall to go to my room and R1 was blocking the hall. I asked R1 to move and R1 began yelling. Refused to move. I used my leg to push R1's chair out of the way. We were swinging our arms, and I had a plastic cup in my hand and hit R1 on head. I didn't mean to hurt R1, but R1 is difficult yelling and swearing.2. On 04/16/2026 at 11:44AM, R3 was sitting in a wheelchair.On 04/16/2026 at 11:44AM, R3 said, R4 threw a cup of coffee in face. R4 was in the doorway of the dining room. I asked R4 to move, R4 turned and threw coffee at me. R3/R4 Abuse Investigation dated 02/27/2026 shows, R3 and R4 were in wheelchairs attempting to pass into the dining room when R3 told R4 to get out of the way and R4 had a cup of [NAME] and tossed towards R3.R3's Abuse statement dated 02/27/2026 at 8:00AM, shows R3 states, was entering the dining room in wheelchair and R4 was just sitting in R4's wheelchair blocking the way for R3 to get to the table. R3 told R4 to move and wheelchairs hit each other. R4 had a cup with liquid and tossed towards R3. R3 states hit my face. Staff indicated it hit R3's arm.The facility's Abuse, Neglect and Exploitation policy dated 10/07/2025 shows, it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuseof all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on interview and record review that facility failed to have fall prevention interventions in place for a resident at risk for fall. This applies to 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 slipping out of his high back wheelchair and sustaining a left femur fracture.The findings include:R4's Face Sheet shows diagnoses of end stage renal disease and dependance on dialysis, acquired absence of right leg-below the knee, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia and Alzheimer's disease.R4's Hospital admission History and Physical dated 3/6/26 shows, Patient reportedly had a fall at the facility yesterday, however it is unclear if any evaluation was performed afterwards. He was sent for his scheduled dialysis session this morning where he appeared agitated and pointed to his left leg-appeared uncomfortable. Dialysis staff directed patient to the ER for further evaluation. XR (Xray) left femur with minimally displaced fracture of the distal femoral metadiaphysis.Patient to be kept n.p.o (nothing by mouth) in anticipation of internal fixation procedure per ortho tomorrow. R4's Hospital Notes show that he had an intramedullary nailing performed on 3/7/26.R4's Fall Incident Note shows that he had a fall in his room on 3/4/26 at 7:25 PM. The Incident Report shows, While resident was yelling in his room. This RN [Registered Nurse] gone to check, found sitting on the floor between his recliner and the furniture next to the heater. Resident stated he was sitting in the recliner in front of the heater sleeping and slid down.R4's Fall Care Plan shows that R4 is at high risk for falls. Fall Prevention Interventions that were in place prior to 3/4/26 include: Remind patient of good posture in wheelchair. If patient slouching or fatigued redirect patient to lay down, staff are to ensure resident is properly seated in his wheelchair, place non-skid mat in wheelchair to assist in preventing patient from sliding out of chair, dycem non-slip pad replaced.On 3/31/26 at 11:45 AM, V16, (Registered Nurse-RN) said that she was at the nurse's station when she heard R4 yelling. V16 said that she entered the room and saw R4 on the floor next to his recliner (high back wheelchair). V16 said that she called for the CNA (Certified Nursing Assistant) and they got him back to bed using a gait belt. V16 said that typically R4 goes back to bed after dinner time. V16 said that she asked R4 what happened, and he told her that he just slid out of his wheelchair. V16 said she noticed that his reclining wheelchair was in the upright position and not reclined how it usually is when he is in it. V16 said that she also noticed that he did not have a non-slip pad on his chair. V16 said that she felt that due to the chair not being reclined and being off-balance due to his amputated right leg, that caused him to slide off of the wheelchair. V16 stated, Maybe that day, the girl (CNA) didn't know all the things.On 3/31/26 at 12:35 PM, V18, (CNA) said that she has worked at the facility for about 3 months. V18 said that on the day of R4's fall, she had brought him to his room after dinner. V18 said that she did not get him up into his chair prior to dinner because he was already up. V18 said that he had just returned from dialysis before dinner, so she is assuming that the transport people put him in his chair. V18 said that typically when he returns from dialysis, the transport people use a sheet to transfer his either into bed or into his chair. V18 said that R4 typically goes back to bed around 7:30 PM. V18 said that she heard the nurse yell for help and entered the room and saw R4 on the floor next to his wheelchair. On 3/31/26 at 1:21 PM, V19 (CNA) said that she routinely took care of R4. V19 said that R4 would typically come back to the facility around 4:30-5:00 PM from dialysis and the transport people would put him into bed. V19 said that he would be transferred to his high back wheelchair before dinner using a mechanical lift. V19 said that after dinner, R4 would be placed in the TV room to watch TV and allow for his food to digest. V19 said that after dinner, his wheelchair should be reclined slightly to prevent him from falling out. V19 said that they also put him in the TV room so they could watch to make sure that he does not fall asleep in his chair and fall out. On 3/31/26 at 2:25 PM, V2 (Director of Nursing) said that she investigated R4's 3/4/26 fall. V2 said that she did not speak to V18 about the incident and she does not recall if she spoke to V16 about it. V2 said that she does not know if R4 had a non-slip pad in his wheelchair or not prior to his fall. V2 said that the root cause of the fall was that he slid out of his wheelchair. V2 said that R4 has slid out of his wheelchair in the past. V2 said that she thinks that she added the intervention of dycem (non-slip pad) to his care plan to prevent further falls. V2 said that if R4's Care Plan shows that he should have dycem on his wheelchair as a fall prevention intervention, he should have had dycem on his wheelchair. V2 said that R4's left leg fracture is from his fall on 3/4/26 and not from anything else. The facility's Fall Prevention Program shows, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on interview and record review the facility failed to ensure residents were free of verbal and mental abuse for 2 of 5 residents (R1 and R2) reviewed for abuse in the sample of 7. The findings include:1. On 3/30/26 at 9:20 AM, R1 said that last week a black male Certified Nursing Assistant (CNA) came into the room around 5:55 AM to provide care to R2. R1 said that the CNA left the room door open. R1 said that he sat up in bed and told the CNA that the door needed to be closed and the CNA responded that he does not close the doors when he is providing care because he is working. R1 said that he then said to the CNA, I could make a complaint to the state and the CNA responded, Do what you have to do mother f***er. R1 said that he then got up from bed, closed the door and went to the bathroom. R1 said that morning, he told V3 (Activity Director) what had happened. On 3/30/26 at 2:30 PM, R2 said that last week he was receiving incontinence care from a CNA when R1 and the CNA started to argue about the door being closed. R2 said that while the CNA was wiping his perineal area, the CNA called R1 a mother f***er. R2 said that then R1 got up and closed the door and went to the bathroom. R2 said that when R1 was in the bathroom, the CNA kept talking about him and referring to him as a mother f***er multiple times. R2 said that the word was used towards R1.On 3/30/26 at 11:01 AM, V3 (Activity Director) said that last week, R1 came up to her and was very anxious. R1 told her that an African American male CNA was using not kind words with him. V3 said that she does not recall exactly what R1 told her, but it was something about he wanted to door closed and the CNA was rude and wanted him reported. V3 then went and immediately told V1 (Administrator).On 3/30/26 at 12:17 PM, V1 (Administrator) said that when she came in on 3/26/26, staff had reported to her that R1 had an issue with a night CNA. V1 said that she immediately went and spoke to R1. V1 said that when she asked R1 what had happened, he said that a CNA told him to F*** off. V1 said that she asked him who it was, and he said it was a black male CNA. V1 said that she interviewed the black male CNAs that were currently working and none of them had any interactions with R1. V2 said that she then looked at the scheduled and called V10 (black male agency CNA) that had worked the night shift. V1 said that when she spoke to V10, he said that he was providing care to R2 and R1 was being rude and disrespectful. V1 said that V10 did admit to swearing in the room. V1 said that V10 said that he had crocs on and hit his foot on the bed and yelled out using profanity. V1 said stated, He yelled out the F word or something like that. R1's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R1's Care Plan does not document that he has a history of making false statements of abuse. On 3/31/26 at 2:25 PM, V2 (Director of Nursing) said that R1 does not have a history of making false statements since she has worked there (since October,2025). On 3/30/26 at 3:45 PM, V13 (CNA Supervisor) said that R1 has not made any false statements that he is aware of in the past. On 3/30/26 at 12:50 PM, V10 had two numbers listed on a witness statement. Both numbers were called and both numbers were disconnected. The undated Witness Statement shows, Asked if he remembers an incident with resident in [R1's room], [V10] indicated, yes. [V10] then stated, I was going into the room providing care to roommate and [R1] had been making rude comments aggressive towards me the entire time I was in his room. I did not engage with him as I was taking care of the roommate. While I was providing care I hit my foot and it hurt. I never swear at any residents I was wrong in swearing in the room.On 3/30/26 at 2:30 PM, R2's bed was observed. R2's bed had wheels at the head of the bed and the foot of the bed. R2 verified that when V10 was swearing, he was in the middle part of the bed providing perineal care to R2. 2. On 3/30/26 at 9:40 AM, R2 said that last week some time, the day after hospice had just came to give him a bath, V7 (CNA) and V8 (CNA) came into his room to clean him and get him up. R2 said that when V7 came into the room, V7 stated, You stink. R2 said that he told V7 that he should not stink because the hospice aid was just in the day before and gave him a bath. R2 said that V7 proceeded to say, Everyone in this place hates taking care of you. R2 said that it made him pretty upset and feel bad about himself. R2 said that R1 was in the room when it happened. On 3/30/26 at 2:30 PM, R1 said that he was laying in bed when V7 and V8 entered the room. R1 said that as soon as V7 came into the room, she told R1 that he stinks. R1 said that then R2 responded that he should not stink because he just got a bath the day prior. R1 said that then V7 said, No one want to take care of you, you are always complaining, not even hospice. R1 said that he thought that those comments were very rude. R2's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R2's Care Plan does not document a history of making false abuse allegations. On 3/31/26 at 2:25 PM, V2 (Director of Nursing) said that R2 does not have a history of making false statements since she has worked there (since October 2025). The facility's Abuse Policy shows, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.

Based on interview and record review the facility failed to ensure a resident received timely medical treatment of a fractured leg that was sustained from a fall for 1 of 3 residents (R4) reviewed for quality of care in the sample of 7. The findings include:R4's Face Sheet shows diagnoses of end stage renal disease and dependance on dialysis, acquired absence of right leg-below the knee, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia and Alzheimer's disease.R4's Hospital admission History and Physical dated 3/6/26 shows, Patient reportedly had a fall at the facility yesterday, however it is unclear if any evaluation was performed afterwards. He was sent for his scheduled dialysis session this morning where he appeared agitated and pointed to his left leg-appeared uncomfortable. Dialysis staff directed patient to the ER (emergency room) for further evaluation. XR (Xray) left femur with minimally displaced fracture of the distal femoral metadiaphysis.Patient to be kept n.p.o (nothing by mouth) in anticipation of internal fixation procedure per ortho tomorrow. R4's Hospital Notes show that he had an intramedullary nailing performed on 3/7/26.R4's Fall Incident Note shows that he had a fall in his room on 3/4/26 at 7:25 PM. The Incident Report shows, While resident was yelling in his room. This RN [Registered Nurse] gone to check, found sitting on the floor between his recliner and the furniture next to the heater.Resident stated he was sitting in the recliner in front of the heater sleeping and slid down.On 3/31/26 at 11:45 AM, V16, (RN) said that she was at the nurse's station when she heard R4 yelling. V16 said that she entered the room and saw R4 on the floor next to his recliner (high back wheelchair). V16 said that she called for the CNA (Certified Nursing Assistant) and they got him back to bed using a gait belt. V16 said that when they got him back to bed, she did a full assessment on him (R4). V16 said that she did range of motion on R4's extremities. V16 said that R4 was not able to move his left leg very much but that was his baseline, and he was not complaining of any pain. V16 said that she did give R4 some tramadol (pain medication) around 11:00 PM because he was agitated. V16 said that she does not remember what he was doing but she sometimes gives him tramadol and melatonin to help him sleep. V16 said that she is not sure why she marked that R4 was having pain on the medication administration record. On 3/31/26 at 12:35 PM, V18, (CNA) said that she heard the nurse yell for help and entered the room and saw R4 on the floor next to his wheelchair. V18 said that R4 was transferred back to bed using a gait belt. V18 said that V16 did an assessment when he was in bed and when she moved his left leg, he said Oww and started cussing. V18 said that she did incontinence care after the fall and R4 was screaming at her to leave him alone but that was normal for him.On 3/31/26 at 3:08 PM, V21 (RN) said that she was the night nurse for R4 on 3/4/26. V21 said that when she got report from V16, V16 said that she gave R4 a tramadol (pain medication) around 11:00 PM because he was yelling in pain. V21 said that during her shift, he was sleeping and had no complaints. V21 said that the next morning when she was on her way out, V7 (CNA) came up to her and V22 (RN) and said that R4 was having leg pain. V21 said that she did tell V7 that he did have a fall the prior day but then she left since her shift had ended.On 3/31/26 at 11:11 AM, V7 (CNA) said that she was R4's CNA on 3/5/26 for day shift. V7 said that she entered the room to get him cleaned up and up in his chair as usual. V7 said that when she went to put his pants on, he started screaming that his left leg hurt and that he fell yesterday. V7 said that she immediately went to the nurse to let her know. V7 said that V21 and V22 were both present when she told them that R4 was yelling that his left leg hurts and is painful when moved. V7 said that they told her that he did have a fall the day prior and they were taking care of it. V7 said that she then went back into his room and made him comfortable and did not get him out of bed. On 3/31/26 at 11:25 AM, V22 said that she was the nurse for R4 on 3/5/26 during day shift. V22 said that R4 has behaviors of screaming out and on 3/5/26, he wasn't screaming out anything more than normal. V22 said that she does not remember V7 talking to her about him having pain. On 3/31/26 at 1:03 PM, V20 (CNA) said that she took care of R4 on 3/5/26 during PM shift and night shift. V20 said that R4 was in bed when she started her shift. V20 said that she was not sure why he was in bed because he is usually up. V20 said that when she provided incontinence care to R4, he was saying, don't touch me, I'm in pain, I'm in pain. V20 said that she asked him where and he said his body. V20 said that she did not report it to the nurse because it was normal for him to be yelling.R4's Progress Notes dated 3/6/26 at 12:11 PM shows, Received call from dialysis center. Per center, sending patient to ER d/t (due to) complaints of pain while at center.R4's March Medication Administration Record shows that between 3/4/26 and 3/6/26 he received one dose of as needed tramadol on 3/4/26 at 11:00 PM for a pain at a level 3. R4's Progress notes between 3/4/26 and 3/6/26 do not show that R4's complaints of left leg pain was assessed nor that the physician was notified of any change in condition.

Based on interview and record review the facility failed to ensure a resident who receives continuous oxygen was provided oxygen services during transportation to an outpatient procedure. This applies to 1 of 3 residents (R3) reviewed for oxygen services in the sample of 9.The findings include: R3's Facesheet dated 2/11/26 shows R3 has diagnoses including, but not limited to: chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, and dementia. On 2/11/26 at 10:32 AM, R3 was seen lying in bed with a nasal canula adorned and the oxygen concentrator supplying oxygen at a rate of 2 liters per minute.R3's Health Status Note from 1/23/26 at 2:49 PM, by V11 (Nurse Practitioner) shows R3 receives chronic 2L (liters) [oxygen] N/C (nasal canula) for COPD.On 2/17/26 at 8:17 AM, V13 (Receptionist/Transportation Coordinator) called R3's insurance company to confirm the information provided at the time R3's transportation services were requested. On the phone, V17 (Insurance Representative) confirmed that V13 had requested R3's transportation included services for 2 liters of oxygen.On 2/17/26 at 9:01 AM, V15 (Transportation Dispatcher/Operations Manager) confirmed the reservation for R3's transportation was completed through R3's insurance. V15 said the level of services requested to transport R3 was for a non-emergency medical stretcher ride. V15 confirmed this type of transportation does not provide oxygen on the vehicle, but V15 said the facility could provide oxygen for the resident and the stretcher could hold the travel oxygen tank. On 2/17/26 at 11:30 AM, V16 (Transportation Driver) said when V16 arrived at the facility, R3 was lying in bed with no oxygen adorned. V16 transferred R3 onto a stretcher and loaded R3 into the transportation van. V16 said staff on site did not indicate R3 required oxygen nor did staff provide R3 with an oxygen canister for the trip. V16 also said at no point during the trip did R3 experience any signs or symptoms of shortness of breath or distress. On 2/17/26 at 11:54 AM, V14 (Manager of Care Coordinator) said it was reported to V14 via direct message from the care team that R3 arrived to the local hospital on 1/21/26 for an outpatient surgery with oxygen saturation levels below 90 percent. V14 said the first recorded oxygen saturation level was at 91% at 12:11 PM after being provided oxygen via a nasal canula. On 2/11/26 at 1:27 PM, V11 said R3 has a history of COPD and chronic hypoxic respiratory failure. V11 would prefer that R3 is transferred to a hospital appointment with oxygen.

Based on observation, interview, and record review the facility failed to provide R3, a resident assessed to have a high level of pain, with pain medication for 1 of 5 residents reviewed for pain in the sample of 15. This failure allowed R3's pain from a traumatic rib fracture go untreated in the facility from 1:00PM to 6:49PM. The findings include: On 01/26/2026 at 11:30AM, On 01/26/2026 R3 was not in the facility. On 01/26/2026 at 9:23AM, R3 said, I fell at home. I was discharged from the hospital with multiple rib fractures. I was using intravenous hydromorphone in the hospital to control the pain. I was admitted to the facility for rehabilitation and pain control. I had pain 20 out of 10. I waited 7.5 hours to get a pain pill. The facility had pain medication available but something about the rules would not allow them to treat me. I was in a lot of pain. I could not even open the door to the room I hurt so bad. I called my friend to pick me up and left. The nurse said I was leaving against their will. What WILL? I had no idea what their will was, no one saw me. V3 RN-Registered Nurse said, (R3) arrived at the facility during medication pass. I needed to finish the medication pass before putting in (R3's) orders. (R3's) admission gave me resident number 30. This hall is a challenge, admitting a new resident makes it more difficult. I did not put (R3's) orders in fast enough. We did not have (R3's) pain medication on hand. It took quite a few hours for (R3) to get treatment for the pain. The medication was provided on the second shift around 7:30PM. The physician was called at 7:00PM, shift change. (R3) left the facility against medical advice. On 01/27/2026 at 11:11AM, V4 NP-Nurse Practitioner said, I assessed (R3) on 01/19/2026 at 4:21PM, (R3) rated the pain 9/10. (R3) had multiple left rib fractures. The fractures extended from rib number 6 to rib number 9. (R3's) number one diagnosis was Rib Fracture; R3's second diagnosis was, Pain. I was notified around 6:00PM, the facility did not have (R3's) pain medications available. If I would have been notified sooner, I would have provided an alternative pain medication immediately. On 01/27/2026 at 3:48PM, V12 RN said, Zero is no pain, 10 is the worst pain ever. R3's Vital Sign Record shows, Pain: on 01/19/2026 at 1:00PM, 8/10, at 5:44PM, 8/10. R3's Medication Administration Record dated January 19, 2026 shows, R3 was provided with her first dose of pain medication at 6:49PM. The facility's Pain Management policy dated 10/01/2025 shows, Acute Pain refers to pain that is usually sudden in onset.caused by injury, trauma, or medical treatments.Policy Explanation: to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage Pain.

Based on observation, interview, and record review the facility failed to ensure grievances were recorded, investigated, summarized, confirmed or not confirmed for 2 of 3 residents (R1,R11) reviewed for grievances in the sample of 15. The findings include:On 01/26/2026 at 10:00AM, R1 was lying in bed on her back. R1's left, and right arms were contracted close to the body. At 2:33PM, R11 was lying in bed on her back. R1's MDS-Minimum Data Set, dated [DATE] shows, R1 is cognitively intact, with impairment to left and right upper and left and right lower extremities. R1 needs extensive assistance from staff to total dependence on staff for all ADLs-Activities of Daily Living. R11's MDS dated [DATE] shows, R11 is cognitively intact, with upper extremity impairment on both sides, lower extremity impairment on both sides. R11 needs partial assist, extensive assist, and is also dependent on staff for ADLs. R1 and R11 need to be supervised when eating. On 01/26/26 at 10:00AM, R1 said, (V5 CNA-Certified Nursing Assistant) refused to get me up a week ago from last Friday (01/16/2026). (V5) told me I had to do it her way or not at all. (V5 CNA) left me for the second shift to get out of bed. I reported the interaction to (V2 DON-Director of Nursing). I also reported the incident to the Ombudsman. I did not fill out a grievance form. I have Cerebral Palsy; I cannot use my hand to write.at least not legibly. I would need the staff to fill out the form; I can sign my name. Documents have a tendency to disappear around here. I prefer to complain to the Ombudsman. On 01/26/2026 at 10:23 AM, V2 DON-Director of Nursing said, I do not have any reports about (V5 CNA). On 01/26/2026 at 10:50AM, V5 CNA said, (R1) likes to get up after lunch. I did not have enough time to get her up and give (R2) a shower before my shift ended. (R1) was upset. The next time I was assigned to (R1), she told me she had talked to (V2 DON) and I was not to help her anymore. I stopped and walked out of the room. On 1/26/25 at 2:33PM, R11 said, (V5 CNA) does not follow the rules. One of the nurses reported her for leaving my roommate hanging alone in the room in a full body mechanical sling lift. (V5 CNA) got written up. I reported the incident to (V2 DON). Last Thursday (01/22/2026) I stayed in bed. I was not going to let (V5 CNA) help me. The next day I let (V5 CNA) help me get out of bed and into my wheelchair. I should not have. I explained how to position the chair and myself, but (V5 CNA) had to do it her way. (V5 CNA) ended up having to leave me in the sling while she left the room to go get help. (V5 CNA) claimed she did not have enough training. It is not training, (V5 CNA) needs to follow directions. I do not know anything about a grievance form. It is easier to tell (V2 DON). On 01/27/26 at 9:14AM, V1 Administrator said, (R1) reported (V5 CNA) is 'bad'. I did not know about (R11's) grievance with (V5 CNA). On 01/27/2026 at 9:45AM, V13 CNA said, I have had a lot of complaints about (V5 CNA). The residents have complained about the way (V5 CNA) speaks to them. (V5 CNA) has been using the full body mechanical sling lift without a second staff member present. (V5 CNA) got into a political argument with one of the residents. I reported my concerns to (V11 Human Resource Director).: On 01/27/2026 at 10:03AM, V11 Human Resource Director said, I have not had any complaints from the residents about (V5 CNA). I received feedback from (V13 CNA). (V13) is (V5's CNA) trainer. There was no need to bring the issues to the Administrator, it was nothing he needed to know about. If the issue is about patient care, it is reported to the Administrator or DON. A resident can go to any manager, speak to any nurse, and file a grievance. We have a grievance form. I will listen to the resident's grievance then follow up with social services to do a written grievance. On 01/27/2026 at 10:22AM, V12 RN-Registered Nurse said, I have no personal knowledge of any resident complaints. The resident file their grievances with the Social Service Director. On 01/27/2026 at 10:44AM, V9 Social Service Director said, The person the resident reports the grievance to needs to be the person that fills out a grievance form. Grievance Forms are available in the office and the nurse's stations. The staff should fill out the form and report to me. If the resident reports a grievance to the CNA or the nurse, the nurse should fill out the grievance form with the resident there. I will do the investigation. I may ask another staff to assist me with the investigation. I also bring the grievances to the morning meeting with administration and the entire management team. The Administrator is required to sign off on every grievance. I have not had any reported issues about (V5 CNA). On 01/26/26 at 11:07AM, V6 Ombudsman said, I encourage the resident to first report their grievances to the facility staff prior to contacting The Ombudsman's Office or The State Agency. However, the residents feel when they report their grievances to the staff, nothing ever gets resolved. The staff are in a better position to resolve the resident's grievances than I am. On 01/26/2026 the facility's Grievance Log dated, December 2025 and January 2026 does not show, R1 and R11's concerns with V5 CNA. The facility's undated Grievance/Concern Report form shows, this form shall be utilized to provide written documentation of any grievance or concern expressed or filed by a resident or resident representative and to record the follow-up action taken and results thereof.

Based on observation, interview and record review the facility failed to ensure residents' non-invasive ventilation machine Continuous Positive Airway Pressure (CPAP) masks fit securely on residents faces to provide the prescribed treatment for their obstructive sleep apnea for 2 of 3 residents (R1, R2) reviewed for respiratory care in the sample of 4.The findings include:1.R1's physician order dated 12/12/25 showed an order for R1 to be placed on CPAP at night when sleeping due to his diagnosis of obstructive sleep apnea. On 1/20/26 at 8:54 AM, R1 was awake, lying in bed. A CPAP machine with attached tubing and face mask was noted on a table by the foot of R1's bed. The CPAP machine and equipment appeared clean and unused. R1 stated he had not used his CPAP at night for months because the mask doesn't fit. It leaks air and blows into my eyes. R1 stated he told nursing and a pulmonology nurse practitioner about his ill-fitting mask, but nothing had been done about it. R1's Health Status note dated 12/10/25 showed R1 was seen and examined by V5 Nurse Practitioner (NP). The note showed, Pulmonary NP to follow for refitting of CPAP for sleep apnea as patient complains of ill-fitting mask.R1's Follow Up Pulmonary note dated 12/17/25 showed R1 was seen and examined by V4 Pulmonary Nurse Practitioner. The note showed R1 requested a new mask for his CPAP machine. The note showed V4 notified facility staff R1 needed a new mask.R1's Health Status note dated 1/14/26 showed R1 still had not received a new mask for his CPAP machine. Facility nursing staff notified V4 Pulmonary Nurse Practitioner that R1 had yet to receive a new mask.On 1/20/26 at 10:00 AM, V4 Pulmonary Nurse Practitioner stated R1 requires the use of CPAP at night due to his sleep apnea. V4 stated in December 2025, facility staffed initially notified her that they could not find the mask to R1's CPAP machine but the facility called back shortly after that to tell me they had found the mask. I wasn't notified until January 14th (2026) that (R1's) mask didn't fit. V4 stated she did not recall R1 telling her that his mask didn't fit on 12/17/25. V4 stated if a CPAP or BiPAP does not fit securely on a resident's face, it can cause the resident to not receive enough oxygen while sleeping which could lead to respiratory distress and/or failure.On 1/20/26 at 11:01 AM, V5 NP stated R1 complained of his CPAP mask not fitting to V5 on 12/10/25. V5 stated, I put in a referral then for him to be refitted for a mask by pulmonology. I don't know why he has not received a new one.2. R2's physician order dated 11/4/24 showed an order for R2 to be placed on CPAP at night when sleeping due to her diagnosis of COPD (chronic obstructive pulmonary disease).On 1/20/26 at 8:48 AM, R2 was seated in a wheelchair in her room. A CPAP machine with the attached tubing and mask was wrapped in a plastic bag, sitting on R2's bedside table. R2 stated she had not used her CPAP at night in a long time because the mask doesn't fit. It's too big. R2 stated, I've been waiting on pulmonology to come fit me for a new mask. I keep asking when they are coming but nothing has happened.R2's Follow Up Pulmonary note dated 12/3/25 showed R2 was seen and examined by V4 Pulmonary Nurse Practitioner. The note showed, Patient reports compliance with CPAP device however is asking to replace her medium sized mask with a small, facility staff notified.R2's Health Status note dated 12/17/25 showed R2 was seen and examined by V5 Nurse Practitioner (NP). The note showed, Patient complained of ill-fitting CPAP mask and not using (CPAP) at night. Patient has lost approximately 50 pounds since the mask was first fitted in 2023 and ordered for pulmonary NP to evaluate regarding CPAP mask refitting to ensure proper seal.On 1/20/26 at 10:00 AM, V4 Pulmonary Nurse Practitioner stated she notified facility nursing staff on 12/3/25 that R2 needed a small CPAP mask so the facility could order the mask. V4 stated, I can't remember which nurse I talked to about this. Once a mask is ordered, the resident should receive the mask within a couple of weeks.On 1/20/26 at 11:01 AM, V5 NP stated, (R2) has a (CPAP) mask that doesn't fit. She has lost weight recently. I put a referral for her to be refitted for a mask when I saw her on December 17th (2025).On 1/20/26 at 8:51 AM, V3 Registered Nurse stated R1 and R2 have been waiting for pulmonary to come fit them for CPAP masks for at least a month. Their masks are too big, so they don't use their CPAP. I have called pulmonary twice about this in the past couple of weeks, but no one has called me back.On 1/20/26 at 2:00 PM, V2 Director of Nursing stated she was not aware that R1 or R2 needed new CPAP masks. The facility's Noninvasive Ventilation policy (undated) showed, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. CPAP or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patient airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose and mouth. Replace equipment immediately when it is broken or malfunctions.

Based on observation, interview, and record review, the facility failed to ensure staff wore a beard guard/net while handling/serving food. This has the potential to affect all 73 residents in the facility.The findings include: The facility's Facility Data Sheet dated 12/19/25 shows 73 residents reside in the facility.On 12/19/25 as the lunch meal was being served/plated in the dining room at 12:08 PM, V15, Cook, was observed to have a beard and was not wearing a beard guard as he plated the residents' meals.On 12/19/25 at 12:30 PM, V4, Dietary Manager, stated a beard guard is required if the (facial) hair is more than an inch long. The facility's Dietary Policies and Procedures Dress Code Policy (not dated) shows beard nets should be used for employees with facial hair.

Based on interview and record review, the facility failed to ensure a resident had privacy during personal activities of daily living for 1 of 4 residents (R2) reviewed for resident rights in the sample of 4. The findings include:On 12/19/25 at 8:44 AM, R2 said about a week and a half ago she was getting ready to get up and V3, Maintenance Director, told V6 and V7, Housekeeping, to do a deep cleaning of her room. R2 said the three of them all said she was getting up, but V3 told them to do it anyways. R2 said they closed the curtains while the CNA (certified nursing assistant), V8, was getting her ready (cleaned and dressed), but she still felt uncomfortable. R2 said V6 said R2 is getting up and asked if they could wait until she was done, but V3 said to do it anyway. R2 said she contacted the Ombudsman and asked him to file a formal complaint.On 12/19/25 at 9:58 AM, V6 said they clean residents' rooms when residents are in there, but they absolutely do not clean while residents are getting personal cares. V6 said about two weeks ago, V3 told her to clean a resident room. V6 said she was training V7 and they were about to clean R2's room. The CNA was getting R2 up and ready for the day. V6 said V3 came down the hall and told them to get started on the deep clean of R2's room. V6 said she prefers to do it later because the CNA was getting R2 ready. V6 said V3 told her he had other places he would like to put V7, so he wanted them to get in there and get the deep cleaning done. V6 said V8 looked at them and closed all the (privacy) curtains in the room. V6 said she didn't feel like it was right, but V3 was forceful about getting the room cleaned then and there, so they proceeded to clean the room even though R2 was getting up for the day.On 12/19/25 at 10:16 AM, V7 said on her first day working in the facility, she, V6, and V3 were talking in the hallway. V7 said she was told to go do a deep clean in a resident room. V7 said she and V6 said they should wait because the resident was being changed. V7 said she was learning and just doing what she was told. V7 said they ended up going into the room and cleaning it while a resident was being changed which they usually don't do while personal cares are going on. V7 said she thinks it would be awkward for the resident because it's disrupting their privacy during a personal moment. V7 said the curtains were all closed, and they proceeded to clean the room. V7 said afterwards she and V6 talked about how they felt it was inappropriate.On 12/19/25 at 10:27 AM, V3 said it is not OK to clean the rooms while residents are getting up for the day. V3 said it would be easier for the housekeeper to give them peace and they could come back in a few minutes. V3 said he tries to respect the residents' rights.On 12/19/25 at 11:04 AM, V8 said she remembers getting R2 up after lunch. She told housekeeping she was getting R2 up. R2 said she told them to wait until she gets up, but the housekeepers said they were told by V3 to do it now. V8 said R2 was very upset about it, but she closed the curtains and proceeded to do her incontinence care, dressing, and transfer all the while housekeeping was cleaning the rest of the room. V8 said the housekeepers don't usually do that; she doesn't know why they couldn't wait. V8 said R2 was upset because she was very uncomfortable. V8 said housekeeping usually would step out and wait for her to finish with her cares.On 12/19/25 at 2:24 PM, V2, Director of Nursing (DON), said housekeeping should only come in and clean if the resident says it is OK.The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (Revised 11/18) shows the facility must treat residents with dignity and respect and must care for them in a manner that promotes their quality of life and the facility must make arrangements to meet residents' needs and choices.

Based on interview and record review, the facility failed to ensure residents were free of mental abuse for 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. This failure resulted in R1 suffering undue, ongoing anxiety and contributed to his leaving the facility and made R2 feel badly. The findings include: On 4/29/25 at 10:17 AM, R1 said he has lived in the facility for over two years but is transferring to another facility later today due to the abusive environment. R1 said on one particular Sunday, V3, Regional Director of Operations/Former Administrator, came into the facility, rounded up all of the staff and lined them up in the hall. R1 said V3 began to walk up and down the line of employees yelling at them and pointing his finger at them. R1 said V3 was reprimanding these adults, these professionals and it was terrible, demeaning, and unprofessional. R1 said he felt upset and intimidated. R1 said the incident upset him immensely, and he was totally and completely stressed out. R1 said V3 had no regard for the feelings of anyone else who was around or witnessed the incident. R1 said during this interview, he became so anxious just talking about it, he had to turn up his oxygen. On 4/29/25 at 11:19 AM, R2 said V3 saw some unmade beds and he lined the Certified Nursing Assistants (CNAs) up in the hallway and yelled at them like a drill sergeant. R2 said it made him feel horrible when V3 would reprimand staff in front of everyone, it is inhumane. On 4/29/25 at 9:58 AM, V4, Licensed Practical Nurse (LPN), said she remembers a weekend when V3 came in and said they were having an in-service. V4 said V3 lined up all the nurses and CNAs in the hallway and was yelling at them. V4 said there were residents around and they were concerned as to why they were all in trouble. V4 said she doesn't remember exactly what was said during this incident because there have been many interactions like that. V4 said R1 asked what it was all about, but V4 said she felt it was pretty evident and the whole incident speaks for itself. V4 said R1 was upset about the incident and how V3 approached things. V4 said V3 would call staff out right in front of everyone and a lot of residents are on edge about how things are handled by V3. V4 said V3 leads with fear. V4 said R1 is transferring to another facility today because of V3's management of the facility. On 4/29/25 at 12:21 PM, V5, LPN, said on a Sunday, 12/1/24 around 10:30 AM, V3 had all the staff lined up in the hall out in front of the dining room. V5 said V3 called it an in-service, but he just started talking down to the staff like they were children. V5 said there were residents present during this incident. V5 said she reached out to one of the managers to look at the cameras because of this incident. V5 said V3 is very authoritative and does not like it when any staff say anything to him. On 4/29/25 at 1:55 PM, V3 said he would conduct in-services with all the staff lined up in the hall and residents could be present and overhear them. V3 said types of abuse include emotional and psychological abuse. On 4/30/25 at 9:40 AM, V9, Business office Manager, said she had a good rapport with R1, and he told her he had seen V3 line up staff members and go down the line one by one yelling at them. V9 said R1 chose to transfer to another facility due to incidences happening with staff over the course of his stay. V9 said R1 was one of the most beloved residents in the facility by staff and other residents. V9 expressed fear of losing her job if management found out what she has reported during this interview. R1's Admission Record dated 4/30/25 shows he was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, panic disorder (episodic paroxysmal anxiety) and adjustment disorder with mixed anxiety and depressed mood. R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact and has no behaviors. R1's current care plan provided by the facility shows R1 demonstrates significant mood distress related to recent medical conditions and previous trauma. R1 has potential for anxiety related to traumatic life event. Interventions include establishing trust with the resident and providing a calming and reassuring environment to help lessen or relieve anxiety and promote a feeling of safety. R2's Admission Record dated 4/30/25 shows R2 was admitted to the facility on [DATE]. R2's diagnoses include, but are not limited to, personality disorder, dysthymic disorder, bipolar disorder, and generalized anxiety disorder. R2's Minimum Data Set, dated dated dated [DATE] shows R2 is cognitively intact and has no behavioral symptoms or behaviors which are potential indicators of psychosis. R2's current care plan provided by the facility shows R2 has a mental disorder and interventions to help R2 maintain the highest practicable physical, mental, and psychosocial well being are to provide an environment and atmosphere that is conducive to mental and psychosocial well-being. R2 has potential for anxiety related to traumatic life event. Interventions include establishing trust with the resident and providing a calming and reassuring environment to help lessen or relieve anxiety and promote a feeling of safety. The facility's Abuse, Neglect, and Exploitation Policy (revised 11/2024) shows the facility will provide protection for the health, welfare, and rights of each resident by implementing procedures that prevent abuse. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (Revised 11/18) shows residents must not be mentally abused by anyone.

Based on observation, interview, and record review the facility failed to ensure a resident that was on an oral anticoagulant medication (blood thinner) was free from physical abuse. This applies to 2 of 3 residents (R12, R13) reviewed for abuse in the sample of 15. This failure resulted in R12 complaining of 5/10 sharp pain to right parietal and temporal area during head examination. The findings include: 1. The facility's Final Abuse Investigation dated 3/18/25 documents on 3/16/25, (R12) reported that (R13) allegedly hit her on the head (R12) reported that she was backing out of the common area with her wheelchair and mistakenly ran into (R13) and (R13) hit her. R13's face sheet shows R13 is a [AGE] year-old male with diagnosis including bipolar, paranoid schizophrenia, schizoaffective disorder, unspecified mood (affective) disorder, anxiety, disorders of and psychosocial development. R12's progress notes printed 3/18/25 at 3:16pm in part documents diagnosis of chronic respiratory failure with hypoxia, vitamin deficiency unspecified, obstructive sleep apnea, gastro-esophageal reflux disease without esophagitis, essential hypertension, other chronic pain, obstructive hypertrophic cardiomyopathy, adjustment disorder with mixed anxiety and depressed mood, presence of left artificial hip joint, muscle weakness and chronic obstructive pulmonary disease unspecified. On 3/18/25 at 9:00 AM, V1 (Administrator) said an allegation of physical abuse was reported on 3/16/25. R12 and R13 were in the dining room, R12 was backing up in her wheelchair and bumped into R13. V1 confirmed R13 hit on R12 the head. On 3/18/25 at 9:27 AM, R12 was in her room lying in her bed. She said, Oh there was an incident. She was in the dining room during the noon meal on 3/16/25. She said she was backing up from her wheelchair and accidentally bumped into R13. R13 who gets easily angered punched me on the right side of my head with a closed fist several times. I've heard of him hitting others and I don't know why they don't do something. He clobbered me and he's a hazard. She said there was no staff in the dining room at the time and R15 witnessed what happened. An egg size bump to the back right side of R13's head was palpated. R13 said it's sore and it hurt. She said she doesn't think R13 belongs in this facility, he's not right. They used to have someone with him all the time, I don't know what happened to that. Sometimes we are understaffed. On 3/18/25 at 11:33 AM, R13 was observed self-propelling himself in his wheelchair in the hallways. He was disheveled, unkempt, with a strong body odor. He was alert to self and unable to answer questions appropriately. On 3/18/25 at 1:24 PM, R15 said she was in the dining room on 3/16/25. They were at the table finishing lunch, R13 was trying to pass R12. He was ramming his wheelchair into her wheelchair. R12 said give me a minute and R13 started ramming his wheelchair harder into R12. R12 was backing up in her wheelchair and accidentally bumped into R13. R13 stood up from his wheelchair and hit her on the head with his fist several times. He was going to swing another time and he fell back into his wheelchair. He then left the dining room. There was no staff in the dining room at the time, they were taking residents back to their rooms after lunch. On 3/18/25 at 12:13 PM, V5 (Social Services) said R13 hit R12 in the head while in the dining room on 3/16/25. R13 could not recall the incident. Hitting another resident is physical abuse. V12's (Nurse Practitioner) progress note dated 3/17/25 documents in part (R12) is alert and oriented, per nursing request (to see resident) after another resident hit (R12) in the head on 3/16/25. (R12) reports backing up her wheelchair and accidently into another resident. (R12) stated, he hit me in the head several times. Bleeding precautions from OAC (oral anticoagulant). C/o (complains of) 5/10 sharp pain to right parietal and temporal area during head examination. Patient taking Eliquis 5mg po (orally) BID (twice a day) and educated on bleeding precautions. Will order neuro checks q (every) 4 hrs (hours) x 24hrs and will re-evaluate. Will order cold compress 20 minute duration over right parietal/scalp pain q shift and PRN (as needed) until pain resolved. Anxious while discussing incident on 3/16/25 and in the setting of pain. The facility's witness statement by V15 (Registered Nurse) on duty and V16 (Certified Nursing Assistant) said they did not witness the incident. The facility's Abuse Policy reviewed 11/2024 states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent, abuse, neglect .abuse means the willful infliction of injury .willful means the individual must have acted deliberately physical abuse includes but not limited to hitting, slapping, punching, biting, and kicking .

Based on observation, interview, and record review the facility failed to ensure dietitian recommendations for an increased tube feeding order were carried out. This failure resulted in R8 experiencing a significant weight loss of 13.9% in 6 months. This applies to 1 of 3 residents (R8) reviewed for weight loss in the sample of 15. The findings include: R8's Face sheet dated 3/18/25 shows R8 has diagnoses that include but are not limited to: dysphagia following cerebral infarction, acute metabolic acidosis, and abnormal weight loss. On 3/17/25 at 12:23 PM, R8 was lying in bed with the head of bed elevated approximately 30 degrees. R8 was not receiving a bolus feed at that time. R8 showed some signs of muscle wasting on his collar bones and cheeks. R8 was unable to make his needs known verbally but was able and willing to provide a thumb up for a yes and a thumb down for a no. When asked if they provided a bolus feed via syringe through his percutaneous endoscopic gastrostomy (PEG) tube two times that day, the resident gave a thumbs up. R8's Weights and Vitals Summary dated 3/18/25 shows R8's current weight is 149 pounds (lbs) and was taken on 3/15/25. R8's six-month weight taken on 9/18/24 shows R8 weighed 173 lbs. This is a difference of 24 pounds, or 13.9%. R8's Nutrition/Dietary Note dated 12/31/24 shows V4 (Registered Dietitian) recommended to increase R8's feeding to a different formula and volume which would provide an additional 90 calories to promote weight gain. R8's discontinued physician's order report does not show this recommendation was ever updated and R8 continued on the lower calorie formula until 3/7/25, when it was discontinued. On 3/18/25 at 3:25 PM, V4 stated she has been seeing R8 since R8's admission to the facility. V4 sees R8 at least twice monthly, or more, and writes a progress note at least once monthly. V4 is unsure of the accuracy of R8's admission weight and believes R8 to have a more accurate usual body weight around 158 lbs. V4 said even with that information, R8 is down 10 pounds from that, and it is a concern. V4 stated R8 is reliant on his tube feeding for all his nutrition. V4 said she has changed formulas, changed bolus volumes, and has even attempted to provide R8 with a continual tube feeding with no success on preventing V4's weight loss. V4 said all formulations were calculated to provide 100% of R8's daily needs and should have at a minimum provided R8 with weight stability and possibly even gradual weight gain. V4's goal for R8 is for gradual weight gain and to prevent further weight loss. Facility Weight Monitoring policy dated 10/2024 states, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range .

Based on observation, interview and record review, the facility failed to ensure hot liquids are served in a safe manner and failed to ensure 1 of 7 residents (R1) in the sample of 7 reviewed for safety and supervision was supervised and assisted while drinking hot coffee. These failures resulted in R1 spilling coffee on herself and sustaining second degree burns to her thighs. The findings include: The Facility Data Sheet dated 2/5/25 shows the facility has 76 residents in residing in the facility. On 2/5/25 at 9:24 AM, R1 said she was drinking coffee out of a Styrofoam cup and somehow the coffee got out of her hand and spilled on her upper thighs and it was really hot. R1 said no one (staff) was in the dining room and she yelled for help. R1 said someone eventually came and a nurse looked at her thighs. R1 said she was sent to the hospital and returned later the same day. R1 said she has been receiving treatment to her burns every day since then. On 2/5/25 at 10:56 AM, R3 said he was in the dining room at dinner time with a lot of other residents when R1 began screaming for help in the dining room. R3 said R1 was saying help, help, I spilled my coffee. R3 said there was no staff in the dining room at the time. On 2/5/25 at 10:30 AM, V4, Certified Nursing Assistant (CNA), said she was outside of the dining room (around 5:00 PM on Sunday, 2/2/25) and heard R1 screaming. V4 said R1 told her she spilled her coffee. V4 said a staff member is supposed to be in the dining room at all times for resident supervision. V4 said no one is specifically assigned to supervise the dining room. V4 said staff know what level of care a resident requires (whether they are independent, dependent, require a mechanical lift, require assistance eating, etc.) from a verbal report from other staff members or from a cheat sheet they compile. On 2/5/25 at 11:15 AM, V3, Registered Nurse (RN), said around supper time on 2/2/25, V4 was outside of the dining room and heard R1 yelling. R1 was visibly in pain and V4 found V3 to go to R1. V3 said he visually assessed R1 and R1 allowed him to touch her clothed legs which were warm to his touch. V3 said a staff member is supposed to be in the dining room at all times during meals for safety. V3 said R1 requires full care and is dependent on staff for her ADLs (activities of daily living). V3 said the level of care a resident requires is available in the resident's care plan. On 2/5/25 at 10:09 AM, V5, (RN), said staff try to be in the dining room when residents are eating meals, but it might not always happen. V5 said it would be hard to say there is someone always supervising the dining room (during meals). On 2/5/25 at 11:43 AM, V5 said she was asked to assess R1 (on 2/2/25) because she can have female caregivers only. V5 said R1's skin was red and warm to the touch from her mid thighs to her groin. V5 said R1 told her it was extremely painful and wanted to call 911. V5 said she spoke to the doctor, and they agreed to send R1 to the hospital. V5 said when she returned to R1 to apply a cool compress, she noticed a blister forming on R1's left inner thigh. V5 said the Care Plan would show what level of care residents need. On 2/5/25 at 1:00 PM, V2, (Director of Nursing), said she received a call from V3 on Sunday, 2/2/25 around 5:30 PM reporting that R1 had spilled hot coffee on her thigh and groin area. V2 said R1 was sent to the hospital and returned later that evening with orders for twice a day burn treatment for the second degree burns she sustained to her groin, thighs, lap. V2 said staff are to supervise the dining room during meals for resident safety. V2 said the level of care a resident requires is available in the resident's care plan. On 2/10/25 at 10:50 AM, V8, (Dietary Manager), said all staff know the temperature of coffee and hot water needs to be 140 degrees F (Fahrenheit) prior to serving it to the residents. V8 said it (coffee/hot water) can be a degree or two below 140 degrees F, but not any hotter. V8 said no hot liquid temperatures above 140 degrees F are acceptable; someone could accidentally spill and burn themselves. Anything greater than 140 degrees F is just too hot for safety. On 2/10/25 at 8:57 AM, V10, (Dietary Aid), said they are supposed to check the coffee and hot water temperature before taking coffee to the dining rooms. V10 said the temperature should be between 138 and 140 degrees F, but she is confused because she was also told it could be around 150 degrees F. On 2/10/25 at 10:10 AM, V10 said the coffee and the hot water currently on the cart is the remaining coffee and hot water served at breakfast this morning. On 2/10/25 at 9:43 AM, V11, (Dietary Aid), said they are supposed to check the coffee and hot water temperatures before going out to the residents. V11 said the temperature should be 165 degrees F. On 2/10/25 at 9:54 AM, V12, (Cook), said he thinks the coffee should be between 145- and 165-degrees F at a minimum. V12 said he thinks burns can happen at 125 degrees F. V12 said the residents would be closely monitored if they are not cognitively capable of handling hot coffee. V12 said he does not know if the coffee temperature is checked before going out to the residents. V12 said he does not know when the coffee and hot water (currently on the cart) was prepared, but assumes it was around 6:00 AM. On 2/10/25 at 10:30 AM, V13, (Dietary Aid), said she made the coffee for breakfast today at around 6:50 AM. V13 said the coffee and hot water should be between 145- and 150-degrees F before going out to the residents. V13 confirmed the coffee and hot water currently in the dispensers on the cart are the same coffee and hot water she prepared prior to breakfast the morning. V13 checked the temperature of the coffee and hot water currently in the dispensers. The hot water was 156 degrees F, dispenser 1 containing coffee was 153 degrees F, and dispenser 2 containing coffee was 122 degrees F. V13 dumped the coffee out of dispenser 2, made fresh coffee, and fully refilled dispenser 2 and topped off dispenser 1 to about half full. On 2/10/25 at 11:13 AM, V13 made fresh coffee and poured it directly into 14 mugs for residents in the big dining room. V13 checked the temperature of coffee in each mug and the temperatures ranged from 146 degrees F to 152 degrees F. V13 put lids on the mugs then checked the temperatures of the coffee in the dispensers. The coffee in dispenser 1 was 149 degrees F and the coffee in dispenser 2 was 154.2 degrees F. V13 did not recheck the hot water temperature. V13 then took the cart with the dispensers of coffee and hot water and mugs of coffee to the big dining room and proceeded to pass the mugs of coffee out to the residents. V13 delivered one mug of the hot water from the dispenser to a resident with a tea bag. On 2/10/25 at 11:44 AM, V10 (Dietary Aide) delivered another cart with three thermal carafes to the small dining room. V10 said she forgot to check the temperature of the coffee and hot water on the cart. When prompted, V10 got a thermometer and the coffee in the two carafes was 151.7 degrees F and 135 degrees F, and the hot water was 145 degrees F. On 2/10/25 at 11:58 AM, staff members were seen dispensing and delivering coffee from both carafes to the residents in the small dining room. R1's Admission Record dated 2/5/25 shows R1 diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction (stroke), chronic kidney disease, dysphagia (difficulty swallowing), epilepsy, seizures, reduced mobility, brain tumor, and cognitive communication deficit. R1's current care plan provided by the facility shows R1 has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. R1's care plan also shows R1 has an ADL self-care performance deficit and is totally dependent on staff for eating, bathing, bed mobility, dressing, toilet use, and transfers. R1's Minimum Data Set, dated dated dated [DATE] shows R1 has moderate cognitive impairment and requires partial/moderate assistance with eating. R1's After Visit Summary from the hospital dated 2/2/25 shows her diagnosis is second degree burns of multiple sites. R1 was prescribed an oral narcotic for pain and cream to be applied twice a day to her burns. The facility's Hot Liquid Safety Policy (revised 2/2025) shows, .residents with difficulties will receive appropriate supervision .interventions will be individualized and noted on the resident's plan of care . and hot liquids can cause scalding and burns. The temperatures of hot liquids will be checked in the dietary department prior to distribution. If the temperature is greater than 140 degrees F, the liquid will be held in the dietary department until it reaches an appropriate temperature. Limit Styrofoam cups to residents with no difficulties.

Based on observation, interview, and record review the facility failed to ensure an exit door with an audible alarm was in functional order and alerting staff when opened, and failed to ensure a resident with severe cognitive impairment and increased confusion was appropriately assessed and supervised to prevent elopement for 1 of 3 residents (R1) reviewed for elopement in the sample of 13. The Immediate Jeopardy began on 10/22/24 when R1 could not be located in the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/24 at 8:20 AM. This surveyor confirmed by observation, interview, and record review that the immediacy was removed on 11/8/24, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnoses including unspecified dementia, COPD, hypertension, atrial fibrillation, and cerebral infarction. R1's Final Incident Report dated 10/29/24 documents on 10/22/24 (R1) was noticed leaving his room on the 400 hall at 12:10 AM, and was last seen by staff at 12:30 AM, walking down the 100 hallway. Upon CNA (Certified Nursing Assistant) rounding at 1:00 AM, staff noticed (R1) was not in his room .he is a long-term care resident with a diagnosis of dementia he is able to make to understand with a current BIMS (Brief Interview of Mental Status) of 6 (severe cognitive deficits). At approximately 12:00 AM, (R1's) nurse entered his room to turn of the TV. At approximately 12:10 AM, (R1) exited his room onto the 400 hall and proceeded to the 300/400 nurse's station. Per staff (R1) was stating there was a black man in my room going through his stuff. Per CNA she stated, I attempted to inform the resident both my role and nurses' role, but (R1) appeared confused and upset .(R1) returned to his room and came out with his jacket and proceeded past the 300/400 nurses' station to the main hall toward the dining room where he interacted with another female resident (R2). Per staff (R2) noticed (R1) appeared distressed R1 continued down the main hallway and arrived at the 100/220 hallway at approximately 12:15 AM R1 was last seen by staff at 12:30 AM walking down the 100 hallway. Upon rounding rooms at 1:00 AM, they could not locate R1. R1 was located at 2:05 AM outside of the facility with police. On at 11/4/24 at 9:12 AM, V3 (Maintenance Director) said R1 exited the 100-exit door from the smoking area. The exit door should alarm when the door is opened. V3 opened the 100-exit door to the smoking patio. This was an enclosed patio with a gate and fencing around the back of the facility. V3 opened the gate from the patio by lifting the unsecured lock. To the left off the patio, and approximately 175 feet, was a double wired unsecured gate left wide open. The unsecured gate lead to the employee parking lot, and approximately 200 feet from that was a two-lane road. V3 said the double gate should be locked. The gate's lock was old and rusty. V3 attempted to close the gate with the rusty lock. The lock did not secure the double gates firmly. V3 moved the double gate and the gates opened easily. V3 stated, I know it's it not the best, but that's how they lock it .I think we could use an upgrade. V3 said staff open the gate to get supplies from the shed and forget to lock the gate. On 11/4/24 at 11:18 AM, the 100-exit door had two alarms secured to the door. This surveyor pressed the handicap button located on the wall and the door opened without alarming. At 12:30 PM, with V1 (Administrator) at the 100-exit door, this surveyor pressed the handicap button located on the wall. The 100-exit door opened without alarming. Seven residents were outside on the patio without staff. V1 stated, that means it was not re-activated (the alarm). The nurse is responsible for re-activating the alarm. V1 said the alarm did not go off. On 11/4/24 at 9:30 AM, R1 was observed in his room with a wander guard on his wrist. He said they put this on me a couple of days ago to keep track of me. R1 said he left the facility and went for a walk to get a cup of coffee at the shell station. He said he found the gas station because it was lit up. He said he went out the back door and did not have any problems leaving, and the gate just opened. He said he did not hear the alarm when he opened the door. He said they pissed me off and they were not paying attention, and they did not know he was gone. R1 said he walked back, and the police were looking for him. He fell outside and was bleeding on his forehead. He said his right wrist was hurting from the fall. It was no big deal. R1 said he was not sure how long he had been at the facility, he said maybe 4-5 weeks. He said he was in (Local City) and could not recall the date or year. R1 said he was not sure where he was from. On 11/4/24 at 11:49 AM, R2 said she saw R1 the evening he left the facility in the hallway. R2 said R1 seemed to be agitated with the staff. He was complaining about V4 (Licensed Practical Nurse/LPN Agency) and V6 (Certified Nursing Assistant) being in his room snooping around. R2 told R1, V6 is the CNA who works here, and he knows her and V4 was his nurse. V4 is agency staff, she is familiar with him because he works at the facility sporadically. That evening she went out to smoke with R1 around 8:00 to 9:00 PM, without staff. Each smoker is a different level. R2 said she is a level one and can go outside anytime, R2 is a level two. She said when she goes outside, she presses the button on the wall to go out the 100-exit door to the smoking patio. The door opens automatically, and usually there is no alarm. R2 said she did not hear an alarm go off that evening when R1 left the facility. R2 said R1 was not himself that evening. On 11/4/24 at 10:29 AM, V6 (CNA) said she was R1's CNA when he left the faciity on [DATE]. She said V4 went into his room looking for the TV remote. R1 came out of his room and was upset, he said there is black guy going through my stuff and kept repeating it. She told him V4 was his nurse. R1 said he didn't know V4 and told me he didn't know who she was either. R1 went back to his room, got his jacket, and said he was going to call the police. She also saw him talking to R2. She was doing her rounds and saw him on the 200 wing. R1 told the staff on the 200 wing he was going to call the police. She said she answered a call light and when she was done assisting the resident, she could not find R1. The last time she saw R1 was about 12:30 AM, she walked outside around the facility and did not see him. V6 said the alarm did not go off, she did not hear any alarm. She said the alarm should set automatically and there is nothing they need to do with the alarm. About 2:00 AM, R1 was found outside with the police in front of the building. R1 said he went to the gas station to get a cup of coffee and fell outside. He had a bruise on his arm and mark on his head. On 11/4/24 at 1:14 PM, V7 (CNA) said she was working the 200 hall when R1 left the faciity on [DATE]. R1 was from the 400 wing. He came to the 200 wing late and said strange people were in his house that he had not seen before. R1 was confused, she told him to go back to his room and get some sleep. She said she answered a call light and when she came out of the room, R1 was not there. The staff said they could not find R1. We searched the facility and could not find R1. She left in her car looking for him outside and could not find him. The 100-exit door has an alarm, and she did not hear the alarm go off. Residents can outside to smoke from the 100-exit door, the door should be locked and alarmed. R1 is forgetful, that night he seemed more forgetful. He is not safe to be outside and needs to be supervised. On 11/4/24 at 2:31 PM, V5 (RN-Registered Nurse) said sometime after midnight R1 was at the 100/200 nurses station trying to re-direct him back to his room. He came about 15 minutes later, and staff reported they could not locate R1. We were not able to locate R1. The police found R1 outside of the facility, when he returned, he had an abrasion to his forehead. R1 is alert with confusion but seemed more confused that evening. The 100- exit door alarms if a resident has a wander guard on and the door opens. A lot of residents go out the 100-exit door to smoke, they go out all night with no time restriction and the door does not alarm when they go out. On 11/4/24 at 12:19 PM, V1 (Administrator) said he was notified by phone on 10/22/24 about 1:45 AM, R1 eloped. He arrived at the facility about 2:05 AM, R1 was outside with the police. We inspected all the doors to find out what happened. The 100-exit door alarm was not functioning. The alarm should go off when the door opens. Leading up to R1 leaving he was agitated; he left the facility about 12:30 AM. R1 said he left to get a cup of coffee and returned to facility and fell outside. On 11/4/24 at 12:56 PM, (Director of Nursing-DON) said on 10/22/24 she was notified about 1:00 AM, they could not locate R1. Staff reported R1 had increased confusion and was seen getting his jacket and on the 100 unit where the exit doors are to the smoking patio. V1 saw him on video leaving the 100 exit doors and going towards the left of the building. The police were called and found R1 in front of the facility. R1 reported he wanted to get a cup of coffee. R1 fell outside and was complaining of wrist pain and had an abrasion to his forehead. He was sent out to the local hospital and was diagnosed with a urinary tract infection. R1 has cognitive deficits, is forgetful, ambulates with a walker, and he needs supervision when smoking and out in the community for safety. R1 crossed the main road to get to the gas station. He shuffles when walking and is not steady. She would expect staff to ensure a resident is safe when they are agitated or change in cognition. On 11/6/24 at 3:00 PM, V1 said he reviewed the video and confirmed R1 was seen exiting the 100-exit door onto the patio and turned to the left where the double gates are located near the main street. On 11/8/24 at 10:38 AM, V1 said V3 measured the distance from the patio to the double gate at 175 feet and from the gate to the street is 200 feet. On 11/8/24 at 9:05 AM, V10 (Nurse Practitioner) said she was notified about the elopement. R1 is alert with forgetfulness, he sustained a fall outside with a forehead abrasion. He was sent out and diagnosed with a urinary tract infection. She would expect staff to report a change of cognition and monitor the resident for safety. R1's nurses note dated 10/22/24 documents at 12:05 AM, during rounds, (R1) was confused and wanted to know why this writer (V4-Licenced Practical Nurse) was in his room. (V4) explained to R1 he was his nurse. (R1) was unable to be redirected and was observed walking down the 100/200 hall nursing station. Art 12:25 AM, (R1) was talking to 100/200 staff .Staff reported (R1) was complaining about a black man and walked down the 100 halls .R1 could not be located in the facility at 2:00 AM, R1 was located with the police. R1' nurses note dated 10/22/24 by V21 (RN) documents received in report, (R1) eloped last night and returned around 2:00 AM with bruises, abrasions, and pain .bruises to skin, abrasion to right forehead and swelling to right hand .(R1) was sent out to the local hospital and returned with diagnosis of urinary tract infection. R1's care plan dated 11/2/23 documents his memory is impaired and has problems with decision-making, insight, logic, calculation, and reasoning, planning and judgement. R1's BIMS scored a 6 out of 15, he is confused and requires cues and reminders. R1 demonstrates movement behavior that may be interpreted as wandering pacing or roaming related to the diagnoses of dementia and problems understanding the immediate environment. R1 can get agitated with staff when redirected. Staff should assess for potential elopement/unauthorized departure risk, make rounds/room checks .R1 is a smoker and requires supervision when smoking. R1's Community Survival Skills dated 9/17/24 documents he does not appear to be capable of unsupervised pass privileges. The facility's undated timeline report shows at 12:10 AM, (R1) walked out of his room by the 300 nurse's station. At 12:12 AM, (R1) walked down main hall, he stopped at the dining room and spoke with R2. At 12:15 AM, (R1) was at the 100-nurse station talking to CNA's. At 12:29 AM, (R1) left the nurses station and walked down the 100 halls. At 12:30 AM, (R1) exited the building to smoking area and did not stop. At 2:05 AM, (R1) located. The facility's Door Alarm Test Log dated October 2024 shows on 10/22/24 FAIL for 100 Wing Exit and 300 Wing Exit. Note: Replace alarms in wing 100 exit and wing 300 exit. The facility's undated Door Alarm Policy and Procedure states, To prevent elopement and thus secure the safety of wandering clients, it is the policy of this facility to have an alarm on all exit doors accessible to clients. 1. All exits are alarmed and are installed at the following locations: a. the front door, b. the exit doors on the 100, 200, 300 and 400 halls .the maintenance director and/or designee will check all doors with an alarm daily to ensure they are in working order . The facility's Elopement and Wandering Residents revised 12/23 states, This facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their personal centered plan of care addressing the unique factors contributing to wandering or elopement risk .the facility is equipped with door alarms to help avoid elopements .this facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The Immediate Jeopardy that began on 10/22/24 was removed and the deficient practice was corrected on 11/8/24 when the facility took the following actions to remove the Immediacy: Abatement plan was provided on 11/8/24. The facility implemented the following corrective action/abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee 1. Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. R1 has a wander guard on his left arm. R1 has been placed on 15-minute checks. R1's care plan has been updated to reflect the current interventions to address his elopement. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice. The DON, designee(s) and/or MDS Coordinator(s) will re-evaluate residents at risk for wandering/elopement using an elopement risk assessment tool. Residents determined to be at risk for elopement will have had their care plans updated to reflect elopement risk if indicated. The facility has a list/ photo of residents that are high risk for elopement that is kept at every nurse's station, the receptionist desk, and every manager's office. The QAPI committee reviewed the facility's elopement policy to determine if any revisions needed to be made. The facility determined the policy did not need changes. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. 1. The facility initiated in-service training for all staff on 11/8/2024 this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the Director of Clinical Excellence RN, and V2, DON. This training includes: 1. Residents identified to be at risk of elopement. 2. Wandering/Elopement Policy 3. Door Alarm Policy 4. Daily Door Alarm checks to ensure proper functioning. 5. Wander guard checks 6. The facility's northwest property gate between the storage shed and garbage dumpster has been repaired and secured. 7. Steps to take when a resident has an increase in wandering behavior. 8. Frequent rounding - Know where your residents are. 9. Assisting/guarding residents back to bed to ensure their safety. 2. The facility maintenance Director inspected all door alarms on 11/8/2024 to ensure that they were in proper working order. 3. New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s).

Based on observation, interview, and record review the facility failed to ensure a resident (R3) was free of physical abuse by a resident (R4) with known aggressive and verbal behaviors. This failure resulted in R3 not feeling safe in the facility. This applies to 3 of 3 residents (R3, R4, R5) reviewed for abuse in the sample of 11. This failure resulted in R3 experiencing pain and fearfulness. The findings include: On 11/6/24 at 9:25 AM, R4 was seen self-ambulating in R4's room and throughout the 100 unit hallway. R4's room is directly across the hallway from R3's room. R3 was seen in R3's room in R3's wheelchair. On 11/6/24 at 10:44 AM, V12 (Certified Nursing Assistant- CNA) said R4 is frequently confused related to a diagnosis of dementia and that R4 wanders the facility. V12 also said R4 has a history of being aggressive in the evenings towards both staff and residents. V12 said R4's aggression has slowly escalated through time and has gotten worse. R4's Care Plan focus initiated on 4/29/24 states, [R4] has a behavior problem: Making statements that people are taking items from her room without her permission . Losing and misplacing items then thinking that they were taken by others . Raising her hand to hit staff or peers when she gets agitated. 9/13/24- Suicidal ideations. 9/20/24- Hit other resident. 11/2/24- Physically aggressive toward another resident. Facility incident report dated 10/29/24 shows R3 and R4 got into a verbal altercation. Per the report, R4 was seen closing R3's door against R3's preference. R3 and R4 were then seen in the hallway in a verbal altercation, understandable individually to themselves. The report states that R3's television was too loud and other residents complain about it. On 11/6/24 at 10:44 PM, V12 stated she was working the evening shift on 10/29/24 and witnessed the verbal altercation between R3 and R4. Per V12, R4 entered R3's room and a verbal argument between R3 and R4 began. V12 and other staff separated R3 and R4 from one another and continued to keep them separated the rest of V12's shift. On 11/6/24 at 2:01 PM, V2 (Director of Nursing) said the only interventions implemented after the incident on 10/29/24 were resident redirection and to keep R3 and R4 separated. On 11/6/24 at 9:25 AM, R3 said she was attacked by another resident (R4) the other day (11/2/24). R3 said R4 walked across the hallway into R3's room and attempted to pull R3's hair. R3 pushed R4 away and R4 slapped R3 across the face. R3 stated her face hurt after the slaps and that R4 is much stronger than she appears. R3 then grabbed a fly swatter from her bedside table and began swinging at R4, trying to hit R4. R3 said staff came and separated the residents. R3 said R4 wanders the hallways in the evening and R3 has seen R4 enter other resident's rooms. R3 stated the facility did not move R4 to another room and she does not feel safe in the facility during the evenings since it can take up to one or two hours for staff to respond to call lights after 10:00 PM. On 11/6/24 at 1:30 PM, V15 (CNA) said on 11/2/24, V15 was going to the 100 hall shower room. When exiting the shower room, V15 saw R3 exit R3's room wielding a fly swatter and R3 began hitting R4 with the fly swatter. R4 then retaliated and slapped R3 on the face. V15 and V14 (Registered Nurse/RN) separated R3 and R4. V15 was aware of the prior verbal altercation between R3 and R4. V15 said that R4 can be mean and has a history of being mean towards staff. R4 has slapped V15 on the shoulder before. V15 said R4 can sometimes be easily redirected but some days, including on 11/2/24, R4 can be difficult to redirect. V15 said there have not been any other altercations between R3 and R4 since 11/2/24. On 11/6/24 at 1:36 PM, V14 said she only works at the facility on Saturdays and sometimes other days if she picks up additional shifts. V14 did not hear about the 10/29/24 altercation between R3 and R4 until after the incident on 11/2/24. V14 said after separating R3 and R4, V14 brought R4 to the 100 unit nurse's station. While at the 100 nurse's station, R4 accidentally bumped into R5 who was in her wheelchair by the 100 unit nurse's station and R5 pushed R4. V14 then assessed R3, R4, and R5 after the incident and stated none of the residents had any injuries, bruises, or lacerations. V14 then sent R5 back to the 400 unit, monitored R4 in the activity room and R3 was in R3's room. V14 told R3, R4, and R5 that their behaviors and actions were not okay. V14 then told the manager on duty that day who notified V1 (Administrator). On 11/6/24 at 1:50 PM, V1 said he arrived to the facility within an hour of the incident and got statements from staff and residents. V1 then filled out the incident form and sent it to the state agency. V1 said that R3 and R4 have had words before related to the volume of R3's television. At the time of the 11/2/24 incident, staff were providing redirection to R4. V1 said that the facility did not move R4 after the incident on 11/2/24 because R4's family requested to assist with the room transfer and was available on 11/6/24. On 11/6/24 at 10:12 AM, V11 (Housekeeping Supervisor) and V13 (R4's Family Member) were seen moving R4's belongings to room [ROOM NUMBER], on the other side of the facility from R4's current room on the 100 unit. Facility Abuse, Neglect and Exploitation policy dated 6/2024 states, . The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; .

I. Based on observation, interview and record review the facility failed to ensure female residents were protected from sexual abuse by male residents. This resulted in R4 placing his penis on R11's knee and telling her to touch it on 5/26/24, and R18 touching R21's breast on 7/5/24, R17's breast on 7/5/24 and R1's breast on 7/7/24. This applies to 6 of 14 residents (R1, R4, R11, R17, R18, R21) reviewed for sexual abuse in the sample of 22. The Immediate Jeopardy began on 5/26/24 when R4 placed his penis on R11's leg and told her to touch it. V1 (Assistant Administrator), V2 (Director of Nursing) and V20 (Corporate Nurse) were notified of the Immediate Jeopardy on 7/10/24 at 11:35 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 7/10/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. On 7/3/24 at 9:55 AM V3 (Registered Nurse/RN) stated, I heard that he (R4) was being inappropriate with a female resident, and he was moved from the 300 wing to the 100 wing. That was a few months ago. I am not sure of any of the details, it happened on PM shift. On 7/5/24 at 11:30 AM, V8 (Registered Nurse/RN) stated, I was doing my 8:00 PM med pass and (R11) was shaking and crying and very upset. I went in and asked her what was wrong, and she told me her and (R4) had eaten dinner together in the dining room. (R4) followed her back to her room and came in her room and pulled his penis out and put it on her leg and told her to touch it. She excused herself and went into the bathroom and through to the other room and told (R14) that she 'needed the CNA (Certified Nursing Assistant) now' and (R14) got the CNA to remove (R4) from the room. I don't know who the CNA was, and I don't think (R11) ever told the CNA what had happened. I notified (R2 - Director of Nursing/DON) but I didn't notify (V1- Assistant Administrator) because he doesn't answer his phone after dark. I charted all of it and it should be there. The social worker who is no longer there moved (R4) to the other wing the next day. I was told he had been verbally sexually inappropriate with CNAs prior to that - especially the young pretty ones. When I went and talked to (R4) he said, 'It is not like we had sex or anything, tell her to get over it. On 7/8/24 at 9:00 AM R14 stated, A man came into (R11's) room and she was scared. She never said what he did but she was really scared. On 7/8/24 at 12:50 PM, V1 (Assistant Administrator) stated, I heard that (R4) went into the wrong room by accident. We look for things that might explain the behaviors, talk to the MD, Psych, check them for a UTI. I did not do an investigation on (R4) and (R11). On 7/8/24 at 1:30 PM, V2 (Director of Nursing/DON) stated, (R4) had gone into (R11's) room and put his hand on her knee. She left the room and went through the bathroom and had a CNA get him out of her room. Then he was moved to a different unit. I did not do any investigation of the incident- I don't know if (V1) did. On 7/9/24 at 11:30 AM V24 (Occupational Therapy Assistant-Director of Therapy) stated, R11 is alert and oriented with some cognitive deficits. I would generally believe what she had to say. Her decision making and her future expectations may be a little off, but I have not known her to fabricate stories. While (R4) was with therapy he opened up his brief and asked one of the therapists to play with it. (R4) was also touching himself during this session. He also made some other inappropriate comments to the speech therapist, and she wasn't sure if it was from his dementia or what it was. On 7/9/24 at 2:30 PM R11 was sitting in her room and agreed to talk to Surveyor and V20 (Corporate Nurse) together. R11 was well groomed with her O2 nasal cannula hanging on the arm of her chair. R11 stated that she had some memory loss while she was in the hospital (7/2/24- 7/8/24). R11 was asked if she had every been touched, felt unsafe, had any wandering residents in her room or was scared of any residents here at the facility. R11 stated no. R11 was asked by V20 if she thought she would remember if she had been touched by a male resident and R11 stated yes, she thought she would remember that. R11's Progress Notes dated 5/26/24 state, During 2000 (8:00 PM) med pass this writer was told by resident (R11) that a male peer (R4) entered her room after dinner, she states he touched her right knee and placed his hands inside his pants. (R11) got up from chair and went into the bathroom to her neighbor (R14) who called for a CNA to remove him from the room, however she did not share what happened with CNA, (R11) verbalized that she is shook up but she is ok, (V2) and (V1) notified. R4's Progress Notes dated 5/26/24 state, Writer asked resident if he was in a female room, and he responded, Well it's not like we had sex, tell her to calm down. Writer instructed resident that all social visits must take place in the dining room, he verbalized agreement, (V2) and (V1) notified. R4's care plan initiated on 5/1/24 states, Resident has been displaying inappropriate sexual behavior: Resident noted touching his private area while not in a private area. 2. The facility reported incident dated 7/6/24 states, Staff member (V19- Social Worker) received a call from the (V22 - Ombudsman) at approximately 2:30 PM, informing the facility that (R17), with a BIMS (Basic Interview for Mental Status) of 11 and diagnosis for schizoaffective disorder, unspecified dementia with behavioral disturbances and anxiety, called him stating that she (R17) was sexually assaulted by (R18). (R18) has a diagnosis of unspecified Dementia without behavior disturbances. (R17) stated that (R18) was making faces at her and touched her left breast on top of her clothes while sitting in the dining room. She (R17) told (V22) that this happened yesterday (7/5/24). The facility was informed today (7/6/24). Doctor and families of both residents were notified. (R18) was placed on 15 min(ute) checks while awake. R18 was offered to go to the hospital for a rape kit. The (City) police were notified. Investigation initiated. On 7/8/24 at 11:25 AM V11 (LPN/MDS/Care Plan Coordinator) stated, I was here on Saturday and just before 3:00 PM (R17) reported to (V19) that (R18) had been making faces at her and had touched her left breast. We called (R20), the corporate nurse and she called her boss. We immediately put (R18) on 15-minute checks. (R17) was a little unclear about what day this had happened, but she agreed to go to the hospital to be checked. We called the police, and they came and spoke with (R18) in Spanish, and we came up with the solution that he should just not touch anyone. This happened on Saturday, so I do not have access to the cameras. Then he was accused on Sunday of touching (R1). He (R18) is not alert and oriented at all and he is only Spanish speaking. His family says he (R18) used to dig in the couches for cigarettes and that is what they think he is doing now is looking for cigarettes. We are hoping to have a care plan this week to figure out what to do. I am not sure is he knows what he is doing. I don't know anything about (R21) being touched, but (R21) likes (R18) and she used to say that (R17) was her boyfriend. On 7/8/24 at 12:50 PM V1 (Assistant Administrator) stated, Yesterday, I spoke with the resident (R17), and she said that (R18) was making faces at her and then touched her left breast. No one else was in the dining room at the time. She called (V22) and then I spoke to (V22), and he said this is not the first time (R17) has made allegations like this. I spoke with the (R17) and the nurses. The cameras are not working right now. The whole system is down and has been for over a week. Someone is supposed to be coming out today. We think one of the storms might have taken it out. We immediately put (R18) on 15-minute checks and now he is on 1 to 1. It is costing me a fortune, but we have to keep our residents safe. The second incident (R19) was yelling and screaming in the dining room and saying, He's touching her, he's touching her! When (V3) walked in they (R1 and R18) were not within reach of each other and (R19) told her that she saw him (R18) touching her (R1's) arm and chest. (R1) is in a chair with a very high back and from where (R19) was sitting we don't know how she could see anything and (V3) (RN) asked her that. We are still doing an investigation and working with the family to try to find alternate placement for him. I am not aware of any incident with (R18) and (R21) but he will be one on one until we figure out what to do with him. On 7/8/24 at 1:50 PM V19 (Social Worker) stated, I was here when (R17) called (V22) and then (V22) called me. I told the staff on the floor and contacted (R1) and (V20- Corporate Nurse) and began investigating right away. V22 told me that (R17) had reported a sexual assault and that (R18) had made faces at her and then touched her left breast. (V22) also said that (R17) tends to fabricate stories like this. When I talked to (R17) she said many people have talked to her and she doesn't really remember the details of what happened. No one else was in the dining room when this happened. I've seen (R18) going towards female residents before but we just need to remind him not to touch anyone. I interviewed (R18) but he has no recollection of touching anyone. On 7/9/24 at 1:20 PM V20 (Corporate Nurse) stated, (V19) got a call from the (V22) about (R17) and (R18). (R17) claimed she was sexually assaulted and that (R18) had touched her breast. We contacted the family and the physician and (the State Agency). Then we sent her out for a rape kit at the hospital. I do my rounds when I am here and try to get to know the residents as much as I can. (R18) is a very quiet man always in the dining room and often trying to leave the activity. No one has voiced any concerns to me about him touching female residents. We put him on 15-minute checks. On Sunday I was made aware of (R18) getting close to (R1) - on the 15-minute checks. (R19) was screaming and yelling and the nurse (V3) intervened immediately. I have never seen him propel himself so I can't say for sure that he can. He was put on 1 on 1's and had to get more staff to do that. We did a complete body assessment on (R1) and contacted the family and the physician. The (City) police had come for (R17) so we called and let them know about this one as well. We have set a care plan with the family. We can't provide 1 on 1 care all the time but under these circumstances we have to keep our residents safe. The cameras have not been working for some time- probably due to construction. I am not aware of any issues with (R4) and (R11). If staff see something they let us know and we take it very seriously. I am not in charge of the investigation, but I am there to say, did we do this? did we do that? On 7/10/24 at 9:55 AM V22 (Ombudsman) stated, (R17) called me and told me that (R18) attempted to provoke her, he stuck out his tongue, and made faces at her and when she didn't respond he grabbed her breast. (R17) told the nurse - but she didn't think it was going to be investigated and wanted to make sure it was, so she called me. (R17) has recanted things in the past but people recant things for a variety of reasons, that doesn't mean it didn't happen. Maybe they don't want to deal with it anymore or whatever. I still believe them when they say it happened. On 7/10/24 at 11:05 AM, R17 stated, We were in the dining room, but I don't remember what time of day it was. I don't know if there were others in the dining room or not. He (R18) was sticking his tongue out and wiggling his tongue at me and then he got in front of me, and he put his hand on my left breast. I told him to 'cut it out' and he stopped. I reported it to staff, but I don't remember who it was. I saw him groping another lady the next day in the dining room. He goes all over in his wheelchair. R17's Progress Notes dated 7/6/24 state, Patient returned from hospital following evaluation. No new orders upon return. Patient assisted in bed in comfortable position with call light within reach. Patient given dinner upon arrival. Will continue to monitor. R17's Progress Notes dated 7/8/24 state, This writer interviewed (R17) in the privacy of her room concerning her sexual abuse claim. (R17) states, I've been asked several times about this. It happened a few days ago and I can't remember all that happened. (R17) seemed to be in good spirits, however, seemed more concerned with the bed control to adjust her bed during our conversation. (R17) is alert and oriented X 2-3. She has a diagnosis of Unspecified. Dementia, Unspecified Severity, with other behavioral disturbances, Other Schizoaffective disorders, anxiety disorder, Other specified depressive episodes. Writer will follow up with (R17) later in the day to see if (R17) recalls incident. R18's Current Care Plan does not show any focus areas related to resident-to-resident sexual abuse or inappropriate touching of others by R18. R18's Progress Notes dated 7/8/24 state, Writer interviewed (R18) at chair side in a private area with a CNA present to translate. Writer asked (R18) is he recalled inappropriately touching any female residents within the past few days. (R18) responded with the statement, I don't remember. This writer conducted a BIMS assessment with (R18) today. (R18 scored a 7 out of 15 on the BIMS.) (R18) has a diagnosis of Dementia. (R18) is currently on a one to one with staff monitoring each shift to ensure that (R18) is not exhibiting any inappropriate behaviors. 3. The facility reported incident dated 7/7/24 states, It was reported to the (V1- Assistant Administrator) that (R19) was yelling and screaming in the dining room to staff that resident (R18) may have touched (R1). Per (V3-Registered Nurse/RN) upon arrival, she questioned (R19) as to how she could have witnessed anything from the angle she was sitting at. (R3) completed body assessment. No noted distress to (R1). However, investigation still initiated and is ongoing. Per policy, ombudsman, police, doctor and family members all notified. Final report due in 5 business days. On 7/8/24 at 2:10 PM V3 (RN) stated, I was at the cart on Sunday in the morning around breakfast and I heard yelling from the dining room. It was (R19) and she was yelling, he is touching her, he is touching her! I walked in and I saw (R1) and (R18) and they were not close enough to be touching. (R1's) back was to (R19) and she is in the big chair so I am not sure how (R19) could have seen anything. We separated them and I took (R1) to the nurse's station and the other nurse took (R18). We contacted everyone (Administration) and put him on 1-1. We have had some problems with him in the past, but it is usually just looking for cigarettes. (R18) has always gravitated towards (R21) and (R1) but I have not seen him touch them before. I make sure he doesn't when I am here. He (R18) likes to go out and smoke and he is always looking for people with cigarettes. (R4 and R11) I was here for the aftermath of that and heard that (R4) had wandered into (R11's) room so they moved him to my hall. I heard (R4) frightened her and (R4) had touched (R11) and (R11) was very scared. So, they moved (R4). On 7/11/24 at 10:20 AM R19 stated, The little man with the hat (R18) I saw him touching (R1) he was rubbing her arm and then up and was rubbing her breast. I was sitting at the table, facing the window and she was at the round table. I don't know how she responded because I started hollering to try to get help. R1's Face Sheet shows that R1 has diagnoses including Early Onset Alzheimer's Disease and Malnutrition. R1 is not interviewable. 4. On 7/5/24 at 8:00 AM Resident (R21) was sitting outside the dining room. R21 was approached by R18, who pulled up alongside of (R21) and started to touch her arm. V15 (RN) intervened right away and pulled (R18) away from (R21) and told him not to touch her. On 7/8/24 at 9:30 AM R16 stated, On Saturday morning about 5:30 AM I saw (R18) out by the nurse's station, and he had his hand under (R21's) shirt. I told him (R18), 'what are you doing, stop doing that!' He doesn't speak English, so I told him in Spanish, and he stopped. (R18) touches (R21) and (R1) all the time. On 7/9/24 at 3:15 PM R21 stated, I just think, they don't mean anything by it. The guys here are really nice. My right breast has been hurting for a little while and I told the nurse about it. I always think, what did I do? or did I do something to him? (Unable to say who him is) How did he hit me? I never had anything like this before, then I got the pain. I think to myself, what did I do? R21's Face Sheet shows that (R21) has diagnoses including Alzheimer's Disease, Malnutrition, Anxiety and Depressed Mood. The Immediate Jeopardy that began on 5/26/24 was removed on 7/10/24 when the facility took the following actions to remove the immediacy. The facility implemented the following abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee help on 7/10/24 at 12:15 PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. R18 has been on 1:1 since 7/7/24. R4's room was immediately changed to the other side of the facility. R4 has been place on 15 min checks. R11, R17, R21, and R1 will be provided counseling per Social Service Director to ensure the feel safe in the facility. Any resident with known sexual behaviors will have a care plan in place with interventions to prevent incidents of resident to resident abuse. All allegations of resident to resident sexual abuse will be investigated and all behaviors will be documented in the resident's medical record. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All female residents had the potential to be affected by this deficient practice. Any resident that is named in the abuse allegation, no matter the circumstances, will be immediately placed on 1:1 until the completion of the investigation. The facility will interview all cognitive resident on 7/10/24, beginning at 1:00PM, to see if any resident has been inappropriate with them or had they witness any resident being inappropriate with other residents. The interviews will be conducted by (V2-Director of Nursing) and (V20- Corporate Nurse). All interviews will be documented. The QAPI committee reviewed the facility's policy on Abuse and Neglect to determine if any revisions needed to be made. It was determined that no revisions needed to be made. 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. The facility will initiate in-service training for all staff in the building on 7/10/24, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the facility Director of Clinical Excellence (V20) and/or the Director of Nursing (V2). All training will be completed on 7/10/24. This training includes: 1) Abuse and Neglect Policy a. What are the eight types of abuse? b. Who do you report abuse or neglect to? c. Who is the abuse coordinator? d. Abuse or Neglect should be immediately reported to the abuse coordinator, do no wait to report. e. All allegations of abuse should be reported to law enforcement. f. All residents will be examined by a physician following an allegation of sexual or physical abuse of any type. g. All staff members that are named in the abuse complaint will be immediately suspended until the outcome of the investigation. h. Appropriate interventions will be put in place for residents that are named in the complaints. i. A thorough investigation will be conducted after an allegation of abuse or neglect. Steps in this investigation will include: a) Prior to the investigation being initiated, any staff member named in the allegation will be suspended. b) The physician, Medical Director, and the family will be notified c) Law enforcement will be notified of abuse d) Medical care will be provided as indicated, if sexual abuse is alleged, the resident will be sent to the hospital for examination. e) Review the completed documentation forms f) Review the resident's medical record to determine events leading up to the incident g) Interview the person reporting the incident h) Interview any witnesses to the incident i) Interview the resident (As medically appropriate) j) Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition. The investigation will continue regardless of the resident's cognitive status. k) Interview all staff members (on all shifts) during the period of the alleged incident l) Interview the resident's roommate, family members and visitors m) Interview other residents to whom the accused employee provides care or services n) Review all events leading up to the alleged incident o) IDPH will be notified p) If investigation has been concluded and new information becomes available, an addendum will be sent to IDPH and other concerns parties. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1) The facility will conduct pre-employment screening of employees and pre-admission screening of residents. This will be monitored to ensure completion by the Director of Clinical Excellence (V20) or designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 2) All newly hired staff will be in serviced prior to working the floor on the facility abuse and neglect policy. This will be monitored to ensure completion by the Director of Clinical Excellence, (V20) or Designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 3) All staff members will be in serviced on the abuse and neglect policy monthly for 3 months, then quarterly for 1 year. This in-service schedule will continue until November 10, 2024. Staff will be in serviced in person by the facility Administrator or DON (V1 or V2), if a staff member is unable to attend the in-service due to vacation or illness, they will be in serviced prior to working the floor on their next shift. This will be monitored for completion by the Director of Clinical Excellence, (V20) or designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 4) The director of Clinical Excellence (V20) will review all abuse and neglect investigations monthly to ensure that the facility abuse policy was followed. 5) All abuse and neglect allegation/investigations will be reviewed by the facility's Quality Assurance Performance Improvement committee until November 10, 2024. Any issues identified will be immediately corrected and additional training will be provided as indicated. 6) A facility created quality assurance tool will be implemented and used by the Administrator (V1), or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. The results of this tool will be reviewed during the facility Quality Assurance Improvement meetings until November 10, 2024. Any issues identified will be immediately addressed. II. Based on interview and record review the facility failed to protect a resident from sexual abuse by another resident. This applies to 1 of 14 residents (R22) reviewed for sexual abuse in the sample of 22. The findings include: The facility reported incident dated 7/10/24 states, On 7/10/24 at approximately 5:15 PM it was reported to the (V20- Director for Clinical Excellence/Corporate Nurse) while conducting interviews of residents on if they experienced any inappropriate behaviors towards them by other residents, (R22) stated no. As (V20) walked out of the room, the (R22) then stated actually 'yes, (R18) touched my breast on Thursday 7/4/24.' Upon initial investigation it was discovered that this allegation was actually on Friday 7/5/24 as staff that she said was working in the facility that day, was in fact not. (R18) is currently on 1:1 supervision. Family, MD and ombudsman of both residents were notified. Investigation initiated. Final report due in 5 days. On 7/11/24 at 10:00 AM R22 stated, It was during the day in the dining room. I was sitting there and (R18) was trying to hold my hand so I was going to let him- I was just trying to be nice. Next thing I know he was moving his hand up my arm inside my sleeve and he grabbed my left boob. I told him to 'quit it!' and then V23 (Activity Director) came and rolled (R18) away from me. I don't think I told anyone else. This has never happened before, and it won't ever happen again. I hope (R18) has not done this to other residents. On 7/11/24 at 10:15AM V23 stated, I was walking back to the office and (R18) was sitting next to (R22) in the hall outside the dining room. She said he touched her boob, and I took (R18) away and told him in Spanish don't touch. I told either (V11- MDS Coordinator) or (V2- Director of Nursing), I don't remember which one. I have seen him get close to other residents and he likes to touch their arm or hand. Never seen anything inappropriate. I am still trying to acclimate to my new position and didn't know I was supposed to do anything else. R22's Progress Notes dated 7/11/24 state, Writer was informed of recent accusation. Res(ident) alert, oriented x3. Writer informed resident of body assessment needed. Skin dry, intact. NO redness, bruising, discoloration, swelling. Ongoing tx (treatment) to right heel in place. Writer informed resident of needing to inform POA (Power of Attorney) of occurrence and resident stated she did not want POA informed. Will speak with resident later this shift for follow up.

Based on observation, interview, and record review the facility failed to provide supervision for R12, a severely cognitively impaired resident and failed to provide progressive intentions to address R12's exit seeking behavior. This failure resulted in R12 exiting the building on 6/27/24 around 4:15 PM, walking across a small gravel area to the end of a driveway (approximately 75 feet) and attempting to step onto the street, a two lane highway with a speed limit of 30 mph. This applies to 1 of 3 residents (R12) reviewed for safety and supervision in the sample of 22. The Immediate Jeopardy began on 6/24/24 when R12 first exited the facility without staff supervision. V20 (Corporate Nurse), V1 (Assistant Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/10/24 at 11:50 AM. The surveyor confirmed by observation and interview that the Immediate Jeopardy was removed on 7/10/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 7/5/24 at 11:30 AM V8 (Registered Nurse/RN) stated, There was a dementia resident (R12) and her husband (R20) was being admitted to the facility that day so they moved (R12) over to the 300 hall. They are both (non-English) speaking and don't really speak or understand English. He is deaf. I got no report from anyone and (R12) is a handful. She (R12) went out the door on the 400 wing and the alarm was going off. There is no wander guard on that door. She speaks no English and has severe dementia. The assigned CNA (Certified Nursing Assistant) was outside with the smokers down the 100 wing, so I was the only staff on the floor. I ran for the alarm, and I got to her just as she stepped off the curb onto Route 47. I remember I stepped in front of a gray sedan and about 3 other cars behind that one and I could feel the exhaust from the cars. I got her off the street and had to really coax her up the sidewalk where her husband and a therapist were standing. Her husband had to convince her to come back in. That day I punched in at 2:45 PM. She (R12) went out the door between 4:00 PM and 4:20 PM and I punched out at 4:25 PM and I quit. No one should have to experience that. When I came back in (V1-Assistant Administrator) and (V2- Director of Nursing) were standing by the fish tank and they were smiling. There was nothing about that situation to smile or laugh about. It was terrifying! (V8 was sobbing). On 7/5/24 at 12:15 PM V1 (Assistant Administrator) stated, She (R12) attempted to get out the door, but staff was right there and brought her right back in. I do not have an incident report because nothing happened. On 7/5/24 at 1:50 PM V12 (Housekeeping Supervisor) stated, I was coming down the 100/200 hall and I heard the alarm going off in the dining room. (R16) was standing in the doorway of the dining room and said, 'someone went out the door'. I went out the door and saw that the gate (about 75 feet to the left of the patio) was open so I went that way. There was a bunch of staff out there (in the smoking area) and they got (V12) right there by the dumpster. V11 (MDS Coordinator) was one of them. She (R12) has the Wander guard on, and the alarm was going off. Then on the 300 wing I was here for that one too. She (R12) tried to get out that door and all I saw from inside was the nurse trying to get her back in the door. I don't know who the nurse was. The alarm was going off and I was at the beginning of the hall and (R12's) husband was inside the door. I have never seen him trying to leave, just (R12). Both of those times were last week - very close together. Surveyor then walked with V12 out the dining room door, through the gate and around the building to the 300 wing door. V12 showed Surveyor which door he saw R12 being brought in through (different hall than the incident V8 described). The hallway door opens to a side walk that goes straight out to the highway approximately 50 feet from the door to the street (Route 47). On 7/5/24 V18 (Maintenance) was asked to measure the distance from the curb to the threshold of the door at the end of the 300 wing- V18 reported the distance as 37 feet, 11 inches (straight line down the sidewalk from the door to the street (Route 47). On 7/5/24 at 2:30 PM R12 was observed at the end of the 300 wing with 3 staff surrounding her. Then a 4th staff member approached. V16 (RN) speaks R12's language and was trying to communicate with R12. V16 stated that R12 was saying that 'we all need to just love each other, and everyone should be very happy and very good to each other'. R12 wanted to go out the door but staff were blocking the door. V1 (Assistant Administrator) stated that V17 (CNA) was the CNA that was present when R12 tried to elope. The 3 CNAs were asked a question and turned away from R12 for a few seconds. R12 quickly exited the door and set off the alarm. Three staff including V16 (speaking in R12's language) were able to get R12 back into the building. R12 was upset and did not want to go to her room. R12's husband was anxious due to R12 being so upset. V16 walked R12's husband out of the area into the small dining room to allow R12 to calm down. On 7/5/24 at 2:45 PM V17 (CNA) asked about the incident when R12 got out the 300 door. V17 stated, She (R12) got to the door and the restorative aid and I caught her and brought her back in. It was one day last week. She never really got out the door. On 7/5/24 at 2:52 PM V1 stated, I am 100% telling you that never happened (incident described by V8). I was here and she did not get out that door. On 7/8/24 at 11:25 AM V11 (LPN/MDS/Care Plan Coordinator) stated, (R12), when she first came was scared and very disoriented and she exited the building. It was reported that the alarm was going off. I was outside smoking and when I saw her head by the dumpster, (V12-Housekeeping Supervisor) was following her. I met her at the dumpster and got her back in the building. That was the first time. The second incident I was in the hall by the employee entrance. I didn't see a lot but V8 was mad and she kind of threw her keys at (V20- Corporate Nurse) and she was swearing. I don't know which door (R12) went out. (R20), (R12's) husband, helped to bring her back in. We moved her from (100 wing) to the 300 wing and we thought it would be good for them to be together and the family wanted them together on the 300 wing because it looks nicer. When (R20) got here he thought he should be in the (100 wing) with her since he had been visiting her for a few days prior. (R12) didn't recognize (R20) and was very agitated that there was a man in her room. I know the doors down there go straight to the street and I thought of that, but we thought if she was in the middle of the hall, it would be better than the end of one of the other halls, due to the need for a private bathroom. No place here is perfect for them. We are checking on her frequently and she pretty much goes where her husband goes. I am not aware of her trying to get out on Friday. On 7/8/24 at 12:50 PM V1 stated, I've been speaking to family of (R12) and hoping to maybe find her a new facility with a locked dementia unit if things did not calm down. I had the same thought as well about putting her on the 300 wing, but it was due to the bathroom situation and the only other rooms are at the ends of the halls, right by the doors. At least this way she is in the middle of the hall. We didn't know she was an elopement risk on admission. Our admission person is fairly new. Initially I think we could handle her, but I don't think we knew the extent of her wandering. We have been monitoring her more closely and monitoring the exit seeking behavior. We will be calling them to schedule a care plan. On 7/8/24 at 1:30 PM V2 (Director of Nursing) stated, The day with (R12) I was in a meeting with my door closed and I got a call from (V8) and she was frantic. V8 said, She went out the door! I asked her if the alarm went off and she said yes, it is going off now. V2 said, I could not hear it in my office. (V8) had gotten the resident back inside but (V8) was going off the wall and then she left. I spoke with V14 (Occupational Therapist) that was there too and she told me what happened. (V8) was at the medication cart at the nurse's station and she saw (R12) walking down the hall and she said to the (V14), 'she is going to go out that door'. (R12) went out the door and (V8) went after her and got her and brought her back in. Surveyor then walked with V2 to the 400 wing door and from the door V2 showed Surveyor where R12 was found. V2 said, (V14) said she saw them about 2-3 steps from the street ( Route 47). After that we did 15-minute monitoring for 3 days and we talked to the family about hiring a private caregiver. They said they would try to come in more often. They (R12 and R20) started having lunch in the small dining room but sometimes he seems to aggravate her. The Wander guard has been on the whole time. We got referrals for both of them at the same time, but they came in a few days apart. The family wanted them to room together, and we only had the room on the 300 hallway available. On 7/9/24 at 12:10 PM V3 (RN) stated, (R12) is very sweet and very forgetful. I took the verbal report from the hospital, but she came on PM shift. It was a Sunday (6/23/24) when I finally met her. She speaks some English, but she had a Wander Guard from day one. No one has ever asked us to remove it. I had no issues with elopement from her. I heard she would go out or open doors on the 300/400 wings. I don't know if she ever got out. I believe the hospital told me she is mobile and always looking for her husband, very confused. They said the reason she came to the hospital was because she was found outside in the middle of the night in her nightgown and no shoes on. V3 said, (V8) left because of them- they moved to the 300 wing, and she didn't know them and then she tried to leave. On 7/9/24 at 4:10 PM V14 (Occupational Therapist) stated, I was at the nurse's station and the wife (R12) and husband (R20) were standing there. She (R12) was moving from the other wing, and he (R20) had just gotten there to the facility. (R12) started walking down the 400 wing and the nurse (V8) said, 'she is going to go out that door, isn't she?' (V8) stayed at her cart and did not try to stop (R12). Then the alarm went off and the nurse sprinted down the hall towards the door. When I got there, I saw (V8) had (R12) by the arm and was trying to walk with her back to the building. They were in the driveway about a foot or 2 from the street. The husband was with me, and we got (R12) in the door and the (V8) was on the phone yelling at someone. (V8) waved me to close the door and she went around and came in another door. (V8) was very unprofessional and was yelling and swearing. She had left her medication cart open when she went down the hall and she was freaking out about that. R12's Progress Notes dated 6/24/24 state, At approximately 1600 (4:00 PM), (R12) attempted to exit facility without an authorized attendant. Wander guard alarm system sounded, and staff responded. Resident was redirected easily. Ambulatory with Rolling Walker. Alert, verbally responsive. (Non-English) speaking with understanding of English. Resident stated she was looking for husband. Reassured resident. Notified NP (Nurse Practitioner) /DON/Admin (Administrator). R12's Progress Notes dated 6/26/24 state, (R12) was recently admitted to (Facility) with a dx: Alzheimer's disease. (R12) is alert, however, has confusion due to dx: Alzheimer's Disease. (R12) hearing and vision seems to be adequate. She walks independently around the facility. (R12) is at risk for elopement and has to be monitored by staff . Progress Notes dated 6 /27/24 at 5:21 PM (written by V2) state, Resident is A/O x 1, ambulates by self and with no assistive devices. Resident has a wander guard in place. At approximately 4:20 PM the resident attempted to exit the facility through unit 400 exit door. The resident was observed in the hallway by the NOD (Nurse on Duty), the NOD was going to the resident when the alarm sounded, as the resident opened the door and stepped out. The resident was in full view of the staff at all times. The NOD redirected the resident back into the facility. Administration sat with resident until calm. Resident is placed on 15-minute monitoring x 3 days and will have psych re-eval. PCP, POA made aware. Son will come tonight to speak and visit with resident. Progress Notes dated 6/28/24 at 9:15 AM state, Alarm was sounding, resident and husband was observed ambulating outside of dining room doors unattended. Writer redirected back into facility, educated they cannot go outside unattended. Resident and husband are now sitting in the small dining room together. R12's Care Plan dated 6/24/24 states, The resident has impaired cognitive function/dementia or impaired thought processes related to Dementia. At risk for elopement: Wander guard in place: 6/21/24- Wander guard alarmed due to attempt to exit. 6/27/24- Wander guard alarmed due to attempt to exit. R12's Care Plan dated 6/27/24 states, Impaired safety awareness Interventions include: Monitor exit seeking behavior. R12's Wandering Risk assessment dated [DATE] shows R12 scored a 14 (11 or above= High Risk to Wander) R12's Wandering Risk assessment dated [DATE] shows R12 scored a 7 (0-8=Low risk) The facility policy entitled Elopements and Wandering Residents dated 3/2024 states, This facility ensure that residents who exhibit wandering behavior and/ or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/ or any necessary supervision to do so. The Immediate Jeopardy that began on 6/24/24 was removed on 7/10/24 when the facility took the following actions to remove the immediacy. The facility implemented the following corrective action/abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee held on 7/10/24 at 12:15 PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. - R12 has a wander guard on her ankle. R12 has been placed on 15 minute checks. R12's care plan has been updated to reflect the current interventions to address her exit seeking behavior. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. - The DON, Designee(S) and /or MDS Coordinator(S) will re-evaluate residents at risk for wandering/elopement using an elopement risk assessment tool. - Residents determined to be at risk for elopement will have had their care plans updated to reflect elopement risk if indicated. - The facility has a list/photos of residents that are high risk for elopement that is kept at every nurse's station, the receptionist desk and every manager's office. - The QAPI committee reviewed the facility's elopement policy to determine if any revisions needed to be made. The facility determined the policy did not need changes. 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. 1) The facility initiated in-service training for all staff on 7/10/24, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the Director of Clinical Excellence (V20) and (V2) Director of Nursing. This training includes: 1) Residents identified to be at risk of elopement 2) Wandering/Elopement Policy 3) Door Alarm Policy 4) Daily Door Alarm checks to ensure proper functioning 5) Wander Guard Checks 6) Steps to take when a resident has increased wandering behavior 2) The facility Maintenance Director inspected all door alarms on 7/10/24 to ensure that they were in proper working order. 3) New hires will receive education on wandering, elopement and resident safety by the DON, Director of Social Services or designee(s). 4) The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1) A facility created quality assurance tool will be implemented and used by the Administrator or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year. This monitoring will continue until November 10, 2024. This tool will monitor that the facility is following the door alarm policy and the elopement policy The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings Any issues identified will be immediately addressed.

Based on observation, interview and record review the facility failed to ensure that the facility was administered in a manner to protect the health and well-being of the residents who reside in the facility. This applies to 7 of 22 residents (R1, R4, R11, R12, R17, R17, R21) reviewed for administration in the sample of 22. The findings include: The IDPH (Illinois Department of Public Health) Facility Data Sheet filled out and signed by V1 (Assistant Administrator) dated 7/3/24 lists V25 as the facility Administrator. On 7/11/24, the facility provided a copy of V25's license showing he is a Licensed Nursing Home Administrator. On 7/8/24 at 4:15 PM, V25 introduced himself to Surveyor for the first time. (Survey Entrance date 7/3/24). V25 stated, I am here every Monday. I have another facility that I own. We had the opportunity to take this place over when they had some problems. Surveyor explained that there were some very serious concerns in the survey so far. V25 said, These are just allegations, not substantiated allegations. Did you see the tape on the wall in the dining room? We are getting 120 inch interactive screen with a gaming system. I am trying to really amp up the activity programing and make this a light and fun environment for the residents. On 7/11/25 the facility presented a copy of the last Quality Assurance Meeting Attendance Sheet undated but shown to cover QAPI (Quality Assurance and Performance Improvement) for April, May and June 2024. V25 was not present for this meeting. During this survey, exited on 7/15/24, the facility was cited for two areas of Immediate Jeopardy related to resident safety and supervision and resident to resident sexual abuse. The facility was also cited for other concerns related to abuse reporting and investigation. The Immediate Jeopardy concerns were presented to V1 (Assistant Administrator), V2 (Director of Nursing) and V20 (Director of Clinical Excellence/Corporate Nurse) around 11:30 AM on 7/10/24, V25 was not present. On 7/11/24 at 1:00 PM, all concerns were reviewed with V20, including concerns related to lack of Administration in the facility. V20 stated, I don't have anything to say about that. The facility Administrator job description, Copyright 2023 states, Position Purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.

Based on observation, interview and record review the facility failed to ensure a resident's safety when in bed and failed to put interventions in place to protect a resident from injury. This failure resulted in R27 sustaining a fractured right ankle on 3/2/24. The facility also failed to ensure a resident ordered to have nectar thick liquids was not given thin liquids, failed to assess a resident for safety when smoking, and failed to ensure that medical equipment was not plugged into power strips in 3 resident rooms. This applies to 6 of 18 residents (R27, R30, R75, R38, R4 & R17) reviewed for safety and supervision in the sample of 18. The findings include: 1. The facility's undated initial incident report for R27 states, On 3/2/2024, at approximately 7:00 PM, (R27) was in her room in her Broda chair resting comfortably, no agitation or discomfort noted by staff. When the CNA (V19) came into the room shortly after to render care, noted (R27) on the floor next to her bed. The nurse (V18) was immediately notified and assessed the resident. At this time, the resident was alert, complete body assessment was rendered with no visible injuries noted and ROM was at her baseline. There was no verbal or non-verbal indicators of pain or discomfort. Vital signs were within her normal. The NP, POA, and DON were notified. On 3/3/2024, at approximately 8:30 am, the nurse on duty noted edema to the right ankle and pain with minimal movement. The NP was notified, and an x-ray was ordered. The x-ray results stated, possible incomplete fracture of the medial malleolus with follow up for confirmation. The NP and POA, were notified. The DON was notified on 3/4/2024. The NP ordered to secure the right ankle with ACE wrap until an immobilizer could be placed, as the resident is non-ambulatory. The DON contacted (X-Ray Company) on 3/4/2024, to confirm the result. The DON was instructed by the radiologist to repeat the x-ray, as the result was inconclusive. The POA was notified and requested the resident to be sent out to ED for further evaluation and x-ray. NP was made aware and with an order to send resident out to ED for further evaluation, per POA request. Resident sent out to ED per NP order and POA request. Resident returned to facility with a 3 view, x-ray result for non dislocated fracture of the right ankle. Investigation initiated and ongoing. R27's Progress Notes dated 3/2/24- (Entered on 3/4/24) states, CNA reported that he was assisting resident to bed. CNA stated that he left resident in Broda to retrieve a gown. When CNA reentered room, CNA observed resident lying on floor. LOC and ROM appropriate to baseline. Resident is nonverbal, however, no nonverbal signs of pain witnessed. Skin assessment was negative for any new injuries. Writer was notified. Writer assessed resident, no injuries noted, and no c/o pain. POA notified. NP and DON notified. BP 118/61 P 71 R 16. Will continue to monitor. R27's Nurse Practitioner Progress Note dated 3/4/24 states, Patient is 64 y.o. woman with PMH (Past Medical History) of CAD (coronary artery disease), CHF (Congestive Heart Failure), hypertension, Presence of defibrillator, hypothyroidism, Alzheimer's with agitation and behavioral disturbances, depression/anxiety, Difficulty swallowing/dysphagia/anorexia. The patient suffers from acute and chronic medical/psychiatric illnesses which contributes to the patient's need for 24/7 assistance and skilled nursing care. Per nursing report, patient had a fall on 3/2/24. Initially, per nursing report, patient presented with no apparent injuries and no c/o pain. However, on the next day, patient started to c/o pain to right ankle and developed edema. Xray was ordered. Xray results came back on Sunday night with impression of possible R ankle/medial malleolus incomplete fracture. Immobilizer STAT and non-weight bearing were ordered after results review. This morning, this PCP (Primary Care Physician) collaborated with primary MD on the plan of care. Collaborated and discussed plan of treatment with DON. Patient is non ambulatory. She needs immobilizer and follow up with Ortho asap. Patient would need another Xray for fracture confirmation. Also, discussed with DON that POA needs to decide if he wants pt to be treated at the facility or wants her to be sent to ED for eval. According to DON, she communicated with POA, and POA decided that he wants patient to be sent out. Upon today's assessment, patient is found resting comfortable in her Broda chair with no s/s of pain or discomfort. She does have edema to right ankle. no bruising or discoloration, and no s/s suggestive of impaired circulation. Patient will be sent out to ED for trauma/injury evaluation. R27's X-ray dated 3/5/24 shows that R27 has an obliquely oriented non-displaced fracture through the base of the medial malleolus. On 5/14/24 at 1:25PM V2 (Director of Nursing) stated, (R27) was in her chair. We have to lay her back because she wiggles a lot in her chair. I've seen her do it. One time she did it we did get her a new chair because the brake did not engage, and she slid forward in the chair. It was an agency nurse and CNA when she fell - we are trying to get their phone numbers for you. On 5/16/24 at 10:40 AM, V19 (CNA) stated, I had just transferred her to the bed. It was in low position, like below my knees and I left the room to get her a gown because I was going to give her a bed bath. I was out of the room for only a few seconds and when I came back in her roommate told me she was on the floor. It was almost like someone flipped her out of the bed. Her head was at the foot of the bed. She seemed alright when we put her back in the bed. She rolled ok as I gave her a bed bath and I didn't see any bruising on her. It was 4 of us, 3 CNAs and the agency nurse (V18) that put her back to bed. The other nurse wouldn't come in the room because she said it wasn't her patient. I remember she walked half way down the hall and then she turned around. I don't remember seeing a floor mat in her room. That was my first time there and I have worked there, and I have been back about 3 times since then. I didn't know anything about her broken ankle. R27's care plan dated 11/18/23 states, (R27) had an actual fall related to sliding out of Broda chair. 2/11/24-fall out of Broda chair, 3/2/24- fall out of Broda chair, 5/2/24- fall rolled from low bed. Interventions added after the fall on 3/2/24 include: Keep bed in lowest position while in bed, monitor resident's movements while in Broda chair as resident becomes restless at times, While in Broda chair, (R27 will be supervised by staff and Make frequent positioning checks while (R27) is in the Broda chair. On 5/13-5/15 a phone number for V18 (RN) was requested from the facility. The Nursing Agency was also called with request for R18's phone number. Both the facility and the Agency were unable to provide a phone number, therefore an interview with V18 could not be conducted. The facility's undated final Investigation Report regarding R27's fall states, Per investigation the (facility) staff have explained the resident is noted to become fidgety at times and she changes her position in the chair frequently, as this can happen quickly, nursing has been instructed and interventions have been placed for the resident to be supervised by nursing/CNA, at all times while in the Broda chair . 40798 2. On 5/13/24 at 10:11 AM R30 was in his room drinking a soda out of the can and a plate of pureed food was on his over bed table. On 5/14/24 at 1:19 PM, V7, Speech Language Pathologist, said she is seeing R30 for dysphagia. V7 said R30 is on a pureed diet with nectar thick liquids. V7 said R30 cannot have any carbonated beverages as they create too many bubbles and create a lot of gas which makes aspiration more likely. V7 said if R30 aspirates, It's pretty much a pneumonia right there. V7 said R30 is definitely not safe on any thin liquid, he needs to be well-monitored. R30's Admission Record dated 5/14/24 shows his diagnoses include, but are not limited to, dementia, cerebral infarction (stroke), muscle weakness, edema of the larynx, and Alzheimer's disease. R30's Order Summary Report dated 5/14/24 shows R30's current ordered diet is pureed texture with nectar consistency. R30's Physician Progress Note dated 5/10/24 at 3:49 PM shows R30 was downgraded to a pureed diet and nectar thick liquids. 3. On 5/13/24 at 10:21 AM, R75 said he can go out to smoke by himself whenever he wants. R75 took his cigarettes and lighter and began wheeling down the hallway in his wheelchair. On 5/13/24 at 10:52, R75 was outside smoking unattended. R75's Admission Record dated 5/14/24 shows R75 was admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis, muscle weakness, lack of coordination, abnormal posture, cognitive communication deficit, need for assistance with personal care, hypothyroidism, type 2 diabetes, chronic pain syndrome and hypertension. R75's Minimum Data Set, dated dated dated [DATE] shows R75 has impairment on both sides of his upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot) and requires partial/moderate assistance with eating, oral hygiene, upper body dressing, and personal hygiene. R75's current care plan provided by the facility does not address safety and/or cigarette smoking. As of 9:00 AM on 5/14/24, R75 did not have a Smoking Evaluation completed. On 5/13/24 at 1:19 PM, V11, Social Services Director, said she does the assessment for smoking/vaping safety for all residents who smoke to determine safety while smoking unsupervised upon admission and quarterly. The facility's Vaping Safety Policy (undated) shows, A Smoking/Vaping Safety Assessment will be completed to determine the level of assistance and supervision needed .the plan of care shall reflect the results of this assessment. This assessment will be completed upon admission . 37232 4. On 05/13/24 at 10:47 AM, R38 was in bed. There was an air mattress on R38's bed. The air mattress pump was plugged into a power strip. R38's bed was also plugged into the power strip. The power strip was attached to the bed frame with tape and zip ties. 5. On 05/13/24 at 10:28 AM, R4 had an air mattress on her bed. The air mattress was plugged into a power strip that was on the floor between R4's bed and wall. 6. On 05/13/24 at 09:37 AM, R17 had an air mattress. The air mattress pump was plugged into a power strip that was on the floor under R17's bed. On 05/14/24 at 12:07 PM, V6 (Maintenance) said medical equipment such as beds and air mattress pumps should be plugged into a wall outlet and not a power strip. V6 said medical equipment can not be plugged into a power strip because of the required amperage of the equipment and the amperage of the power strip.

Based on observation, interview, and record review the facility failed to keep an indwelling urinary catheter bag below the level of the bladder, clean the end to the drain on the catheter bag, and ensure a secure device was in place for 3 of 3 residents (R59, R22, & R6) reviewed for catheters in the sample of 19. This failure resulted in R59 sustaining trauma to the tip of his penis. The findings include: 1. On 4/12/23 at 9:10 AM, R59 was sitting up in bed and had a urinary catheter drainage bag attached to the lower side of his bed. R59 stated V11 LPN (Licensed Practical Nurse) had just recently started putting an anchor on the catheter tubing. R59 stated he doesn't want his catheter to get pulled out on accident. On 4/12/23 at 9:30 AM, V11 LPN (Licensed Practical Nurse) stated R59 has had urogenital damage because the tape that was supposed to secure the catheter tubing kept pulling and coming off. V11 stated it didn't stick to R59's skin like it should. V11 stated the secure tape for the catheter tubing was not efficient enough to keep catheter tubing in place and caused damage to the end of the penis. V11 stated next month R59 must have surgery to get a suprapubic because of the damage. V11 stated she went and bought a different secure device for R59's catheter two weeks go with her own money. V11 stated she told the facility about it and they couldn't order them for some reason. V11 stated she helps the CNA's with care and she does wound care. V11 stated there were times when she would come in and nothing would be in place to secure the catheter. V11 stated R59's catheter has been pulled out before. On 4/12/23 at 9:46 AM, V11 LPN went into R59's room and he did not have a device in place to secure the catheter tubing. V11 stated the catheter secure device they have used doesn't work very well to keep the tubing anchored and comes off. R59 stated his catheter has been pulled out before and has caused damage to his penis. On 4/12/23 at 1:42 PM, V2 DON (Director of Nursing) stated catheter tubing should be anchored so the tubing doesn't tug or get pulled out and cause trauma. V2 stated she did not know there was any problem with R59 and his catheter until V11 brought it to her attention two weeks ago. V2 stated V11 had her go into R59's room and showed her R59 did not have anything in place to anchor his catheter tubing. V2 stated R59's urinary meatus was torn and the tubing wasn't anchored. V2 stated that she and V11 discovered together that the anchor device they used for R59 was not working for him. V2 stated she went online shopping to start looking for a different device but did not purchase anything else to anchor R59's catheter. V2 stated she didn't make any changes to secure the catheter tubing. V2 stated, I see I should have done that. V13's Progress Note dated 3/27/23 for R59 showed she saw him that day related to his chronic indwelling urinary catheter with urogenital trauma; urology referral. V13's note stated the tip of R59's penis was excoriated and splitting. V13 discussed the need for a urology appointment and the possibility of a suprapubic catheter. On 4/13/23 at 12:20 PM, V13 NP (Nurse Practitioner) stated R59 had a catheter in and that was what caused the trauma to his penis. V13 stated she did not know how consistent they were with anchoring R59's catheter tubing. V13 stated, It is standard procedure and common sense to anchor the catheter tubing. I would expect it to be utilized for safety to prevent injuries to the ureter and bladder. I saw him when the injury was noticed and assessed him. I ordered a urology consult for placement of a suprapubic catheter because of the trauma and to prevent future trauma. The trauma didn't just happen overnight. I can't say 100 percent that the trauma was because the tubing wasn't secured but it could have contributed to it. The Admission Record for R59 printed on 4/12/23 showed diagnoses including cervical spinal cord injury, muscle weakness, need for assistance with personal care, C5 - C7 incomplete quadriplegia, hypertension, stage 4 pressure ulcer of the sacrum, and neuromuscular dysfunction of the bladder. The Care Plan dated 10/17/22 for R59 with a target date of 7/12/23 The MDS (Minimum Data Set) dated 1/20/23 for R59 showed no cognitive impairment; total dependence on staff for bed mobility, transfers, and toilet use. Extensive assistance needed for dressing and bathing. The facility's Catheter Care policy (7/14/21) showed, evaluate need for catheter securement device and implement if indicated. 34491 2. R22's Admission Record, printed by the facility on 4/13/23, showed he had diagnoses including paraplegia, Alzheimer's disease, schizoaffective disorder, anxiety disorder and neuromuscular dysfunction of bladder. R22's facility assessment dated [DATE] showed he had moderately impaired cognition (BIMS score of 11). The assessment showed R22 had an indwelling catheter and he was dependent on staff for toileting and dressing. R22's Order Summary Report for active orders as of 4/13/23 showed an order for an indwelling urinary catheter. R22's ADL (activities of daily living) plan of care, with a revision date of 1/15/21, showed he has an ADL self-care deficit related to paraplegia, anxiety disorder, contracture of unspecified knee, and chronic pain. The plan of care showed R22 requires total dependence of one staff for toileting. R22's Indwelling Suprapubic Catheter plan of care, with a revision date of 1/15/21, showed he had an indwelling suprapubic catheter related to neuromuscular dysfunction of bladder and paraplegia. On 4/11/23 at 1:45 PM, V17 (Certified Nursing Assistant-CNA) was emptying R22's urinary drainage bag. V17 was having difficulty closing the lock on the tubing for the urinary drainage bag, to stop the flow of urine into the cylinder that she was emptying the urine into for disposal. The spout at the end of the tubing was immersed in the urine as it was overflowing from the cylinder. After emptying the cylinder and emptying more urine from the urinary drainage bag into the cylinder, V17 reattached the tubing to the urinary drainage bag without disinfecting the end of the tubing. On 4/12/23 at 1:36 PM, V17 (CNA) said she should have used alcohol to clean the end of the tubing after emptying the catheter bag, to prevent infection. On 4/12/23 at 1:46 PM, V16 (CNA) said after emptying a catheter bag, the tubing should be cleaned with alcohol before closing and reconnecting the tubing to the bag. On 4/12/23 at 3:12 PM, V2 (Director of Nursing-DON) said the catheter tubing should have been cleaned with alcohol before closing the tubing and reconnecting it back to the catheter bag for infection control. The facility's policy and procedure titled Urinary Drainage Bag-Emptying, with a revision date of 4/2005, showed the purpose of the policy was to empty the resident's urinary drainage bag without contamination, and measure and record amount of intake/output record. The policy showed 3. Bacteria grows rapidly inside the urinary drainage bag. If urine from the drainage bag is allowed to flow back into the bladder, it can cause a bladder infection which can travel up the urinary system to the kidneys .8. Make sure that the drainage spout and the tubing are kept off of the floor . The procedure showed 4. Detach the spout and point it into the center of the measuring container, not letting the tubing touch the sides of the container (to prevent contamination of the tubing). 5. Unclamp the spout and drain the urine. Use the alcohol pad to wipe off the spout, Re-clamp the spout and replace it in the holder . The rationale listed on the procedure for step 5 was that it decreases the amount of bacteria left on the spout after opening to empty. 34891 3. R6's face sheeted printed on 4/13/23 showed diagnoses including but not limited to diabetes mellitus with chronic kidney disease, neuromuscular dysfunction of the bladder, and chronic respiratory failure with hypoxia. R6's facility assessment showed no cognitive impairment and extensive staff assistance needed for dressing, toilet use, personal hygiene, and transfers. R6's April 2023 physician's order summary showed an order started on 12/8/21 for a suprapubic catheter and a second order started on 3/23/23 for catheter care every shift. The same order summary showed an order started on 4/4/23 for doxycycline hyclate (antibiotic) 100 milligrams every morning and at bedtime for 10 days. On 4/11/23 at 11:56 AM, R6 said she has a UTI (urinary tract infection) and is being treated for it with an antibiotic. At 1:25 PM, V9 (Certified Nurse Aide) donned a pair of gloves and got supplies to empty R6's urinary drainage bag. V9 opened the drainage tube and wiped it off with several peri wipes (incontinence wipes). V9 allowed the urine to flow into a collection beaker and again wiped the tubing off with the peri wipes. V9 reinserted the tubing back into the closure device. V9 preformed peri care to R6 and placed the drainage bag on the mattress, near the foot of the bed. R6 was rolled several times from side to side while the bag remained on top of the bed. At 1:45 PM, V7, V8, and V9 (Certified Nurse Aides) transferred R6 from the bed to a wheelchair using a mechanical lift. R6's drainage bag was held above the bladder several times during the transfer. On 4/13/23 at 10:06 AM, V9 said we need to wipe the tubing with alcohol pads or peri wipes. Either one is okay to use. It is important to cleanse the tubing properly to prevent UTIs or bladder infections. Drainage bags should remain below the level of the bladder during care. If it is above the stomach, urine can drain the wrong way and hurt the resident. Germs could travel up the tubing and get into the bladder. On 4/13/23 at 10:14 AM, V2 (Director of Nurses) said the aides should be using alcohol wipes to cleanse catheter tubing before and after emptying the bag. It is important to remove contamination or anything it potentially touched at emptying. Peri wipes should not be used. It does not have the sanitization properties that alcohol has. There is the potential for bacteria to travel back up and into the bladder, causing UTIs. V2 said the bags should be always below the level of the bladder. Placing them on the foot of bed is not low enough. Staff should be keeping it below the bladder at transfers also. V2 verbally confirmed R6 was currently on an antibiotic to treat a urinary tract infection. The facility Urinary Drainage Bag-Emptying policy revision dated 4/2005 states: 2. The bag must always hang below the level of the bladder to prevent the flow of urine back into the bladder and to allow gravity to flow. The policy further states under the procedure section: 5. Unclamp the spout and drain the urine. Use the alcohol pad to wipe off the spout. Re-clamp the spout and replace it in the holder. Rational: Decreased the amount of bacteria left on the spout after opening to empty.

Based on observation, interview, and record review the facility failed to ensure a dependent resident was transferred safely with a total lift machine for 1 of 3 residents (R2) reviewed for safety in the sample of 11. This resulted in a strap of the full body sling, snapping and R2 falling to the floor and experiencing a pelvic fracture. This Past Non-Compliance lasted from February 4, 2023, to February 9, 2023. Past noncompliance - no plan of correction required. The findings include: The facility's Incident Report Form dated 2/5/23 showed R2 experienced a fall with a fracture on 2/4/23 at 10:30 AM. This report showed R2 was alert and oriented and can express her needs. R2 had an acquired left leg amputation and is non-ambulatory, requiring the use of a mechanical lift for transfers. On 2/4/23 at approximately 10:30 AM, 2 CNA's (later identified as V5 and V8) were transferring R2 from her bed to her motorized wheelchair. R2 was lifted above the bed and began to turn the lift towards the motorized wheelchair. At that time, the strap under her right leg ripped causing her to fall to the floor, landing on her buttocks. R2 was complaining of pain in her lower back and left knee area. R2 went to the emergency room and returned to the facility with a diagnosis of a pelvic fracture. R2's Facesheet dated 3/1/23 showed she had diagnoses to include, but not limited to: left-sided hemiplegia and hemiparesis; morbid obesity; contracture of left arm; epilepsy; diabetes; hyperlipidemia; depressive episodes; anxiety; high blood pressure; coronary artery disease; COPD (chronic obstructive pulmonary disease); stroke; and left below the knee amputation. R2's facility assessment dated [DATE] showed R2 was cognitively intact; had no behaviors of rejection of care; and was totally dependent on two staff members for transfers. R2's Health Status Note dated 2/4/23 at 10:32 AM showed, CNA reported to the nurse resident fell during transfer via (mechanical) lift. Per two CNAs, the sling snapped during the transfer. Resident slid off from the full lift sling feet first and fell on her buttock per the CNA. Resident denied hitting her head. Assessment conducted and completed. V/S (Vital signs) BP 171/85, HR 85, RR 20, T 97.9, Sp02 96% on room air . The writer called V29 (Nurse Practitioner), R2's POA, and 911. R2 was transferred to the emergency room . R2's Nurses Note dated 2/5/23 at 6:36 AM showed R2 complained to the CNAs, during cares, that she had pelvic pain with turning. R2 was given Tylenol 650 mg. R2's Nurses Note dated 2/5/23 at 2:15 PM showed R2 remained in bed this shift and requested Tramadol for pain in her tailbone. R2's Provider Note dated 2/6/23 at 5:16 PM showed R2 was being transferred with the mechanical lift on 2/4/23, the lift strap broke, and she fell on the floor. R2 complained of left knee and hip pain and was sent to the emergency room . The CT scan of the chest, abdomen, and pelvis showed a fracture of the left pubic ramus. R2 reports pain in her left lower back/hip, which exacerbates with movement/turning to left and rates 9/10 (1-10, 10 is worst pain felt) with movement. R2 takes Tramadol (opiate pain medication) and Tylenol for pain control. R2 reports that she is in pain, even after taking Tramadol. This document showed, .Assessment/Plan: fall with fracture of left pubic ramus on 2/4/23. Had long conversation with patient's daughter/POA. She agrees to start the following pain management: Norco 5-325 mg . Give 1 tablet by mouth at bedtime for severe pain, post fall for 7 days. Robaxin (muscle relaxant) 750 mg three times a day for low back pain for 7 days . R2's Care Plan revised 9/29/21 showed R2 had impaired transfer skills. R2's Care Plan revised 2/6/23 showed R2 had pain related to pelvic fracture. R2's pain was aggravated by movement. On 3/2/23 at 9:54 AM, R2 was lying on her in bed and said she was staying in bed until around 12:30 PM. R2 stated, I have pain everywhere, but it's worse on my left side because they dropped me from that lift. It was awful and scary. V8 and V5 (CNAs) were the ones helping me. They were getting me out of bed to my chair. The sling was old, [NAME], and faded. Now they have all new ones since I fell . My chair was down the end of my bed. They put the sling under me and lifted me off the bed. Then they started to move the me over towards the chair, then I was on the floor. I'm not even sure what happened. It happened so fast and I screamed. I landed on my left stump area first, then my butt. I had pain right away. I'm not sure what the CNAs did after that. I was in shock. The male nurse came in and wanted the CNAs to get me back to bed, but they refused. They said that they couldn't move me. Then the ambulance came to get me and I went to the hospital. I stayed on the floor until the ambulance came. The hospital did a bunch of tests and said that I cracked my pelvis. I never heard of that before. It hurt so bad and there isn't much they can do for it. I just have to let it heal on it's own and take pain medication. I don't think that's fair. My roommate (R7) saw it happen. I don't know about R8. I have sharp pain at a 7 most of the time. The muscle relaxant seems to help the most. Now I guess, the slings are assigned to us. It wasn't like that before I fell . On 3/1/23 at 10:31 AM, V8 (CNA) said she and V8 (CNA) were getting R2 up for the day. They used the mechanical lift to get R2 out of bed and everything seemed okay. V8 stated, I was controlling the lift and V5 (CNA) was down by the chair. We lifted R2 off the bed and started to turn toward the chair. It all happened so fast after that. The strap by her right leg ripped. It was scary. The sling had fuzzies on it from the dryer. She fell immediately and hit her butt. I don't remember what R2 was saying because of what happened. I've never had that happen to me before. V5 (CNA) notified V6 (Agency RN) and he came and checked her. She went to the hospital and came back later that day. She was being cooperative with the transfer and we did everything we should have; the sling just broke. On 3/1/23 at 10:43 AM, V5 (CNA) said he and V8 were transferring R2 with the mechanical lift. We had R2 lifted of the bed and were turning toward the chair when the strap (bottom strap by her right leg) snapped in the middle. V5 stated, I was surprised it snapped. As soon as all her weight was in the sling and the momentum of turning toward the chair. I assume the momentum of the movement is what made the strap snap. It snapped right tin the center of the loop. I've never seen that happen before. Once it snapped, she fell and landed on her butt, in a seated position. V8 (CNA) stayed with R2 and I went to notify the nurse (V6). She said she was in pain, scared, and wanted to go to the hospital. The ambulance picked her up and she seemed better when she came back (to the facility). On 3/1/23 at 11:42 AM, V6 (Agency RN) said the V5 (CNA) told him that he and V8 (CNA) were transferring R2 with the mechanical lift, the strap broke, and she fell to the ground. V6 stated, I went into the room immediately and did an assessment. She seemed to be in quite a bit of pain so I called 911 right away. V6 said R2 was in a seated position, on the floor. R2 had a left below the knee amputation, but that's the side she hit on the ground. She was crying. Her roommate saw everything and stated, One minute she was in the lift. Then next minute she wasn't. V6 stated, The CNAs showed me the sling. It snapped on the right side, by where R2's legs/feet would be. She came back from the hospital and I gave her some Tramadol for the pain. R2 had a fracture from the fall. I haven't seen a sling snap like that. On 3/1/23 at 9:41 AM, V1 (Nurse Consultant/Assistant Administrator) stated, The loops of the slings can pick up lint. It can be hard to tell if the sling just had lint on it or if it was frayed. If they don't remove the lint to inspect the sling, then it could impede the inspection. We decided to stop drying the slings and purchased a large drying rack. On 3/1/23 at 1:28 PM, R4 said he hates the mechanical lift. R4 stated, The first time I was in that thing it hurt my neck and the second time it hurt my back. It felt like it just dropped me down on the bed. Those old slings looked awful. I wouldn't be surprised (if one broke). On 3/1/23 at 1:44 PM, R5 was sitting up in a custom wheelchair, using his laptop. R5 had a new full body lift sling underneath him. R5 stated, They just got new slings a couple weeks ago and it's better now. I was concerned with the other ones. They looked frayed and worn on the straps. They got rid of all those old ones. The slings have various straps to adjust the angle of the lift and I always told them not to use the green strap on me. I told them to use a different one because you could tell the green one wasn't good. On 3/1/23 at 2:23 PM, R7 (R2's roommate) said she saw the whole thing. R7 stated, I saw R2 in the lift, then she fell real fast. I heard all the commotion too. I heard, Oh s***! Oh s***! I'm didn't see the strap break, but I heard the commotion. R2 was crying and in pain. She went to the hospital and came back. On 3/2/23 at 10:11 AM, V13 (Laundry) entered the laundry room where there were 2 large washers and dryers. There were hooks by the door, with lift slings drying. The surveyor asked V13 what the dryer temperature is. V13 replied, I'm not sure, but V14 (Laundry) will know. V14 walked into the room and stated, Both dryers are set at 190 degrees (Fahrenheit). V14 stated, We were hang drying the slings for a while, but the hooks kept coming out. So, I would put them in the dryer until they were just damp, then remove the slings. Both dryers reach 190 degrees. Now we aren't drying the slings at all. V13 put some new hooks up and we hang dry all the slings. When we were drying the slings, they would collect lint all over them, especially on the straps. And we were not removing the lint. I guess it interfered with the sling inspections. V14 indicated that the washer and dryer nearest the doorway were used to launder the slings. The surveyor asked V14 if they write down their sling inspections. V14 walked across the hall, to the folding room and stood in front of bulletin board. V14 looked at the bulletin board and stated, I used to have a form that I would complete with my inspections, but I haven't been writing them down lately. V14 said the facility replaced all their slings a couple weeks ago. V14 stated, I can't remember the last time we ordered new slings before this batch arrived (in mid-February). On 3/2/23 at 10:48 AM, V15 (CNA Supervisor) said the CNAs should inspect the sling before each use to ensure resident safety and make sure the equipment is working properly. V15 said prior to R2's fall from the lift (2/4/23), the CNAs were supposed to inspect the slings with each use and laundry inspected the slings when they laundered them. V15 stated, I don't know if there were any other inspections completed. I'm not even sure how many slings we had. We did order new slings. Now, I'm checking the new slings weekly. I complete an audit tool and write the date the sling was initiated, meaning the day the sling was put into service. I'm not sure when the old slings were put into service. (The surveyor showed V15 the monthly audit tools and the date initiated was blank for November and December 2022 and January 2023.) I wouldn't know when the sling went into service by looking at these audit tools. The new forms include more information because the manufacturer of the slings suggested slings be replaced after 6 months of normal wear and tear. On 3/2/23 at 12:16 PM, V20 (Case Manager for Sling Manufacturer) said the facility should follow the deterioration log for proper laundering and inspection of the slings. V20 said the slings can deteriorate by the way the facility launders the sling; if any harsh chemicals are utilized to clean the slings; and if they are not washed on the gently cycle. V20 said the full body sling is made of plastic fibers and the high heat can problematic. The high heat will break down the fibers. V20 said with normal wear and tear at a facility, the sling will likely lose integrity after 6 months of normal wear and tear. On 3/2/23 at 2:50 PM, V29 (Nurse Practitioner) said she was called by V6 (Agency RN) on 2/4/23 and notified that R2 had fallen from the lift and was in pain. V6 told me that R2 wanted to go to the hospital. V29 said she gave the orders to send R2 to the hospital for evaluation. R2 returned later that day and the emergency room diagnosed a pubic ramus fracture (pelvic fracture). V29 stated, I don't remember if V6 told me the sling broke. I became aware of the sling breaking when I rounded at the facility on Monday. V29 said R2's fracture must heal naturally and the facility will do their best to control her pain. V29 said falling from the lift, approximately 3-4 feet caused R2's pelvic fracture. On 3/2/23 at 3:05 PM, V2 (Director of Nursing - DON) said she was not working when R2 fell , but she was notified that R2's lift sling had snapped. V2 said the staff reported that R2 was in the full body sling and had been lifted from the bed. V5 and V8 (CNAs) were starting to turn R2 toward the chair when the strap snapped and R2 fell ,d+[DATE] feet to the floor and landed on her buttocks. R2 was sent to the emergency room and came back later that day with a diagnosis of a pelvic fracture. V2 stated, V22 (Dietary Manager) was the MOD (Manager On Duty) on 2/4/23. V22 removed R2's sling from circulation and inspected the other slings. On Monday I saw R2's sling and the strap had snapped right in the center. It split right where the weight would have been the greatest on the strap. The facility's Monthly Sling Inspection Logs dated 11/16/22, 12/16/22 and 1/13/23 showed slings numbered 1-18. The Date Initiated: was blank on all three forms. The updated Monthly Sling Inspection Logs dated 2/17/23 and 2/24/23 showed that 9 slings were inspected and were put into circulation on 2/10/23. The facility's Monthly Sling Inspection Log dated 2/21/23 and 2/28/23 showed 20 new were assigned directly to residents and put into circulation on 2/14/23. The surveyor requested a Mechanical Lift Policy. The facility reported they follow the manufacturer's recommendations and instructions for safe lift transfers. The undated Sling Manufacturer's Guideline for Identifying Deteriorated Slings showed, Accelerated Deterioration from Bleach, High Temperature Wash or Drying. Slings, especially the loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised an pose a safety risk and should not be sued for lifting a patient or resident . (The Manufacturer) slings have been designed and tested for laundry wash conditions of 170 degrees Fahrenheit and air dry or dry at low temperatures . Care instructions in the sling label should always be followed . Causes of Deterioration Due to Laundry Conditions: .2. Temperature or high heat damage. This can occur if slings are left in the dryer for too long or dried at excessive heat. The slings are made from plastic fibers and do not absorb as much water and require less drying time than other laundry of natural fiber and fabric. 3. Mechanical/Wash Action can contribute to the accelerated deterioration of the slings, especially if they have been subjected to the above conditions. Slings should be washed using a gentle cycle to minimize excessive agitation and internal fiber abrasion. The undated Sling Manufacturer's Full Body Sling Instructions Manual showed, .Carefully inspect the sling before each use for wear and damage to seams, fabric, straps, and strap loops. Torn, cut, frayed or broken slings can fail, resulting in serious bodily injury to the user. Use only slings that are in good condition. Discard and destroy old, unusable slings . Washing instructions: 1. Machine wash warm or cold. a. Maximum washing temperature 185 degrees F. b. Wash at 160 degrees F for 3 minutes. c. Wash at 145 degrees F for 10 minutes. d. Air dry or tumble dry at cool or very low temperature . After each laundering (in accordance with the instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately . Useful life of this product is six months from date of purchase under normal use, heavy or excessive washing may reduce useful life of the product . Prior to the survey date of 3/1/23, the facility took the following actions to correct the non-compliance. 1. Inspect each Hoyer sling for torn/worn/frayed or unstable material. Completed 2/4/23. 2. Review laundering process for issues. Completed 2/4/23. 3. Install area away from vents for Hoyer slings to air dry. Completed 2/7/23. 4. Educate laundry personnel on inspecting straps and removing lint that impedes inspection and air-drying slings. Completed 2/5/23. 5. Perform mechanical lift competencies of the 2 CNAs involved in event. Completed 2/5/23. 6. Conduct mechanical lift competencies for all remaining CNAs. Completed 2/5/23. 7. Review manufacturer's guidelines to ensure all components are met. Completed 2/5/23. 8. Review Monthly sling audits for compliance. Completed 2/5/23. 9. Interview CNAs to identify any issues they have encountered. Completed 2/5/23. 10. Conduct RCA (Root Cause Analysis) to identify issue/corrective action or enhancements to system. Completed 2/4/23. 11. Impromptu QAPI meeting for input and review. Medical Director involved and reviewed RCA and approves plan. Completed 2/4/23. 15. All slings were replaced. Completed 2/9/23.

Based on interview and record review the facility failed to ensure a resident (R1) was properly identified prior to administering medications to prevent a significant medication error. This failure resulted in R1 receiving another resident's (R2) antihypertensive (high blood pressure) medications in which R1 subsequently required emergency medical intervention and hospitalization . This past noncompliance occurred from December 10, 2022 to December 13, 2022. This failure applies to 1 of 5 residents (R1) reviewed for medication errors in the sample of 9. The findings include: R1's current care plan showed R1 had diagnoses including Down Syndrome, congestive heart failure, encephalopathy, and seizures. The care plan showed R1 had no diagnosis of hypertension. The care plan showed R1 was severely cognitively impaired. R1's Medication Incident report dated December 10, 2022 showed R1 was, inadvertently given three medications that would lower blood pressure around 8:00 AM. The report showed R1 was administered three antihypertensive medications, metoprolol, hydrochlorothiazide, and lisinopril that were prescribed to/for R2. The report showed, Approximately 9:30 AM, Patient was visibly lethargic .Blood pressure was 92/58. RN (registered nurse) called Emergency Services to transport out .Approximately 9:40 AM, Emergency Services arrived at facility . R1's hospital records dated December 10, 2022 showed R1 was admitted to the hospital with a diagnosis of hypotension (low blood pressure) secondary to incorrect administration of antihypertensive medication. The records showed R1 was discharged back to the facility on [DATE]. On January 3, 2023 at 10:48 AM, V5 Agency Nurse stated, It was my first day working in that facility (12/10/22). I didn't realize there were two residents (R1/R2) on that wing with the same first name. Around 8:00 AM, I gave (R1) all of (R2's) morning medications which included metoprolol, hydrochlorothiazide, and lisinopril. I didn't know the residents. Around 8:20 AM, I realized I gave (R1) the wrong medications. I didn't verify the right medication for the right resident . By 9:20 AM, (R1's) blood pressure was dropping. By 9:30 AM, (R1) was more lethargic. His blood pressure and pulse were dropping so I called 911 . On January 3, 2023 at 12:10 PM, V6 Nurse Practitioner stated V5 Agency Nurse notified her of the medication error involving R1 on December 10, 2022. V6 Nurse Practitioner stated, (R1) has a history of low blood pressure, not high blood pressure, so his blood pressures tend to run lower .Giving those three medications (metoprolol, hydrochlorothiazide, lisinopril) can be detrimental to a person. They could cause a person's blood pressure and heart rate to drop which could cause that person to pass out and become unresponsive . On January 3, 2023 at 10:15 AM, V2 Acting Administrator stated the medication error involving R1 was caused by V5 Agency Nurse not verifying she was giving the right medication to the right patient. The facility's Medication Administration-General Guidelines policy dated December 2019 showed, Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away .8) Residents are identified before medication is administered using (two) methods of identification. Methods of identification include: a. Checking photograph attached to medical record. b. Calling resident by name (except in residents with cognitive impairment). c. Having resident verify his/her name. d. If necessary, verifying resident identification with other facility personnel . Prior to the survey date of 1/3/23, the facility took the following actions to correct the noncompliance on 12/13/22: 1. Moved (R1) to a different hall. 2. Conducted a root cause analysis. 3. Performed a QAPI meeting to discuss plan of action. 4. In-serviced nursing regarding medication administration. 5. Conducted audits of resident profiles and updated EMAR (electronic medical records) resident pictures. 6. Facility called Agency (nursing) and requested they do not send V5 Agency Nurse back to the facility. 7. Med pass observations conducted. 8. The facility enhanced the orientation of the facility for Agency Nurses. 9. The facility will try not to have residents with the same first name on the same hall.

Based on interview and record review, the facility failed to supervise a resident with escalating behaviors for two of three residents (R1, R2) reviewed for safety and supervision in the sample of three. This failure resulted in R1 being punched in the right cheek and experiencing physical pain. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including history of Covid, dependence on [CONDITION(S)], [CONDITION(S)], Alzheimer's Disease, and Depressive Disorders. R1's MDS (Minimum Data Set) dated 8/17/21 shows R1 is cognitively intact. R1's Care Plan initiated 1/6/21 shows, [R1] displays behavioral symptoms related to: resident has a diagnosis of depression and anxiety. Intervene when any inappropriate behaviors are observed. Communicate that the resident is responsible for exercising control over impulses and behavior. R2's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including: Alcoholic [CONDITION(S)] of liver, chronic [CONDITION(S)] C, adjustment disorder with anxiety, and cognitive communication deficit. R2's MDS dated [DATE] shows R2 is cognitively intact. R2's Care Plan initiated 9/10/21 shows [R2] demonstrates significant mood distress related to: Adjustment disorder. [R2] has demonstrated difficulty in adjusting to long term care placement related to: Adjustment disorder with anxiety. R2's psychiatry note dated 9/15/21 shows, [R2] is quickly agitated, somewhat unkept. R2's Nurses Notes dated 10/31/21 at 3:33 AM shows, At 12:15 AM, resident was witnessed by staff nurse falling out of his wheelchair slowly by the nurses' station. 911 was activated and transported resident to (local emergency room ) for evaluation secondary to fall and possible intoxication .this writer and evening shift nurse were in the middle of shift-to-shift narcotic counts and resident [R2] came out of his room with his leg rest and demanded to put his leg rest on. He was instructed that staff will assist him once staff done with counting the narcotics. Resident became angry and threw his leg rests on the floor. Resident phone camera on and recording the staff. Both nurses suspected resident under the influence of alcohol due to his unruly behavior. Resident was very belligerent, argumentative, and calling staff names. Three bottles of 1.75 ml (milliliters) of vodka found in resident room. One bottle was half empty, the other bottle was 1/4 empty and the other was full . On 11/8/21 at 11:39 AM, V4 CNA (Certified Nursing Assistant) said, early in the morning on 10/31/21, R2 hit R1's wheelchair and R1 said to R2 If you would turn around you would see where the f**k you were going. R2 stopped and V4 said she stepped in between the two residents. V4 said she told R2 to keep going through the dining room. V4 said she reported this incident to V5 RN (Registered Nurse) but that she doesn't know where the report went from there. V4's written signed statement obtained by the facility dated 10/31/21 shows, [V4] states that she observed [R2] in his wheelchair in the main dining room back up into [R1] who was stationary in his wheelchair. [R1] said 'If you turned around you could see where the f**k you were going.' [R2] then said, 'If you'd get out of the way that wouldn't happen.' [V4] said that [R1] cursed as he spoke but did not call [R2] names. [R2] was already propelling away and [V4] told him 'Just keep going.' and he did. [V4] then stood by [R1] to block his view so that neither would be antagonized. [R1] remained in the main dining room and [R2] went to his room. R1's Nurses Note dated 10/31/21 at 7:56 AM, written by V3 RN (Registered Nurse) shows, This writer was approached by resident [R1] saying another resident had hit him in the face while he was outside in the courtyard smoking. Resident stated [R2] asked [R1] if he wanted to fight, then hit him in the face-pointing to his right cheek. Body assessment-right cheek noted with redness. No other redness or bruising noted in other parts of the body. DON (Director of Nursing) [V2] and POA (Power of Attorney) made aware. Non-emergency police called-responded to facility and interviewed resident [R1] and [R2]. On 11/8/21 at 9:29 AM, V1 interim administrator/nurse consultant said (in regards to incident that occurred 10/31/21 between R1 and R2), R1 got punched in the right cheek by R2. R1 said if R2 leaves the facility he would not press charges. Initially R2 denied hitting R1 and R2 denied it to the police. V1 said she reviewed the camera footage and there was a brief exchange of words between R1 and R2. R2 went up to R1 and struck him with his right hand onto R1 right cheek. The two residents exchanged words again, both residents were swinging again at each other with little to no contact. The two residents exchanged words again and R2 hit R1 on the right cheek again. V1 said that there may have been a trigger for the incident. V1 said that she received reports from staff that the two residents were yelling at each other prior to this incident. V1 said earlier that morning the two residents (R1, R2) bumped wheelchairs. R1 was in the dining room stationary and R2 bumped into R1's wheelchair and words were exchanged then. At 12:02 PM V1 said she would have wanted V4 to report any negative exchanges between residents. V1 said she would expect staff to report any negative exchange between residents right away or report it to the nurse or the director of nursing. V1 said prior to the physical altercation, R1 and R2 were unsupervised smokers. On 11/8/21 at 11:48 V5 RN said she was told that someone had mentioned that R2 had bumped R1's wheelchair unintentionally. But V5 said that she cannot remember who told her. On 11/8/21 at 10:31 AM, V3 RN said early morning on 10/31/21 she was at the nurse's station and she could hear R1 and R2 yelling at each other shortly before the physical altercation that occurred between R1 and R2. V3 said that she could not hear what the residents were saying but could hear them yelling. V3 said that at some point both R1 and R2 went outside to smoke. The facility's Investigation Report dated 11/5/21 shows, Asked [R2] what happened between him and [R1] and [R2] said, It was nothing. [R2] again denied striking [R1] (previously denied striking [R1] when questioned by officer). Informed him [R2] we have camera footage that shows he struck the other resident. [R2] then said he did strike [R1]. When asked why, he said their wheelchairs had bumped into each other earlier that morning and [R1] said something to him [R2]. [R2] did not give details of the conversation (other than to say [R1] called him [R2] a name) but stated, Where I come from you stand up for yourself and you hit them before they can hit you. Review of camera footage supports interview with [R1] that on the morning of 10/31/21 [R1] was outside in his wheelchair in the smoking area. No one else was present. [R2] exited the building in his wheelchair and propelled himself up to [R1] and said something (footage does not have audio) and then raised his right hand and struck [R1] on the right cheek. The two then exchange words and swung at each other making minimal contact at times. However, [R2] does strike [R1] on his right cheek again. [R2] then propels himself in his wheelchair over to another table and [R1] propels himself into the facility. On 11/8/21 at 2:29 PM, R1 said that R2 came outside and asked R1 if he wanted to fight. (R1 raised his voice to signify that R2 raised his voice when he asked R1 if he wanted to fight) R1 said that R2 then punched R1. (R1 made a motion with his fist to the right side of his face). When R1 was asked how many times he got punched, R1 said, I don't remember. I don't want to remember. R1 said he feels safe in the facility now. R1 said that if R2 stayed in the facility, I'd feel like s**t. I would find another place to live. On 11/8/21 at 12:57 PM, R2 (when asked about the incident between R1 and R2) said, I got into a fight with a guy with a big mouth. R1's Nurses Note dated 10/31/21 at 2:47 PM shows, [R1] complains of some pain to the face below right eye. States he was hit by a resident. Area slightly red, no swelling noted. Did give two Tylenol for pain. The facility's Behavior Emergency Policy not dated shows, The goal of the facility is to provide a safe, secure environment. In order to foster a safe environment, a consistent staff approach to behavioral problems and emergencies are necessary. Initiate 1:1 observation/monitoring until the resident is calm. After the incident document in the nursing notes: The resident's behavior and/or symptoms at the onset. The events and/or reasons potentially contributing to the resident's behavior. An assessment of the resident. Each intervention utilized. Notification of family/physician and subsequent orders.

Based on observation, interview, and record review the facility failed to transfer a resident in a safe manner for 1 of 3 residents (R3) reviewed for safety in the sample of 6. This failure resulted in R3 sustaining a rib fracture. The findings include: On 6/28/21 at 11:05 AM, R3 was sitting in his wheelchair. R3 coughed and said ouch. R3 stated I broke a rib. I was getting into the van and I hit my ribs on the chair. I didn't feel it right away, it started hurting later. It hurts right now, can you tell the nurse I need some pain medication. The facility's Incident Report Form dated 6/13/21 shows R3 was transported to an appointment for a CT scan escorted by V10 Certified Nursing Assistant (CNA). The report shows R3 put his knees on the threshold., let go of the door frame, and lowered himself to a position of stooping over the seat, CNA was providing hands on support but resident inserted himself awkwardly and was facing backwards in the vehicle (upper torso stooping on seat while in a kneeling position). On 6/28/21 at 9:36 AM, V1 (Administrator) said R3 went to an appointment with V10 on 6/10/21 for a CT scan. V1 said after the appointment was done, when leaving the facility, R3 stood to get into the car and put his knee on the floor of the car, facing the seat. V1 said V10 reported instructing the resident to exit and then assisted him into the car. V1 said V10 didn't use a gait belt for the transfer just held his belt loop on his pants. V1 said V10 should have used a gait belt and V10 was in-serviced. V1 said V10 is currently hospitalized and unavailable to speak with surveyor. On 6/28/21 at 9:25 AM, V6 (Restorative Nurse) said when transferring a resident you need to use a gait belt to have control in case a resident slides, you have the extra support to help hold them. V6 said R3 is alert and oriented and transfers with one assist. V6 said R3 can stand and pivot but has good days and bad days. V6 said R3 can be very weak at times. V6 said R3 went to an appointment with V10 and couldn't get into car, R3 was unable to get his feet on the step and slid on his knee. V6 said staff are supposed to use a gait belt with R3. R3's Physician Progress Note dated 6/10/21 shows R3 was seen and assessed and resting comfortably. R3 is scheduled for an abdominal and pelvis CT later this same day. R3's Nurses Note dated 6/13/21 at 5:20 AM shows R3 was yelling out that he was having severe pain in his lower back he told this writer that he has been in pain for 3 days called Dr to get orders to send out resident continues to yell out in pain. R3's Nurses Note dated 6/13/21 at 1:40 PM shows called hospital to follow up on resident and was told that resident was admitted , is in Intensive Care Unit for left rib fracture. R3's CT scan dated 6/14/21 shows acute left ninth rib fracture. R3's CT scan dated 6/10/21 (prior to the incident during transfer) does not show R3 having a rib fracture. On 6/28/21 at 12:23 PM, V7 (R3's Medical Doctor) said he has not seen R3 since R3 returned to the facility, but yes R3 did sustain a left rib fracture. R3's Nurses Notes shows R3 returned to the facility on [DATE] and has been using an abdominal binder and medication for pain management of the rib fracture. R3's Restorative Admission/Quarterly Evaluation dated 4/7/21 shows R3 requires extensive assistance of one person for transfers, and is not steady, only able to stabilize with staff assistance when moving from seated to standing position. The same form shows Resident is on [CONDITION(S)] which highly impacts his ability to do activities of daily living. Resident requires extensive assistance and constant cueing. On 6/28/21 at 9:23 AM, V5 (CNA) stated you should always use a gait belt when transferring a resident in case they slip. R3's Care Plan dated 6/27/18 shows transfer skills impaired limited mobility, generalized weakness, impaired balance . secure gait belt with all transfers. The facility's Resident Handling Policy Limited-Lift dated 11/16/18 shows Gait belt usage is required for all residents requiring weight-bearing assistance.

Based on observation, interview and record review the facility failed to provide a safe environment for a resident which resulted in an unwitnessed traumatic finger amputation of a resident (R1). This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. The findings include: R1's Progress Note dated (MONTH) 17, 2019 at 6:41 AM showed, At approximately 0330 after CNA (Certified Nursing Assistant) finished care on pt (patient) and was caring for pts roommate pt began banging on bedside table with bed controller, CNA went over to pt .when CNA noticed pts finger tip laying on her shirt on her chest. RN (Registered Nurse) went to assess pt, noted right hand 4th finger without tip, pts finger fell off at interphalange joint . R1's Nurses Notes dated (MONTH) 17, 2019 showed R1 was sent to a local hospital for an evaluation where it was determined that they were unable to reattach the tip of R1's right hand, ring/fourth finger. R1 returned to the facility on (MONTH) 17, 2019. R1's right hand X-ray report dated (MONTH) 17, 2019, showed the findings of the X-ray as a traumatic amputation of the majority of the distal phalanx of the ring finger . R1's Incident Investigation Report dated (MONTH) 17, 2019, showed, The patient cause of this spontaneous detachment was likely related to (R1's) behavior of banging her call light . R1's Minimum Data Set, dated dated dated (MONTH) 18, 2019 showed R1 was rarely/never understood and was severely cognitively impaired. On (MONTH) 29, 2019 at 8:35 AM, R1 was seated in a wheelchair in her room, on supplemental oxygen via nasal cannula. R1's right hand, fourth finger was wrapped in a dressing. R1's speech was garbled and incomprehensible when responding to questions from staff and this IDPH surveyor. No bleeding, bruising, or wounds were noted to R1's hands or undressed fingers. R1 exhibited no behaviors of banging her hand or call light on the bedside table or wheelchair or behaviors of putting her hands in her mouth. At 12:39 PM, V11 Wound Nurse, removed the dressing on R1's right fourth finger. R1's right hand, fourth finger showed a healed stump at the distal interphalange joint. On (MONTH) 29, 2019 at 11:55 AM, V7 CNA stated, I was the CNA working with (R1) the night of the incident. I checked on (R1) around 1:00 AM, and did peri (perineal) care on her. There was nothing wrong at that time. She didn't have any bleeding or bruising to any of her fingers. I checked on (R1) again around 3:00 AM. She was picking her nose, she did that a lot. She had dried blood below her nose, on her cheeks and hands. I got a wash cloth and cleaned her up . I finished wiping her up and then did peri care again and got (R1) into a clean shirt. (R1) was lying on her back in bed the entire time. I covered her with the sheet, with her hands lying on the sheet, and turned off the light above (R1's) bed. I went into the bathroom to wash my hands and heard (R1) banging the remote bed controller against the bed rail. I walked over to ask (R1) what was wrong and noticed 3 spots of blood on her shirt. I turned on the light about her bed and that's when I saw the tip of (R1's) finger lying on her shirt, over her stomach area .I have no idea what happened to her finger . V7 stated she provided cares alone to R1 during her shift on (MONTH) 17, 2019. On (MONTH) 29, 2019 at 10:40 AM, V4 RN stated, On (MONTH) 17, 2019 at 12:30 AM, I was in (R1's) room. I glanced over at (R1), she was sleeping on her back. I didn't notice anything on (R1's) bed or anything out of the ordinary .At 3:30 AM, (V7 CNA) came to me and told me (R1's) finger tip fell off. I went into (R1's) room and found the finger tip lying on her shirt .I have no idea how it happened . Yes, (V7/CNA) was providing cares to (R1) alone. I was not in the room during her cares . On (MONTH) 29, 2019 at 9:55 AM, V6 Activity Assistant stated, I gave (R1) a manicure on (MONTH) 16, 2019. I took the old nail polish off, filed her nails. There was no bleeding, bruising, or anything abnormal with her fingers . On (MONTH) 29, 2019, V1 Administrator, V4 RN, V8 CNA, and V9 Licensed Practical Nurse (LPN) each stated R1's right hand, fourth finger had no wounds, issues with recurrent bleeding, or bruising prior to the incident on (MONTH) 17, 2019. On (MONTH) 29, 2019 at 1:25 PM, V1 Administrator stated, I honestly think (R1's) finger amputation was due to her repetitive banging of her call light or bed remote against her bed along with her new [DIAGNOSES REDACTED]. On (MONTH) 30, 2019 at 2:52 PM, V13 Orthopedic Physician stated, There is no such thing as a spontaneous amputation .(R1's) injury was a traumatic amputation of that finger. Whether she got it caught in something, I don't know, but something cut that finger off It was not related to her banging her hand on something and her recent [DIAGNOSES REDACTED].We usually see these types of injuries in patients that get their finger caught in a door, drawer, wheel, or edge of the bed.

Based on observation, interview and record review the facility failed to safely turn a resident in bed. This failure resulted in R1 being rolled out of bed, falling and sustaining a cervical neck fracture on October 21, 2017. This resulted in R1 requiring complete bed rest, and R1 feeling sad and socially isolated. This applies to 1 of 3 residents (R1) reviewed for safety in a sample of 3. The findings include: The Physicians progress note dated September 1, 2017 shows R1 has [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set Assessment) shows R1 requires extensive assist with bed mobility and has impairment to upper and lower extremities on both sides. On November 2, 2017 at 10:00 AM, R1 was lying in bed on his back with a neck brace in place. R1's TV was on to a Spanish speaking channel. The walls next to R1's bed were beige and bare with areas of damage to the wall. The curtains were pulled between the beds in the room and the curtain at the door was partially pulled blocking R1's view out of the room. On November 2, 2017 at 10:00 AM, R1 said he remembers falling from the bed 10/21/17 while his linens were being changed. R1 said one CNA (Certified Nursing Assistant) was rolling him side to side to change his bed sheets that were wet. R1 stated, She rolled me away from her to lay down fresh sheets then she turned me towards her kind of fast and I rolled right out of bed landing on my head. R1 said he has to be on bedrest and wear a neck brace for 3 months now since his neck was broken. R1 states the neck brace is tight and rubs his neck, very uncomfortable. R1 said he feels like he has no one to help him. R1 began to cry and said, I can't get out of bed now, I can't go outside or go to activities. I feel so sad. R1 said he loved to go play bingo, go to exercise, attend church, and he loved to sit outside. On November 2, 2017 at 9:45 AM, E4 CNA said she was rolling R1 side to side to change his bed linens on 10/21/17. E4 said she was working alone, rolling him side to side. E4 said she rolled R1 towards the wall to put clean linen under him, then rolled him towards her, reached over him to pull out the dirty linen and R1 began to fall head first out of the bed. E4 said she tried to grab his legs to prevent him from falling but it happened so fast. On November 2, 2017 at 10:53 AM, E5 LPN (Licensed Practical Nurse) said R1 had severely limited mobility that even moving his arm to put on the call light was a chore. E5 said he heard a commotion on the night R1 fell out of bed 10/21/17. E5 went to residents room and saw R1 lying on his right side on the floor next to his bed. E5 said he positioned R1 on his back and R1 began to complain of pain to his head, shoulder, and hip. On November 2, 2017 at 11:50 AM, E7 LPN (Licensed Practical Nurse) said she thought R1 should be a two person assist while in bed to change his linens. E7 said R1 could not assist with turning because his arms were contracted across his chest. E7 said it was not safe to do it by themselves. E7 said restorative staffs are responsible for determining how many staff provide assistance to a resident. On November 2, 2017at 11:55AM, E8, E9 and E10 (CNA's-Certified Nursing Assistants) all agreed R1 was not able to help at all with positioning in bed due to his limited mobility. On November 2, 2017 at 1:15 PM, E6 restorative CNA said, R1 couldn't help the staff, and could not hold onto the bedrails. The director of restorative would ask for input when completing quarterly assessments to determine the number of staff needed for all care. E6 said R1 has the same physical functions since the fall but mentally it's been difficult for R1. E6 said R1 was very active with activities and now he is bed bound due to the type of injury he has after the fall. On November 2, 2017 at 3:53 AM, E3 activity director said R1 loved to come to activities. E3 said R1 loved bingo, movies, exercise programs, religious events, any social activity and loved to sit outside. Since his fall he has to remain in bed. On November 2, 2017 at 12:45 PM, E2 DON (Director of Nurses) said the restorative director determines how many staff is needed for all cares. E2 said this information is added to the MDS, kardex and care plan for the staff to see. E2 said the restorative director quit and now all the care plans and kardex's the staff use need to be looked at to make sure the information is correct and up to date. E2 said with all of R1's physical problems and R1 not being able to help staff with his care, that it was not safe to roll R1 in his bed with just one staff present. The hospital records dated October 22, 2017, for R1 show a fracture to cervical spine (C2) secondary to trauma from fall from bed. The physician's orders [REDACTED]. The mental health provider progress note dated October 4, 2017 shows R1 (prior to the fall) has a history of depressive disorder and anxiety. The note goes on to show the resident is seen by staff to be sitting outside, pleasant, and talkative with other residents. The patient is seen participating in group activities and he denies any anxiety or depression. The Restorative Quarterly Evaluation dated September 29, 2017 for R1 shows severe loss for head and trunk range of motion, ability to restore or maintain normal alignment. The evaluation also shows extensive assistance of two people is needed for bed mobility. The fall care plan dated December 9, 2013 shows R1 to be at risk for falls related to decrease sensation, decreased ability to maintain good posture, dependent on staff for transfers, cognitive loss, poor safety awareness, and decreased ability to determine the edges of the bed. The ADL (Activity of Daily Living) care plan dated December 9, 2013 and revised on April 7, 2016 shows R1 to be dependent on staff for all aspects of dressing, bathing, personal hygiene, transfers, toileting, and bed mobility. This care plan shows R1 to have impaired balance related to inability to use extremities due to extreme weakness, pain, neuropathy of lower and upper extremities. The care plan dated January 9, 2017 shows R1 has a history of depression. The interventions include: provide the resident with a program of activities that is meaningful and of interest. The facilities activity log shows R1 attended an activity 29 out of 30 days in September 2017 and 17 out of 21 days in October 2017 (up to the day of his accident). The activities included bingo, movies, trivia, sitting outside, exercise, music, and mass/rosary. The facility policy with a revision date of March 2009 for falls shows the purpose is to minimize the residents' potential for injury be early assessment and interventions. Residents are to be reassessed no less than quarterly. The restorative nurse will be responsible for completing all quarterly or significant change reassessments. The facility's bed making procedure with a revision date of October 2013 shows: 4. when making an occupied bed to raise the bed to the appropriate work level and put one side rail up. 8.Turn the resident to the side with side rail up. 12. Raise the side rail on the side you were working and go to the opposite side of the bed. 13. Lower the side rail and roll the resident over the linens toward the other side rail.

Based on Observation, Interview and Record Review the facility failed to ensure safety was provided for a resident during a transfer. This failure resulted in R1 sustaining a fracture to her left leg during a transfer. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: On October 17, 2017 at 1:46PM R1 was sitting outside in her wheelchair with a purple cast to her left lower extremity. R1 stated, E7 (Certified Nursing Assistant - CNA) went to get E8 (Rehab CNA) for help to get me up. E8 was in a hurry and E7 wasn't near me. I was sitting on the side of the bed and E8 tried to pick me up. I told her E7 isn't even ready, she is on the other side of my wheelchair not paying attention. E8 tried to pick me up and I sat back down. They didn't put a gait belt on. E7 and E8 tried to stand me up and E7 did not have me all the way and I went down. Both of my legs bent under me on the floor. I had my sandals on my feet. They didn't have a hold of me. If they had not been in a hurry this would not have happened. They didn't stand me like they normally do. After I was on the floor, E9 (CNA) came in with a gait belt and told them to put it on me and they were going to try and stand me. I showed them my leg, it looked like a Z; I told them it was broke and they needed to use the mechanical lift device. The Radiology Report dated September 8, 2017 for R1 showed, Ankle anterior/posterior and lateral 2 view, left (xray). There is a fracture of the distal tibia and fibula posteriorly seen on the lateral view. There is soft tissue swelling. The hospital Discharge Instructions dated September 8, 2017 for R1 showed, Sprain of right knee; closed non displaced transverse fracture of the medial malleolus of the left tibia and closed nondisplaced transverse fracture of the lateral malleolus of the left fibula. On October 17, 2017 at 1:10PM, E7 stated R1 is a 2 person transfer and that they (E7 & E8) were transferring R1 from her bed to her wheelchair and her legs started to shake so they slid R1 to the floor. E7 stated they forgot to put the gait belt on R1 for the transfer. On October 17, 2017 at 1:29PM, E8 stated, I was involved in the transfer. I was in the middle of taking splints off of other residents and E7 asked me if I could transfer R1. I said okay and that I would be right back. We had R1 in restorative; R1 had been standing. Her husband wanted us to work with her. R1 couldn't pivot. R1 couldn't take steps. We did not put on a gait belt. R1 was in bed and she has a weak torso so you have to help her sit up. We usually go under her arms, grab the gait belt, count to three and stand up. E8 stated gait belts are used to help residents move one place to another safely. The facility's Incident Report Form dated September 8, 2017 for R1 showed, Resident is alert and oriented x 3 (person, time & place). R1 requires assist with all of her activities of daily living. R1 is able to bear weight. R1was being assisted by a restorative CNA and a staff using a gait belt, transferring from bed to wheelchair as per her plan of care.In the process, resident knees buckled up and she was unable to bear weight and staff lowered R1 to the floor. Assessment done by the nurse; R1 complained of pain to her lower extremities. The physician ordered an xray of both lower extremities and revealed a fracture of the left distal tibia. On October 17, 2017 at 3:32PM, E2 (Director of Nursing - DON) stated, When I first talked to them they said they used a gait belt. After doing some investigation I called E8 back and asked her to tell me the truth and she said they did not use a gait belt. I had already sent the report to state. E2 stated they should have used the gait belt. The facility's Gait Belts policy (10/03) showed, Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. To transfer the resident, assist to standing position by holding belt at waist and pivot resident to the chair. The Minimum Data Set (MDS) dated [DATE] for R1 showed a brief interview of mental status score of 15, cognitively intact; Extensive assistance of 2 ormore people for transfers. The Order Review Report dated October 17, 2017 for R1 showed [DIAGNOSES REDACTED].

Based on Observation, Interview and Record Review the facility failed to ensure safety was provided for residents during care and transfers. This failure resulted in R1 sustaining a left humerus fracture during care and transfer after a shower. This applies to 2 of 3 residents (R1 & R3) reviewed for safety in the sample of 3. The findings include: 1. On May 31, 2017 at 9:15AM, R1 stated, She put me in a shower chair and rolled me into the shower. She did the shower and rolled me out of the shower. There was a railing I was holding onto while I was standing so she could dry me off. My legs gave out and I don't know why and I went into this falling position. I was scared and kept holding on. She told me she had me and to let go. I felt a snap in my left arm and went to the ground. Six firemen had to pick me up. She didn't have a belt around me and I was scared of falling so I held on. R1 stated he is unable to walk in therapy and can only stand for 30 seconds. R1 states it takes 3-4 people to transfer him and one of the people is from therapy. On May 31, 2017 at 9:34AM, E4 (Certified Nursing Assistant - CNA) stated, E5 (CNA) gave R1 a shower and I went in to help stand R1 and transfer him from the shower chair to the wheelchair. R1 was standing, facing the wall and holding onto the bar. E5 was on his left side and I was on his right side. There wasn't a gait belt.There was a shower chair behind him, he stood up and his legs gave out. R1 was leaning to the left with all his weight to the left. The snap happened or sound happened in the midst of everything. R1 was already down and I had to tell him to let go. R1 is fairly new, I believe 2 people to transfer. All transfers when they are assists we are to use a gait belt. On May 31, 2017at 9:45AM, E5 stated, I gave R1 a shower. I dried R1 off while he was standing in front of a grab bar. R1's legs buckled. I tried to push a chair up under him but he said his legs won't move. E4 and I had to guide R1 down. R1 was holding onto the grab bar. I told him to let go and he didn't. I heard a noise and told him to let go. We tried to get him to go back but he was sliding to the left. R1 didn't have anything on. I should have used a gait belt. On May 31, 2017 at 11:40AM, E2 (Director of Nursing - DON) stated, I did an investigation and they did not use a gait belt. I told them they should use it and that it was policy. R1 was admitted to the facility on [DATE] and the Nurses Notes for R1 showed, May 21, 2017 - R1 was found on the floor next to the bed and stated he tried to get up from the wheelchair and lost his balance, no injuries noted. Mechanical lifted to the bed and body check done; May 22, 2017 - R1 was in the shower with staff and he tried to get up out of the shower chair and lost his balance. Staff grabbed him and lowered him to the floor due to the fact that he was very heavy. R1 complained of arm pain and his left arm made a snapping noise when he went down. R1 was assessed on the floor and was very anxious. 911 was called. The Care Plan dated May 22, 2017 for R1 showed, R1 has an ADL (activities of daily living) performance deficit related to activity intolerance and impaired balance; Resident requires extensive assistance of 1-2 staff to move between surfaces; The resident is at risk for falls related to deconditioning, gait/balance problems. The fall care plan does not show that R1 had a fall on May 21, 2017 and shows R1 had a fall on May 22, 2017 only. There was no evaluation of possible causes of the fall on May 21, 2017 or interventions for that fall on the care plan. The Kardex for R1 that showed an admitted [DATE] and a print date of May 31, 2017 showed a section for accidents - fall risks with nothing written inside the box to show he had a fall on May 21 and 22, 2017; the assistive devices to be used were not marked. The Kardex for R1 did show he is Not steady during transitions/walking when moving from seated to standing; walking; moving on and off toilet; and surface to surface transfer. On May 31, 2017 at 10:14AM, E6 (CNA) stated, R1 is not as steady as he should be. I always have my gait belt. I get a coworker or therapy for transfers. I use a gait belt for transfers and ask the resident what their limitations are and what they can do. I explain what I am going to do. There is a Kardex in the room and I can look for that information. The electronic medical record on May 31, 2017 showed [DIAGNOSES REDACTED]. The Physical Therapy Plan of Care for R1 dated May 13, 2017 showed his standing balance was able to be maintained for less than 1 minute with a goal to reach 15 minutes. On May 31, 2017 at 11:56AM, E3 (Director of Rehabilitation) stated, R1 transfers with minimum to moderate assist for us (therapy) theirs (nursing) is an extensive assist of 2 people. Physical therapy assessments are different than the minimum data set. We always told the staff to use gait belts with R1; we have x-large gait belts. R1 is now a max of 2 for transfers and possibly a mechanical lift. E3 stated staff is to use a gait belt for all transfers and are advised to use a gait belt. The Minimum Data Set, dated dated dated [DATE] for R1 showed extensive, 2 plus person physical assistance is needed for transfers and bed mobility; ambulation in R1's room did not occur. The facility's Gait Belt policy (October 2003) showed, Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. 2. On May 31, 2017 at 1:11PM, R3 was in a reclining padded wheelchair. E7 (CNA) and E8 (CNA) put a gait belt around R3's waist. They put there arms behind R3 and under her legs and lifted her from the wheelchair to her bed. E8 stated, We transfer her like this because the mechanical lift scares her and she screams. We are able to lift her to bed. On May 31, 2017 at 3:14PM, E2 (Director of Nursing - DON) stated, I don't think R3 stands. I think her source of transfers should be a mechanical lift. E2 stated that lifting R3 was not safe. The Minimum Data Set for R1 dated April 24, 2017 showed total dependence on staff for transfers. The Care Plan dated May 31, 2017 for R3 showed, Resident will be transferred at all times using a mechanical lift. R1 does not bear weight.

Based on observation, interview, and record review the facility failed to ensure a resident was positioned properly to prevent pressure to his hand and hip, the facility failed to implement pressure relieving interventions to prevent a decline in a pressure ulcer, the facility failed to identify a stage II pressure ulcer, and the facility failed to ensure an open skin concern was reported to the nurse. These failures resulted in R1 sustaining purple/blue discolored blisters to his right hand, a stage 3 pressure wound to the right hand, an unstageable deep tissue injury of the right hip, an unstageable pressure wound to the right sacrum, and an unstageable pressure wound to the right elbow. This applies to 3 of 11 residents (R1, R6, R16) reviewed for pressure ulcers in the sample 19. The findings include: 1. The Minimum Data Set (MDS) of April 11, 2016 shows R1 is totally dependent on staff for positioning, transfers, dressing, toileting, hygiene, and bathing. The MDS shows R1 is always incontinent of urine and stool, uses a gastric feeding tube for nutrition, and has a [MEDICAL CONDITION]. The MDS shows R1 does not have any skin concerns, or pressure ulcers. R1's May, 2016 Physician order [REDACTED]. On May 18, 2016 at 10:30 AM, R1 was in bed, positioned on his left side, with his right hand elevated on a pillow. R1's right hand had a large fluid filled, purple/blue discolored blister to his first finger, and two irregular, circular discolored black/blue/purple areas on the palm and lateral side of his right hand. R1 had a yellow, fluid filled blister to the top, side of his right hand, and blisters to his pinky finger, and the hand was reddened, swollen, and had [MEDICAL CONDITION] present when the nurse pushed on it. R1 had a large purple discolored fluid filled blister to his right hip with reddened edges. At 11:00 AM, E4 RN (Registered Nurse) and E5 (Wound Care Nurse) repositioned R1 onto his side, and R1 had a circular open area to his right elbow that the surveyor pointed out to E5. E5 said she was not aware the wound was there and it must be new. E5 said she thought it was an abrasion and said I think it's shearing. E5 removed R1's [MEDICATION NAME] dressing to the right side of his coccyx and R1 had an irregular shaped wound with slough (dead tissue) present, and an irregular depth throughout the wound bed. E5 said the wound was a skin tear or abrasion, and the wound looked different from Monday when she last assessed it, and the wound now had some slough in the wound bed. On May 20, 2016 at 2:00 PM, E9 removed a saturated incontinence brief from R1. E9 rolled R1 on his side, and R1's [MEDICATION NAME] to his coccyx was rolled up and coming off, exposing the wound to urine. R1 had an open area over his coccyx with slough present. R1's May 16, 2016 Nurse Note shows Called to room by CNA (certified nurse assistant) due to blistering of fingers on right hand .Observed reddish area to base of right index finger at distal joint. Area appears to be misshapen in appearance with some difficulty on range of motion . The May 16, 2016 incident report for R1 shows observed skin to entire right palm and fingers both top and bottom surfaces to be macerated from pressure/moisture. Observed small linear black areas, almost with scab formation texture to inner surface of 1st and digit . R1's Skin/wound notes dated May 17, 2016 shows patient assessed on May 16, 2016 with the following findings. Patient has numerous blisters to right hand and fingers. Pinky finger has blister measuring 2.5 cm x 1.2 cm on the medial side, blister measuring 4.0 cm x 1.2 cm on the lateral side, blister measuring 1.0 cm x 0.8 cm on the top, and blister measuring 4.5 cm x 2.0 cm on the underside. Patient has blister on the lateral side of the right hand measuring 2.4 cm x 1.5 cm. Patient has blister on index finger measuring 3.0 cm x 1.3 cm Treatment order in place and carried out will monitor and continue with treatment until resolved. R1's May 16, 2016 wound documentation shows an abrasion to Coccyx measuring 2.5 cm x 2.3 cm x less than 0.1 cm depth, with 100% granulation, and wound improving as evidenced by decreased size (on May 18, 2016 there was slough present to the wound bed). R1's May 18, 2016 wound documentation shows Stage II to right elbow, 1.5 cm x 1.0 cm x 0.1 cm with 10% slough, and during wound dressing changes today, right elbow noted to have open area. The wound care physician's assessment dated [DATE] shows R1 has a stage III pressure wound to the right dorsal hand (top of hand) measuring 3 x 1.0 cm x 0.1 cm, and an unstageable deep tissue pressure injury of the right hip measuring 1.8 cm x 4.5 cm. The May 23, 2016 wound care physician assessment shows the skin tear wound to R1's sacrum declined to an unstageable (due to necrosis - dead tissue) of the right sacrum with 75% necrotic tissue present. The same assessment shows the stage II pressure ulcer to R1's right elbow declined to an unstageable pressure wound (due to necrosis) with 75% necrotic tissue. R1's At risk for impaired skin integrity care plan initiated on June, 19, 2015 shows interventions to include: assess the skin daily, paying attention to bony prominence's, and Avoid undue exposure to moisture due to incontinence or perspiration. On May 18, 2016 at 10:40 AM, E8 (CNA) said there were 2 times this week, (Monday and Wednesday) morning that she found R1 soaking wet and wet from head to toe and she could tell he had no rounds done on the night shift. E8 said she found R1 on Monday morning with blisters to his elbow, right hip, and hand and she reported it to the nurse. E8 said R1 was laying in urine for hours, and the urine was strong, and was on his skin. E8 said R1 already had a spot on his bottom prior to the blisters forming, and is supposed to be turned and given incontinence care every 2 hours. On May 18, 2016 at On May 18, 2016 at 1:55 PM, E8 said when she went into R1's room on Monday morning, R1 was laying on his side facing the window, with his right hand tucked under his hip, and his weight on his right arm and hip. E8 said R1 was really soaked and his right hand was wrinkly from being wet under him. E8 said R1's hand looked like when you go into the pool and your hand gets wrinkly, that's what it looked like, and it was white like it had no circulation. E8 said she was crying when she saw R1, that is was unacceptable how he looked, and it looked like he had not been changed or turned at all during the night. On May 18, 2016 at 11:35 AM, E6 (RN) said the CNA (E8) told her at approximately 7:20 AM, she wanted her to look at (R1). E6 said R1's hand definitely had blisters on his right hand. E6 said R1's knuckle on his index finger was discolored, and he had a blister on his pinky. E6 said R1's skin on his hand was whitish and wrinkly on the palm, fingers, and hand. E6 said the CNA reported to her that R1 was laying on his hand when the CNA found him. E6 said R1's hand was not swollen prior to this, and she felt the moisture led to the wrinkly skin, and pressure caused the blisters. On May 18, 2016 at 2:45 PM, E11 said he has worked night shift in which he is the only CNA for the 100 and 200 wing (approximately 55 residents- R1 resides on the 200 wing) and is the only CNA for the 100 wing on PM shift this evening. E11 said it is very difficult to complete rounds which included repositioning and toileting/incontinence care every two hours when there is only one aide. E11 said it often is more like 2.5 hours in between turning and repositioning. On May 19, 2016 at 5:55 AM, E11 said on night shift when he is the only one working he usually does 2.5 to 3 (instead of 4) really good rounds with incontinence care and repositioning but cannot round and reposition every 2 hours. On May 19, 2016 at 9:30 AM, Z3 (Nurse Practitioner) said she was informed of the injury to R1's hand on Monday, Z3 looked at the wound to R1's bottom and said she was told it started as a skin tear, and now there was slough present in the wound, which would be a decline in the wound. Z3 said the decline in R1's coccyx wound was from pressure over the pressure point of his coccyx, and the weight of his body. Z3 said the blisters to R1's right hand and right hip were caused from the pressure from the hand and hip touching. Z3 said R1 should be able to heal, has not had a lot of skin issues, has proper nutrition, has good capillary refill, and does not have any vascular issues that she is aware of. On May 19, 2016 at 10:20 AM, Z1 (Primary Care Physician) said the blisters to R1's hand and hip are avoidable, and caused from pressure from the way R1 was positioned. Z1 said R1 has had a decline in the wound to his coccyx with the presence of slough, and the decline is due to pressure over the coccyx. On May 19, 2016 at 11:40 AM, E5 (wound care nurse) said she has not had any formal training in wound care. On May 19, 2016 at 1:10 PM, E9 (CNA) said she worked Sunday night (May 15, 2016) to Monday morning. E9 said she was the only CNA for the 200 hall, and she left early, around 3:00 AM, because she worked the PM that evening, too. E9 said she was not positive when R1 was last changed/repositioned, but she did her last set of rounds around 2:00 AM, and she did not know of any skin concerns on R1 at that time. E9 said it is not realistic to toilet and provide incontinence care and reposition the residents every 2 hours on the evening shift when she is the only CNA on the hall, and she is scheduled as the only CNA on the 200 hall at least 3 times per week. On May 23, 2016 at 2:00 PM, E5 said R1 should be repositioned, and checked for incontinence at least every 2 hours. E5 said a resident's skin should be monitored, cleaned, and barrier cream applied with every incontinent episode, especially if they are high risk for breakdown. 2. R6's MDS of March 30, 2016 shows R6 is totally dependent on staff for repositioning, and transfers, and requires extensive assistance with dressing, eating, hygiene, and bathing. The MDS shows R6 is always incontinent of bowel and bladder. R6's wound assessment dated [DATE] shows a full thickness wound to the coccyx as Moisture Associated Skin Damage, 1.9 cm x 0.5 cm x 0.2 cm, small slit like wound to gluteal fold at coccyx level . On May 19, 2016 at 5:25 AM, R6 was in bed on her back with her heels resting on the mattress. E11 (CNA) rolled R6 to her side, and her incontinence pad was saturated with urine. R6 had a [MEDICATION NAME] dressing on her coccyx, and had long thin open area to her right gluteal fold. E11 said the open area was new and I have to report it. After removing the soiled linen, and without providing incontinence care, or applying barrier cream, E11 placed R6 onto her left side, with her heels resting on the bed. On May 19, 2016 at 2:30 PM, R6 was in bed, and had a small open area, with depth to her upper coccyx. E4 and E5 said the area started as a crack but is now a pressure sore (has more depth). E4 said it started because when the CNAs clean her, they hold her over and her skin cracks from pulling on the skin. At 3:00 PM, this surveyor pointed out the open area to R6's right gluteal fold. E4 said the area was approximately 1.5 inches in length, and the CNA should have reported the open area to the nurse, and the nurse would report it to the wound care nurse. E5 said she did not know about R6's wound, and nothing was reported to her that day. E4 said the wound is from R6 being wet, and staff pushing R6 over to her side with moist skin, causing the fragile tissue to split. At 3:10 PM, E12 (LPN) said she was R6's nurse for the day shift, and no new wounds were reported for R6. E12 said the CNA should report any new open area to the nursing staff. R6's At risk for impaired skin integrity care plan initiated March, 26, 2014 shows Assess the skin daily, paying attention to bony prominences, avoid undue exposure to moisture due to incontinence or perspiration .Barrier cream to skin after each incontinence episode .Cleanse skin with a mild cleansing agent after soiling .Reposition frequently to prevent skin breakdown. 3. The MDS of May 10, 2016 shows R16 is cognitively intact, and requires extensive assistance from 2 staff with bed mobility, transfers, and is totally dependent on staff with toileting. On May 19, 2016 at 2:30 PM, R16 was in bed, on his back. R16 said he was admitted to the facility because he needed treatment for [REDACTED]. R16 said the last time he had been repositioned was 9:30 PM the night before so he was in the same position from 9:30 PM to 5:00 AM, and he has a pressure ulcer to his left foot and right buttock. R16 said the nurse told him she was working all alone and it was hard for her to see everyone. R16 said the staff members are not good about turning and repositioning him, he only gets turned if he calls them and asks them to. R16 said he is a quadriplegic, and is in a lot of pain when he is waiting to be turned, and the bed gets all wet from sweat. On May 20, 2016 at 12:23 PM, R16 had a wedge at the foot of his bed, and said he is too tall for the bed, they ordered a longer bed for him over a month ago but he is still waiting for it to be delivered, and he has the wedge in place to prevent his feet from resting on the footboard. R16 said he has been in a lot of places with staff issues in which he has to wait for help, but never as bad as this facility. R16's wound assessment shows on April 18, 2016, R16 had an unstageable area to his coccyx with 10% [MEDICATION NAME] tissue and 90% granulation. The May 16, 2016 assessment shows a decline in the wound with a full thickness wound to his coccyx with 70% granulation, and 20% slough R16's April 18, 2016 wound assessment shows a partial thickness wound to R16's right thigh with 20% [MEDICATION NAME], and 80% granulation. The May 16, 2016 assessment shows a decline in the partial thickness wound with 60% granulation and 20% slough. R16's high risk for contractures care plan initiated March 14, 2016 shows provide turning and repositioning per schedule. R16's Impaired skin/tissue integrity care plan initiated March 18, 2016 shows avoid undue exposure to moisture due to incontinence or perspiration .reposition at least every 2 hours .use lifting device or bed linens to move resident . On May 24, 2016 at 10:05 AM, E5 said R3 is alert and oriented, and is compliant with repositioning. E5 said R3 can use his call light, to let staff know when he wants to be turned. E5 said R3 should be repositioned at a bare minimum of every 2 hours, and it would be nice if he was repositioned more often. E5 said she is not sure why R3's wounds are declining, and the coccyx wound is at a stand still, and is not betting better. The undated Facility Policy: Management of Wounds shows: A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s) . It is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction,and shearing forces. this will be accomplished through the use of appropriate positioning practices, positioning devices, and support surfaces. The facility October, 2003 Incontinence Care policy states: Incontinence care is provided to keep residents as dry, comfortable, and odor free as possible. It also helps in preventing skin breakdown. Incontinent residents are changed every two hours and more frequently if needed .apply barrier cream if appropriate .notify nurse of areas of red skin or breakdown so that the physician or nurse practitioner may be notified for further orders.

Based on observation, interview and record reveiw the facility failed to notify the physician of decreased oral intake, numerous episodes of emesis and montior and act on signs and symptoms of dehydration for two residents out of seven (R62 and R34) reviewed for dehydrations from a total sample of 14. As a result of this deficent practice, R62 and R34 requried hospitalization and treatment for [REDACTED]. Findings include: 1) According to the facilities profile information, R62 has been a resident at facility on and off for almost six years with most recent re-admission on 1/27/15. According to R62 ' s January 2015 Physician order [REDACTED]. According to hospital record, R62 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. According to R62 ' s medical document dated 1/22/15 titled Laboratory Report, the following abnormal labs were noted: Sodium 159 CH (Critical High) (Normal 131-145), Glucose= 136 H (High) (Normal 64-112), BUN-Blood Urea Nitrogen=41 H (Normal 5.0-28.0), Creatinin; Serum=1.4 H (Normal 0.6-1.2), BUN/Crea Ration=29.3 H (Normal 12-20), Calcium 11.2 H (Normal 8.4-10.2). According to R62 MAR (Medical Administration Record) for January 2015, R62 is to receive the diuretic [MEDICATION NAME] 80 milligrams by mouth two times a day. R62 ' s nurse ' s note dated 1/17/15, documents, " appetite continues to be poor. Emesis noted several times this week. None noted this shift. MD (doctor) aware and seen yesterday(1-16-15), no new orders noted. No appetite for lunch. Resident slept through meal and possibly due to new medication [MEDICATION NAME]. Will continue to monitor. " No additional nursing notes were noted in the medical record concerning R62's oral intake and episodes of vomitting. No nurse ' s notes or other documentation indicating that R62 was having any type of emesis or vomiting or that the doctor was notified of these multiple episodes of emesis. On 1/21/15 another nurses note states " Resident noted with emesis x1 during dinner. Was not able to eat dinner ". No additional documentation was noted concerning notification of the physician of emesis and or poor oral intake. Nurses note dated 1/22/15 states " Resident being admitted (to hospital) for dehydration, [MEDICAL CONDITIONS] and elevated troponin. " R62s meal intake record for January 1, 2015 to January 22, 2015 has resident with 3 episodes of refusing meals. Seven episodes where no meal intake was documented. Intake of 0-25% happened 38 times. Intake of 26-50% happened 8 times. Intake of 51-75% happened 6 times. Intake of 76-100% happened 3 times in this time frame. No documentation was found or provided by facility regarding snacks. No documentation was found making the doctor aware of poor meal intake until 1/21/15. Meal intake record from 1/12/15 to 1/21/15 has resident eating less than 25% or refusing meals for every meal except for 1 on 1/14/15 at the am in which she consumed 76-100% On 2/19/15 Z2(R62 ' s Primary Care Physician) stated he could not recall that he was ever made aware that R62 was not eating or drinking until the day before she entered the hospital (1/22/15). On 2/19/15 Z2 stated that if he had been made aware of the multiple episodes of emesis that was documented by the nurse on 1/17/15 sooner, when they actually occurred, the resident treatment plan could have been adjusted. Z2 also stated that R62 could have received intravenous fluids at the facility, fluids could have been encouraged sooner to attempt to increase R62 ' s oral intake. Z2 continued to state that a possible change in diuretic medication could have been made. Z2 stated that R62 ' s hospitalization on 1/22/15 and resulting dehydration and other [DIAGNOSES REDACTED]. On 2/19/15, Z2 stated that dehydration is a very serious condition and verified that R62's lab values were critical upon admission to the hospital. Z2 stated that nursing staff should be using good nursing judgment and notifying him as needed and if resident had been having emesis for over a week he should have been made aware of this a lot earlier and a hospitalization and dehydration could have been prevented. According to R62 ' s medical record on 1/13/15 she was referred to Z11 (psychiatrist) related to worsening memory and [MEDICAL CONDITION]. On 2/19/15 Z11 (psychiatrist) stated that worsening memory, [MEDICAL CONDITION] and lethargy could absolutely be indicators of dehydration. Z11 stated that nursing staff should be doing a better job of notifying the primary physician if he (primary physician) was not made aware of R62 not eating, drinking and having episodes of emesis/vomiting. On 2/18/15 E9 (Certified Nurse ' s Aide) stated that R62 had not been eating, refusing meals, and had increased periods of sleeping for over 2 weeks. E9 stated she had worked with this resident for extended period and was familiar with her habits and that she had always been a picky eater but appetite had definitely declined since before Christmas. E9 also stated R62 required assistance with eating. On 2/28/15 E10 RN (Registered Nurse) stated that she was familiar with R62 and resident had been gradually declining since the New Year and appetite had also decreased. E10 stated that if a resident was having emesis the nurse should send a fax or call him within twenty four hours to make him aware of problems or changes. On 2/28/15 E26 (Certified Nurse ' s Aide) stated that she was familiar with R62 and resident had been declining for a while, probably since the New Year and she had always been a picky eater but she would usually eat something but lately had been refusing and simply wouldn ' t open her mouth at time to be assisted with feeding. E26 also stated that R26 had begun being more lethargic and would fall asleep in her wheelchair and lean forward in the wheelchair E26 stated R62 require help with meals. According to R62 ' s Plan of Care with initiation date of 12/18/14 the resident has dehydration or potential fluid deficit related to diuretic use and the goal is the resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions include: Educate the resident/family/caregivers on importance of fluid intake; monitor/document/report PRN(as needed) for signs/symptoms of dehydration: decreased urine output, concentrated urine, strong odor, tenting skin, cracked lops, furrowed tongue, new onset confusion, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes; notify physician if: persistent symptoms of diarrhea, nausea/vomiting unresolved 48 hours; pristine output exceeding intake past 48 hours, abnormal labs. On 2/19/15 E1(administrator) was unable to provide any documentation how R62 was being monitored for signs/symptoms of dehydration since start of plan of care on 12/18/14 to 1/22/15 when R62 was admitted to hospital with [DIAGNOSES REDACTED]. On 2/18/15, E1 also could not find any documentation that E62 ' s fluid intake and output were being monitored until after her return from the hospital on [DATE]. 2. According to R34 ' s facility face sheet/information sheet, she is [AGE] years old with her initial admission to facility on 7/9/10 and most recent re-admission on 2/8/15. R34 ' s [DIAGNOSES REDACTED]. On 2/4/15 R34 ' s nurse ' s note has at 5:30pm resident was brought to nurse unresponsive. Resident was clammy and pale. Resident was not breathing and had no pulse. Was unresponsive to sternum rub. Put resident on 10 liters via non re-breather. Resident started to regain consciousness as paramedics arrived. Blood Sugar: 148. Vital signs: 128/68, 75, 97.9. Sent out 911. Director of nursing/Power of Attorney notified. According to R34 ' s Physicians Order Sheet for 1/2015 and 2/2015 under lab order section she is to have a complete blood count (CBC) and chemistry 6 every six month and is on diuretic [MEDICATION NAME] 20 milligrams daily. According to the documentation from the hospital with admission date of [DATE] for R34 from the hospital under History of present Illness: Under laboratory: " White blood count 12.0 H (High) (Normal 4.1-11.0), hemoglobin 23.2, (High) (normal 12.0-16.0), hematocrit 38.7(high) (normal 36-46), [MEDICATION NAME] 2.7. (Low) (Normal 3.5-4.8), which is significantly low. According to Hospital report dated 2/4/15 the admitting [DIAGNOSES REDACTED]. On 2/24/15 Z2 (primary care physician, stated he could not remember if staff had made him aware of multiple refusal of R34 ' s labs on 1/29/15. Z2 did state that if those labs (CBC, Chemistry 6, BUN/CREA, and electrolytes) would have been done per the order, that it could have shown abnormal values and would have been early indicators of possible problems with infection and dehydration. Z2 also stated that R34's hospitalization would not have been necessary because the problem could have been addressed sooner. Z2 also stated that the fact R34 was on a diuretic only made her more at risk for the resulting dehydration and the nursing staff need to be able to identify the signs and symptoms of dehydration. Z2 stated the labs were ordered in part due to the fact that the resident was on the diuretic [MEDICATION NAME] and one of the risks with the use of this medication is dehydration and the BUN/CREA and electrolytes are usually where you can first identify possible problems. According to R34 ' s identified current Care Plan there is an identified focus of " The resident has dehydration or potential fluid volume deficit related to poor intake, diuretic use with date of initiation as 12/19/14. Goal is " The resident will be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor. Interventions are: Monitor/document/report PRN(as needed) any signs/symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increase pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Notify physician if: Persistent symptom of diarrhea, nausea/vomiting unresolved past 48 hours: persistent output exceeds intake past 48 hours, abnormal labs. Obtain and monitor/diagnostic work as ordered. Report results to doctor and follow up as indicated. On 2/24/15 E1 (administrator) or E2 (Director of Nursing) were unable to provide documentation on how R34 was being monitored for signs and symptoms of dehydration. They were also unable to provide documentation of a hydration assessment on R34 until re- admission from hospital to the facility on [DATE]. On 2/24/15 E1 (administrator) stated that the nursing staff had not done a very good job charting on R34 ' s medical record. On 2/18/15 and 1/24/19 E1 (administrator) and E2 (Director of Nursing) were unable to provide how staff are monitoring identified persons at risk for dehydration per plan of care. On 2/18/15 E1 stated R62 or R34 had no documentation on Medication Administration Record [REDACTED]. According to facilities Hydration Policy with revision date of 10/2010 states under General: This policy allows for each resident to provide with sufficient fluid intake to maintain proper hydration and health. Under Policy: 1.) Nursing will routinely monitor each resident for signs of dehydration such as cracked lips, dry oral mucosa, poor skin turgor and dark urine. If present they will be recorded in the medial records and the physician or nurse practitioner notified. 2.) Nursing will routinely observe the residents ' consumption to determine if individual residents have reduced fluid intake. Pertinent observations will be recorded in the resident ' s medical record. The fluid intake record may be used for this purpose. According to the facilities Notification of change in Residents Health Status, states The facility will consult the residents physician, nurse practitioner or Medical Director and when indicated notify the residents legal representative or an interested family member when there is: (B) Acute illness or a significant change in the resident ' s physical, mental or psychosocial status (i.e. deterioration in health, mental, psychosocial status in either life-threatening condition or clinical complications). Criteria: Life threatening conditions such things as [MEDICAL CONDITION] or respiratory distress. Clinical complications are such things as developing of a stage 2 pressure ulcer, onset or recurrent periods of [MEDICAL CONDITION], urinary tract infection, a persistent decline in psychosocial status. Notification time: immediately. Definition of Immediate: As soon as possible no longer than 24 hours. Nursing judgment is an integral part of the skilled care provided in this facility; therefore, such judgment must be applied in a case by case basis in keeping with acceptable nursing practice According to the facility ' s policy titled: Documentation by Exception with revision 11/13 states under General: A resident is not generally documented on daily unless there is an unusual event or circumstance that requires frequent documentation. Under Policy: 2.) Documentation should include any unusual event or change of the resident. 3.) Any communication with the physician, nurse practitioner, consulting physician or family should also be documented. 4.) Medicare resident will be documented on daily either in narrative form or using the Daily Skilled Note on Pointclick Care. Other documentation is not required unless an unusual event occurs. 6.) New admission, change in condition, residents on antibiotics, and residents who have had an unusual occurrence should be documented on every

A. Based on observation, record review and interview the facility failed to ensure a safe resident environment by not implementing a heating system plan to assure the facility's ambient air temperatures were safe and acceptable to residents during extremely cold weather. This failure resulted in the facility using electric space heaters in resident rooms, common areas and hallways creating a hazard with electrical cords and heating unit surfaces. As a result an Immediate Jeopardy was identified. The Immediate Jeopardy began on 1/1/2015 at 3:40PM when inside ambient temperatures dropped below 71F in resident rooms and the facility started using electric space heater. On 1/8/15 at 3:15PM, E1 (Administrator) was informed of the Immediate Jeopardy. The immediacy was removed on 1/9/15 at 6PM, when all residents at risk for hypothermia were reassessed and the temperatures in resident rooms and common areas were sustained at 65 degrees Fahrenheit (F) or above. The facility remains out of compliance at a level two. Additional time is needed to monitor and ensure the system can maintain ambient temperatures at or above 71F and evaluate the effectiveness of revised policies and procedures. This affects all 88 residents in the facility. The findings include: The facility's Census and Condition form dated 1/6/15 showed the census was 88. On 1/5, 1/6 and 1/7/15 R11, R13, R20, R24, R26, R27, R29 and R34-R47 had small electric space heaters on the floor in their rooms, plugged into power strips or extension cords. Large electric heaters, mounted near the ceiling at the end of the 100, 200, 300 and 400 hallways, were plugged into wall outlets with an orange electrical extension cord that draped over and wrapped around water sprinkler piping in the hallways. The Life Safety Code #0700 documented, "Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where heating elements of such devices do not exceed 212 degrees Fahrenheit (100 degrees Celsius)." Unregulated use of space heaters cause fires. On 1/5/15 at 10am, R36 said, "There were heating issues and they put heaters in the hallway. The facility had to flush the system." On 1/5/15 at 10:15am, R12 said, "I have been here for 3 years and there have been problems on and off with the heat. It's drafty in here." On 1/6/15 at 1:10pm R12 said, "I was never offered a heater. I spoke to E6 (Environmental Services) and received no response." On 1/6/15 at 1:15pm E1 (Administrator) said the mounted electrical heaters at the end of the wings were added because the rooms at the end of the halls tend to be cooler. The space heaters were given to residents who wanted them. On 1/7/15 at 2:30pm, the facility removed the electric space heaters from the resident rooms and turned off the hallway mounted heaters. The facility's room temperature log sheet dated 1/7/15 documented hourly temperature monitoring from 7pm to 8am and showed 32 resident rooms affecting 61 residents had an ambient temperatures below 65 degrees F. On 1/7/15 at 3:10pm, E22 (Corporate) said space heaters were issued starting January 1st when requested by the residents. On 1/8/15 at 7:40am, R48 said, "I was cold all night." R46 said, "They were putting plastic on the windows. It was a godsend." On 1/8/15 at 11:50am, Z4 (Local heating/plumbing service coordinator) said, (the facility) was dragging its feet on getting a (heating/cooling) contract last year. "We told them make sure they got some space heaters to make it livable, but if they can't have space heaters that makes it so much worse." On 1/8/15 between the hours of 3:15pm and 4:05pm, surveyors monitored temperatures on all wings. At 3:10pm, all thermometers were calibrated in an ice bath accurate to 32 degrees F. The temperatures in all 10 resident rooms on the the 100 wing were between 60F-64F. R47 was wearing a winter hat and was covered with several blankets. R47 said, "We had a really nice space heater in here that kept us nice and cozy but they took it out." R48 was sniffling. R48 said, "It's freaking cold. A place like this should have heat for us. My nose is stopped up. Can you check the dialysis place. Monday and Wednesday it was really freaking cold. Colder than in here." R58 had a shawl wrapped around her shoulders and was dressed in a hospital gown. R58 said she had just gotten out of the shower. R58's room was drafty, there was frost formed on the inside of the air conditioning unit and there was no plastic on the window. R58 said, "I was not asked if I wanted plastic on my window." The temperature in the middle of R58's bed was 55F. R51 said, "I'm freezing. I've got 4 blankets. Oh, my God! I'm so cold!! I shouldn't have to have another blanket." The temperatures in 9 of the 14 resident rooms on the 200 wing ranged from 60F-64F. Rooms 203, 204, 206, 210 and 212 registered a temperature above 65F but less than 71F. R41 was covered with 2 blankets and the room was drafty. R41 said, "It's freezing!" R15 was ambulating in the wheelchair in the 200 hallway with arms folded across his chest. R15 stated, "I'm cold." R28 just came out of the shower and was requesting a jacket. R29 said, "I'm comfortable as long as I'm covered up." The room was drafty. R29 had 3 layers of blankets. R53 said, "At night its cold. I didn't get any extra blankets last night but they gave me one today." On the 300 hallway 7 rooms 304, 308, 310, 312, 316, 317 and 319 registered 66 degrees F. Rooms 309 and 311 were closed for construction. Three rooms 302, 305, 307 were above 66 degrees but below 71F. Six resident rooms on the 300 wing were 58F- 64F. R24 was in bed covered with 4 blankets and wearing a jacket with a hoodie and a winter coat. R24 said, "I used to have a heater in here. It was warm then." R53 said, "I wouldn't mind it being a little warmer." R55's room temperature registered at 62F. R55 said, "It was 64 last time they checked an hour ago." R56 said, "I got bronchitis the beginning of January." Three of the 4 rooms on the 400 wing had a temperature between 62F and 64F. Room 405 had a temperature of 66F. R39 was in bed covered with 2 blankets. R39 said, "I'm freezing." R27 said, "It's pretty cold in here. I have a cold from it." R1 said, "It's very cold in here, since they took our space heater away." A total of 28 resident rooms in the facility affecting 66 residents (75%) were below the ambient temperature of 65 degrees F. On 1/9/15 between the hours of 11:55am and 1:00pm, surveyors recorded temperatures on all resident wings. Resident rooms 208, 210, 212, 215, 312, 315, 318, 319 had ambient temperature that remained below 65 degrees F. By 3:00pm, rooms 215 and 319 remained below 65F. During this time the following observations/interviews were made: R33 said (per interpreter) "When they close the door it's cold. The heater in the hall doesn't work good. They closed the door yesterday and it was warmer. Two days ago, I couldn't sleep that's when they told me to talk to E1 about it. " R36 was sitting on the bed in her room. R36 was wearing a winter coat and said, " I'm cold. I didn't sleep well last night." R27 was wearing a winter coat and sitting in a chair in her room. R27 said, "I'm cold. I have a runny nose because its cold. I have 8 blankets on my bed and double socks on with my boots." R11 said, "It took a lot of blankets to stay warm. It could be warmer. Why can't we get another heater in the hall like the other part of the building?" R38 said, "This boiler thing should have been taken care of months ago not during the winter. It's gets warmer in here when the sun is shining." The National Weather Service issued severe weather alerts on 1/5, 1/6, 1/7 and 1/8/15 for wind chills 20 to 35 degrees below zero. The weather website Wunderground.com documented local temperatures on 1/7/15 as a high of 4.5F and a low of -6.8F, with wind gusts up to 25 mph (miles per hour). On 1/8/15 showed a high of 16.6F and a low of -9.9F, with wind gusts up to 28 mph. The temperatures on 1/9/15 were a high of 10.2F and a low of -1F with wind gusts up to 21 mph. The State Health Department Hypothermia and Frostbite News Release dated 1/3/14 documented, Hypothermia is a drop in body temperature to 95 degrees F or less can be fatal if not detected promptly and treated properly. The condition usually develops over a period of time, anywhere from a few days to several weeks. Even consistent, mildly cool indoor temperatures of 60 degrees F to 65 degrees F can trigger hypothermia. The facility's undated action plan to ensure safe and comfortable temperatures throughout the facility showed space heaters were issued when requested starting January 1, 2015. The (local plumbing/heating company) will be called to recheck boiler/furnace to ensure functioning at capacity. (no start time indicated) The status showed the facility was coordinating with local company for service. Mount ceiling space heaters at the end of each hall, installation started January 2, 2015. If resident room temperatures fall below an acceptable level move residents to a common area. Action plan showed that a start time was not indicated. Implement full evacuation plan if the facility is unable to maintain appropriate temperature levels. Action plan did not specify what "appropriate" temperature levels should be. On 1/9/15 at 6PM surveyors confirmed the facility took the following actions to remove the immedicacy of the situation: 1. All resident rooms and common areas will be temped hourly and temperatures will be recorded on the temperature log. 2. Residents residing in a room with a temperature below 65 degrees will be assessed for signs and symptoms of hypothermia and relocated to another room or common area. 3. The Therapy Room will be utilized to house the female residents overnight and the dining room to house the males. 4. Residents will be issued extra blankets and clothing. Hot beverages will be offered to enhance their comfort. Additional staff will be added to ensure resident needs are met. 5. Residents will be divided into a 3-tiered criteria to prioritize evacuation according to resident risk for hypothermia. 6. Transfer agreements were confirmed for bed availability with other facilities and plans for transportation was made with in the event that an evacuation is necessary. 7. Contact was made with the County Emergency Management Agency to obtain a temporary portable heater. 8. The gas pressure regulator valve was adjusted to increase the water flow to the boiler and maximize heating ability to the boiler. An hourly audit of the temperature gauge of the boiler will be done. 9. Received proposal for a new boiler. B. Based on Observation, Interview and Record Review the facility failed to supervise a confused resident to prevent multiple falls. This applies to 1 resident (R25) reviewed for falls in the supplemental sample. The findings include: On 1/6/15 at 3:45 PM, R25 was in the dining room unsupervised, R25 released her lap belt alarm, stood up and attempted to ambulate. The chair alarm did not sound. R25 fell and hit her head on the dividing wall. R25's Progress note dated 1/3/15, stated "Resident continues to try and ambulate without assist before dinner." R25's Transition care report from a local hospital dated 12/12/14, stated R25 was at a high risk activity precaution. Between 12/15 /14 - 1/6/15 R25 had 6 falls on the following dates: 12/15/14, 12/16/14, 12/17/14, 12/26/14, 12/31/14, 1/6/15. The care plan dated 12/15/14, showed no interventions or approaches were added after each fall. On 1/7/15 at 10:15AM, E12 (Licensed Practical Nurse) asked R25 to remove her lap belt alarm. R25 said she is not supposed to. E12 said that alarm device checks are done every shift. E12 believed the Certified Nursing Assistants check the alarms. "Let me find out if there is a log." On 1/7/15 at 10:20AM, E12 was unable to find documentation for the alarm checks for R25 since the alarm was placed on 12/26/14. The facility's Fall Program policy dated 9/17/14 states, "The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate suprvision is provided, and that assistive devices are utilized when necessary. "

Based on observation, interview and record review the facility failed to have a boiler working at full capacity to maintain safe and comfortable temperatures in resident areas. This failure resulted in an Immediate Jeopardy when the facility did not maintain the boiler in good working condition during severe cold weather. The Immediate Jeopardy began on 1/1/2015 at 3:40PM when inside ambient temperatures dropped below 71F in resident rooms and the facility started using electric space heater. On 1/8/15 at 3:15PM, E1 (Administrator) was informed of the immediacy related to temperatures below 65F in the building. The immediacy was removed on 1/9/15 at 6PM, when all resident areas had stabilized temperatures at 65 degrees Fahrenheit (F) or above. The facility remains out of compliance at a level two. Additional time is needed to monitor and maintain ambient temperatures at or above 71F and evaluate the effectiveness of revised policies and procedures. This affects all 88 residents in the facility. The findings include: The facility's Census and Condition form dated 1/6/15 showed the census was 88. On 1/7/15 at 3:10pm, E22 (Corporate) said space heaters were issued starting January 1st/2nd when the weather turned colder and residents began complaining of being cold in their rooms. The facility's room temperature sheet on 1/1/15 at 3:40pm showed 5 random resident rooms at 66 degrees F or less. The National Weather Service issued severe weather alerts on 1/5, 1/6, 1/7 and 1/8/15 for wind chills 20 to 35 degrees below zero. On 1/5, 1/6 and 1/7/15 the facility was using electric space heaters and ceiling mounted electric heaters in the hallway. On 1/7/15 at 2:30pm, facility removed the electric space heaters and turned off the hallway mounted heaters. On 1/6/15 at 1:00pm, E6 (Environmental Services) said the facility is working on the heat by getting a new boiler. The timeframe to get it installed would be 8 weeks. On 1/8/15 between the hours of 3:15pm and 4:05pm surveyors monitored temperatures on all wings. At 3:10pm, all thermometers were calibrated in an ice bath accurate to 32 degrees F. The surveyors checked temperatures room to room throughout the facility. The temperatures in all 10 resident rooms on the the 100 wing were between 60F-64F. The temperatures in 9 of the 14 resident rooms on the 200 wing ranged from 60F-64F. Rooms 203, 204, 206, 210 and 212 registered a temperature above 65F but less than 71F. On the 300 hallway 7 rooms 304, 308, 310, 312, 316, 317 and 319 registered 66 degrees F. Rooms 309 and 311 were closed for construction. Three rooms 302, 305, 307 were above 66 degrees but below 71F. Six resident rooms on the 300 wing were 58F- 64F. Three of the 4 rooms on the 400 wing had a temperature between 62F and 64F. Room 405 had a temperature of 66F. A total of 28 resident rooms in the facility affecting 66 residents (75%) were below the ambient temperature of 65 degrees F. The baseboard heating in the resident rooms felt barely warm to the touch. A minimal amount of warm air was coming from the base board. The top ledges of the baseboards under the windows were ice cold. An invoice dated 10/15/14 from a local plumbing and heating company documented that checks of the boiler were done only when called by the facility on 11/19/13, 9/12/14 and 9/22/14. No ongoing maintenance was done. The invoice showed: 9/12/14- "Boiler would not ignite. Found a bad sparker/flame rod. Remove and replace flame/sparker and install new, customer provided. Recommend boiler replacement over repairs due to age and condition. Had to silicone door in place." 9/22/14- "Return and install high/low limit aquastat. Cycle unit and test operation. Change pilot ignition controller with one from a bad boiler on site. Cycle unit and test operation. Okay at this time." On 1/8/15 at 11:50am, Z4 (Local heating/plumbing service coordinator) stated, "The boiler was "barely limping along". They said the boiler or preventative maintenance wasn't in their budget. We told them if they wait, they will have a problem. (The facility) was dragging its feet on getting a (service) contract last year. They wanted to sign a contract last week and asked if we could do it right now. No, we couldn't, the timeframe was 6-8 weeks to build/install the boiler. We were worried about the people (residents). We wished they would have replaced it last year and they wouldn't be in this sticky situation." The boiler was so old there were no parts available. We got it working with parts from the non-working boiler onsite. "We rigged it as much as we could." We told them to get some space heaters to make it livable, but if they can't have space heaters that makes it so much worse. They had trouble with the boiler 2 weeks ago. "We told them to call us the minute it went out. We put a rush on it (the boiler), but it's unpredictable when the boiler will be ready." On 1/9/15 at 1:28pm, E1 (Administrator) said the facility has a 2-step (valve) boiler. One of the valves was not opening. The boiler temperature was around 140F. The second valve was opened and we are hoping that the increased flow will raise the temperature to 180F. "I was told by the previous vendor it was working at 50% and there was nothing they could do. They told me in September 2014 it was not working correctly and needed to be replaced." On 1/9/15 at 1:35pm, Z8 (Service Rep from a different plumbing/heating company)said (the boiler) was not operating properly. The baseboard heat should be 165-170F. "I corrected the valve wiring and now it's 100% open which increased the flow. I changed it to a two stage. It was wired to only work in low." On 1/9/15 at 2:25pm, E6 said, (the local plumbing/heating company) changed the high limits switch and sealed the door with silicon. It was serviced at the end of September (2014). Z7 (Service Rep from the original plumbing/heating company) told me he had adjusted the boiler as high as he could. He was afraid to turn it up any more. He thought there would be a problem due to the age of the boiler. (The facility) has two boilers. This is the only boiler they have had working since I've been here (2 years). The boiler is a two switch system and we found out on (1/9/15) from (another heating company) that the switch had been turned off. I don't know who did it. I'm not blaming anyone. I do not do anything with the boiler. The (local plumbing/heating company) monitors our boiler heating system. The facility's undated Preventative Maintenance Program documented for the Fall check list: Check heating units, Call HVAC (Heating, Ventilation and Air Conditioning) if any concerns. The Winter check list showed: Monthly temperature check list, review cold weather policy and ensure that all windows close properly. The preventative maintenance program did not specify who is responsible. There were no guidelines given to identify problematic areas. On 1/9/15 at 6PM the surveyors confirmed the facility took the following actions to remove the immediacy of the situation: 1. All resident rooms and common areas will be temped hourly and temperatures will be recorded on the temperature log. 2. The local Director of Emergency Management Agency was onsite and coordinated efforts with the facility. The facility is coordinating other Heating contractors and other counties to obtain additional heat sources (temporary portable heater) in an effort to prevent a full evacuation. 3. The gas pressure regulator valve was adjusted to increase the water flow to the boiler and maximize heating ability to the boiler. An hourly audit of the temperature gauge of the boiler will be done. 4. Received proposal for a new boiler.

Based on observation, record review, and interview the facility failed to prevent a stage II pressure ulcer, and failed to monitor the wound for infection. These failures contributed to R3 developing a stage II pressure ulcer on 1/30/14 and deteriorating to an infected stage III ulcer. R3 was hospitalized on 2/4/14 for treatment for [REDACTED]. This applies to one of three residents (R3) reviewed for pressure ulcer in the sample of 19. The examples include: R3's March, 2014 physician's orders [REDACTED]. R3's Minimum Data Set (MDS) of 3/9/14 documents R3 has severe cognitive impairment. R3 requires extensive assistance of 2 or more persons for bed mobility, transfer, and toilet use. R3 is incontinent of bladder and bowel. R3's Braden Scale (Prediction for Pressure Ulcer development) dated 1/12/14 shows a score of 14. (Moderate Risk) The Wound Assessment Flow sheet shows on 1/30/14 R3 developed a stage II pressure ulcer of the Left Trochanter. The wound measured 2.1cm x 0.8 cm x 0.2 cm. It is described as 75 - 100 % granulation tissue. The same document shows that the edges were ill-defined, scant serous drainage and [DIAGNOSES REDACTED] surrounding the wound. The Nurse Practitioner progress note of 2/3/14 (4 days after onset of R3's pressure ulcer) documents R3's pressure ulcer is a stage III with [MEDICAL CONDITION] and [MEDICAL CONDITION]. Recommend transfer to the Emergency Department of immediate evaluation and treatment. The same note shows R3's wound was reported to have "gotten significantly worse over the week-end." R'3's Nursing Notes for 2/3/14 (3:37 PM) documents R3's wound to the left lateral thigh has worsened. It is deep red/purple in color and measures 5.6 cm x 2 x 0.2 cm. The wound is described as 50 - 75% dark red [MEDICATION NAME], 25-50 % granulation, and slough greater than 25 %. The area is indurated and hot to touch, [DIAGNOSES REDACTED] present, and edges are denuded. R3's oral temperature is 101.3 F and she complains of burning pain. The same date (2/3/14) entry for 5:21 PM, the nursing note shows R3's physician was notified and R3 was to be sent to the hospital for evaluation. R3's Nursing Notes for 1/29/14 documents a history open areas. The note shows when R3 received a shower, the Certified Nursing Assistants identified a right gluteal open area, the coccyx had shearing, and there are 2 small blisters to the back upper thigh The left gluteal also had an open area. R3's left heel was found to be dry, cracked, and bleeding. The hospital history and physical dated 2/3/14 documents R3 had been having fevers up to 102 F while at the nursing home. The left buttock area was draining. R3 was also found to have Pneumonia. The patients left buttock is multi-colored with some areas of drainage, [DIAGNOSES REDACTED] and tenderness. A left heel decubitus was also noted. The same report shows R3 has Acute Pneumonia, Infected buttock decubitus and Alzheimer's Dementia. R3's treatment included IV antibiotics. The hospital consult note of 2/5/14 documents R3 developed this pressure ulcer to the left trochanter over time. On local examination the patient has a fairly large pressure ulcer to the left trochanter area . There is a marked induration which goes at least 3 to 4 inches across, at at least an inch deep. On compression there is a pus-like material coming out. There is associated tenderness. The Plan included excision of ulcerative necrotic tissue. E3 (Nurse) said when she returned to work on Monday, (was off the week-end) she saw R3's wound was worse. She said there were no reports of any abnormalities regarding R3's wound from the week- end nurse. R3's Care Plan for Skin Integrity dated through 3/27/14 documents the following plan for R3. The identified risk factors include fragile skin, altered mental status, limited physical mobility and refuses care. The goals (not individualized) are listed as: maintain and improve tissue tolerance in order to prevent skin breakdown. Modify or stabilize comorbidities affecting potential skin breakdown. Protect against adverse effects of external mechanical forces; pressure, friction, and shearing. The approaches include assess the skin daily, avoid massage to bony prominence's, avoid exposure to incontinence. Uninterrupted sitting in chair. On 3/26/14 at 11:15 AM, E14 (CNA) said that R3 will tell us if she wants to lay down. We lay her down if she asks us. During the survey on 3/26/14, R3 was observed up in her wheel chair from 7:15 AM until 11:30 when surveyor asked to observe R3's wound on her left hip. According to the facility Pressure Ulcer Prevention Policy and Procedure page 6 and 7) : All residents who are at risk for skin breakdown should avoid long periods of sitting in a chair without being repositioned. According to the AHRQ Guidelines, the resident should be repositioned, shifting the points under pressure at least every hour or be placed back in bed. Many residents may not tolerate sitting in a chair in the same position for even an hour and may require more frequent position changes. Evaluate the resident's tissue tolerance on an individual basis. When a resident refuses, evaluate the basis for the refusal and identify potential alternatives.

Based on observation, interview and record review, the facility failed to provide one resident (R16) out of 19 sampled residents with foot care and foot wear and this deficient practice resulted in R16 developing a wound that became infected on the right foot that needed treatments with antibiotics. The facility also failed to follow their "Central Venous Access Device", peripherally inserted central catheters (PICC line) policy and procedures related to care, maintenance and assessment for one of one resident (R4)in facility with a PICC line from a total sample of 19. The findings include; 1. On 03-24-14 at 10:08 AM, R 16 was propelling his wheelchair with his feet towards the hallway. R16 ' s right foot was swollen and has a bandage wrap around toward the middle- front half of the foot. R 16 has no shoe or socks on the right foot. On 03-25-14 at 11:05 AM and 1:45 PM, the same observation was noted. R 16 said, " I have a sore on my right foot. My shoe was too tight and it keeps rubbing off on my foot. It opened up then it got worsen. The nurse (Treatment Nurse/E3) said it is infected. I went for bone scan and they said I have osteo[DIAGNOSES REDACTED] they put me on antibiotic. No, I never refuse to take my antibiotic; I know that is very important. They (staff) told me that the doctor wants me to wear a special boot but they had given me the boot yet. Yes, I would like to elevate my right foot when am on a wheelchair so I don ' t drag it like this. " On 03-25-14 at 2:40 PM, E 3 explained, " on 02-03-14 he (R 16) developed an abrasion from his shoe. A week later, the Certified Nursing Assistant told me the dressing came loose. It was on 02-10-14 the wound got worsen, it has 75 to 100% slough. It was on his right dorsal (part) of the foot. He was started on antibiotic (Cipro 750 mg BID X 10 days) because of signs and symptoms of infection. The whole area (right foot) was red, tender and with moderate amount of drainage with foul odor. We sent him for bone scan and showed osteo[DIAGNOSES REDACTED]. They recommended MRI to be done but we did not schedule it. " The communication " fax " form dated (1) 02-03-14 from the facility staff to the doctor reads: observed open wound to right big toe, no drainage, and scant amount of blood 0.7 cm X 0.5 cm X 0.1 cm ...apply triple antibiotic ointment and cover with transparent dressing ... (2) 02-17-14 (from E3 to the doctor) reads: open area to right dorsal foot worsened. Black/ yellow /red in color ...measures 2.2 cm X 1.5 cm X 0.2 cm ... Telephone message dated 02-17-14 at 02-17-14 (from doctor ' s office to nursing home) reads spoke with nurse (at nursing home) skin tear on right dorsal foot is worse- now necrotic area with pink/red surrounding ... R 16 ' s Physician order [REDACTED]. On 03-25-14 at 2:50 PM, E 3 and E 7 explained the facility is still waiting for the delivery. The foot rest was discussed with the Restorative Nurse/E7 at 4:00 PM; E 7 stated, " He (R 16) refuses to have leg rest. " R 16 told E 7 " No I did not; it was not even offered to me. I would like to elevate my leg because it hurts at times. " E 3 was unable to provide a comprehensive a foot assessment for R 16 and there was no plan of care initiated related to R 16 ' s right foot wound. The Director of Nursing / E 2 and E 3 confirmed these finding on 03-25-14 at 3:02 PM. 2. On 3/24/14 at 8:50AM, R4 observed with a left upper, inner arm PICC line with a gauze pad over insertion site and gauze pad covered with a non-occlusive dressing. The PICC line dressing was dated 3/17/14 and was compromised, with peeled off edges, not completely adherent to skin. R4 stated " the tape started peeling off the other day." On 8/24/14 at 8:50AM, E22 (nurse), observed to attach a [MEDICATION NAME] intravenous piggyback (IVPB), to R4's PICC line without addressing the compromised dressing. On 3/25/14 at 9:00AM, R4 observed with a non-occlusive dressing covering his left upper arm PICC line insertion site. This dressing was dated 3/24/14 and the entire bottom portion of the dressing was not completely adhered to skin, with rolled up edges. On 3/24/14 at 3:00PM, E8 (nurse consultant) and E27 (transitional care nurse), said when a resident is admitted with a PICC line nursing has to verify placement prior to using it. Nursing must measure arm circumference and external catheter length with each dressing change and as needed. Nursing is to document assessments of PICC line on the residents medication administration record (MAR). Facilities PICC line policy and procedure "Central Venous Access Device", includes: - Measure and obtain a baseline and routine assessments of upper arm circumference and PICC line external catheter length. Assess that the PICC line dressing is completely adherent with no moisture accumulation under it. - Dressing changes = 1) Transparent (non-occlusive) dressings in which insertion site is fully visible, must be changed every 7 days and as needed (if compromised). 2) If the insertion site is covered by gauze and not visible, change dressing every other day. R4 was initially admitted to facility 01/07/14 with [DIAGNOSES REDACTED]. R4 was admitted with a left arm PICC line for IVPB antibiotics until 02/13/14. R4's 02/2014 MAR and nursing progress notes fail to include any dressing changes, upper arm circumferences or PICC line external catheter length assessments having been completed. R4 was hospitalized ,[DATE] through 3/03/14. R4 readmitted [DATE] with a right upper arm PICC line for IVPB antibiotics. R4's 3/2014 MAR and progress notes document initial PICC line external catheter length and upper arm circumference on 3/04/14, not on admission (3/03/14). R4's 3/04/14 MAR document arm circumference 23cm and external catheter length 13cm. R4's 3/05/14 12:58AM nursing progress note includes: 11:10PM R4's PICC line site with bleeding around site and in dressing area. PICC line external catheter length 5cm, R4 observed picking at PICC line site. Dressing changed. R4's 3/05/14 1:00PM progress note includes wife notified nursing that while using the toilet, R4 observed with bleeding on his arm. Nursing assessed R4 to have bright red blood coming from underneath right arm PICC line dressing and running down his arm and wrist. When dressing removed no active bleeding noted, as new dressing was about to be applied bleeding started again from PICC line insertion site. "Pressure dressing applied. Will continue to monitor." No documentation that R4's physician was notified. R4 is on [MEDICATION NAME] daily (anti-coagulant). R4's 3/07/14 MAR document arm circumference 23cm and external catheter length 13cm. R4 hospitalized [DATE] through 3/11/14 with bleeding from his surgical incision site. R4's 3/11/14 readmission progress note includes PICC line dressing changed, external catheter length 7cm and right arm circumference 30cm. R4's 3/17/14 MAR document PICC line external catheter length 9cm and right upper arm circumference 32.5cm. R4's 3/24/14 MAR document PICC line external catheter length 9cm and right upper arm circumference 32cm.

Based on observation, record review, resident and staff interview, the facility failed to assess, provide care and repositioning to prevent the reopening of pressure ulcers and development of friction tears for 1 of 2 residents (R2) reviewed for the presence of pressure sores in a sample of 18. This failure resulted in R2's sacral wound re-opening and developing friction shearing tears to interior right and lateral thighs related to indwelling catheter placement. Findings include: R2 [DIAGNOSES REDACTED]. R2 has a indwelling catheter due to [MEDICAL CONDITION]. R2's last pressure ulcer risk assessment of 1/16/12 assessed R2 as high risk. R2's current care plan for impaired skin integrity approaches included : assess the skin daily paying attention to bony prominences, cleanse skin with a mild cleansing agent after soiling, reposition at least every two hours. R2's February 2012 physician's orders [REDACTED]. On 2/8/11 at 10:00AM, R2 was observed sitting in high back chair in her room. R2 was again observed at 11:00AM in same position in chair. At 11:15 am during a a skin check and incontinence care on R2 with E8 (CNA) and E10(CNA), E8 stated, "R2 has been up since around 8:00AM." While providing care to R2, extreme redness to R2's buttocks was noted. A soiled [MEDICATION NAME] dressing dated 2/7/12 fell off while during incontinence care, and open area was noted to the sacral area. R2 also had a [MEDICATION NAME] to the left and right heel dated 2/7/12. E10 stated the dressing on the heels are on for preventive measures. On 2/8/12 at 11:30 AM at nurses station, E7 (treatment nurse) was asked how often skin checks are completed and how long R2 had the wound to the coccyx. E7 stated "wound assessments are done weekly and R2 doesn't have a coccyx wound." During skin with E7 on 2/8/12 at 11:45 AM, E7 identified R2 with a Stage 2 to the sacral measuring, 1.5 centimeters (cm) x 0.7 cm < 0.1cm. Petechiae were noted to left and right buttock. Multiple other areas areas E7 identified were: 1) a wound measuring 0.3 centimeters (cm) x 3.0 cm, to left inner thigh, posteriorly and distal from perineal area, related to (R/T) friction and shear from urinary catheter tubing. Wound bed is non-blanchable and [DIAGNOSES REDACTED]tous, with intact epithelium. 2) friction/ shear wound to the right inner thigh, posteriorly and distal from pubic area, measuring 0.2 cm x 1.5 cm. Wound be is non-blanchable, [DIAGNOSES REDACTED]tous, intact epithelium. E7 was informed by E10 a dressing was in place to R2's sacral area, E7 responded "I had no idea it (wound) was there." Review of nurse notes lacked documentation a wound was found to R2's sacral area, or that R2's physician was notified of the sacral wound and an order for [REDACTED]. Facility skin assessment policy and procedure states: 1. On admission, a head -to -toe assessment of the resident's skin will be completed by a licensed nurse along with the admission nursing history. 2. Resident' s' who are determined "at risk" for the development of pressure ulcers will have a head to toe assessment done by a licensed nurse CNA daily and documented on the Daily Skin assessment record of the Treatment Administration Record (TAR). 3. All resident's, regardless of risk, will have a documented weekly review of skin condition utilizing the CNA skin attention form. Review of R2's treatment admission record there is no documentation a daily skin check was completed. A request for wound care notes on 2/14/12. E13 (corporate nurse) stated there were no wound notes for R2 in January 2012 because R2 had no wounds. E13 stated R2 was receiving preventative [MEDICATION NAME] to sacral area and heels as preventive. The order for the [MEDICATION NAME] was discontinued on 1/24/12. .

Based on documentation and interview, facility staff failed safely transfer its residents with a mechanical lift, in order to prevent an avoidable injury for 1 of 2 residents reviewed for safe and proper transfer (R1). This failure resulted in the sling coming loose from the lift, resulting in R1 falling out of the sling, and falling 3 feet to the floor. R1 sustained 2 abrasions to the left elbow, and a laceration to the forehead, which was treated at a local hospital. The findings include; The facility's report dated 12/17/10, describes an incident where R1, while being transferred with a mechanical lift, fell out of the sling on to the floor. The report identifies E3 and E4 (CNA's) as the staff responsible for this incident. During an interview, conducted on 12/22/10, E1 (Director of Nurses) explained that all transfers with mechanical lifts require 2 staff. The staff are required to do the entire process together, which includes placing the resident in that sling and then attaching the sling to the hooks on the lift. On 12/22/10, surveyor interviewed E3. E3 explained that while she was giving evening care to her residents, she was summoned by E4 to come and assist her in transferring R1 from his wheelchair to his bed. E3 stated that when she entered the room, R1 was in his wheelchair, and the sling was attached to the mechanical lift. E3 further stated that she was at R1's feet, while E4 was positioning the lift. After R1 had been lifted out of his wheelchair, and was suspended in the air, the left top strap came loose from the hook, and R1 fell out of the sling and on to the floor. When asked about how R1 was placed in the sling, E3 answered that E4 has already attached the sling to the hooks of the lift, and stated that she wished she had double checked the placement of the straps to the hooks, prior to the transfer. E3 commented that after the incident she checked the loops of the straps, and the hooks on the lift, and found them to be in proper working order The facility's incident report, stated that the lift was not positioned correctly or the resident not positioned in the sling as being a Cause/Probable Cause of the event. Subsequent to this incident E4 was terminated in part due to failure to follow facility protocol for transfers.