Every finding on record at Lakeland Rehab & Healthcare Center

Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices were used during resident care for 1 (R5) of 6 residents reviewed for infection control in the sample of 51. The Findings Include:R5's admission Record documents an admission date of 04/13/2024 with diagnoses including sepsis, obstructive and reflux uropathy, and essential hypertension.R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 05, indicating R5 has severely impaired cognition. The same MDs documents that R5 has an indwelling catheter.R5's Care Plan documents a focus area of R5 has a catheter with an initiation date of 04/22/2026. Corresponding interventions include catheter care every shift and as needed, R5 has 18/10 cc French, position catheter bag and tubing below the level of the bladder, and away from the entrance room door, and check tubing for kinks. All interventions listed have an initiation date of 04/22/2026.On 06/24/2026 at 2:10 P.M., an EBP (Enhanced Barrier Precautions) sign and PPE (Personal Protective Equipment) supplies were observed outside of R5's room. The sign notified staff and visitors of completing hand hygiene, including before entering and leaving room, and staff to wear required PPE during high-contact resident care, including providing hygiene, changing briefs or assisting with toileting. V3 (Certified Nurse Assistant) was already in R5's room with a gown and gloves on when this surveyor entered the room. V3 stated she had completed hand hygiene prior to entering the room. V3 explained to R5 that she was going to provide catheter care and removed R5's cover. V3 then removed R5's adult brief and started catheter care. V3 took an incontinence wipe from V4 (Registered Nurse) and without unhooking the catheter tubing from the secure strap, grabbed R5's penis with her left hand and cleaned around the meatus with the wipe. V3 then discarded the wipe, took another wipe from V3, wiped the left abdominal fold, the right abdominal fold, and discarded the wipe. V3 took another incontinence wipe from V4 and cleaned the catheter tubing from the meatus to the secure catheter strap. V3 assisted R5 to his right side, cleaned R5's coccyx with an incontinence wipe, and placed a new incontinence brief under R5. V3 then assisted R5 back to his back and pulled the covers back up. V3 then placed the indwelling catheter bag into a dignity bag that was on the side of the bed. V3 then removed gloves and sanitized hands, gathered trash and left room. During this observation, V3 was never observed doffing dirty gloves, performing hand hygiene, and donning clean gloves until just prior to exiting R5's room.On 06/24/2026 at 2:23 PM, V3 stated she is not sure if she should have changed her gloves. V3 stated maybe I should have changed my gloves before I put it into the privacy bag. V3 then stated that she can find out but she is not sure off the top of her head what the policy states for changing gloves.On 06/25/2026 at 8:41 AM, V2 (Director of Nursing) stated V3 should have changed her gloves after providing care before going on to the next step. V2 stated before V3 touched the covers or rolled R5 over she should have taken her gloves off, sanitized her hands and placed new gloves before going on to the next step. V2 stated she will review the policy and the skills checklist to make sure it is listed when the staff should be changing their gloves. On 06/25/2026 at 2:14 P.M. V2 stated she reached out to corporate, and they are reviewing the policy / skills checklist for catheter care and will update it as needed to ensure it clearly specifies when staff should be changing gloves and performing hand hygiene. The facility policy titled Catheter Care, Urinary with a date of 12/2024 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. Under section titled Steps in the Procedure . 11. For a male resident use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site outward. 15. discard disposable items into designated containers, remove glove, wash and dry your hands thoroughly.The CDC's (Centers for Disease Control and Prevention) guidelines for Clinical Safety: Hand Hygiene for Healthcare Workers (dated 2/27/24) found at www.cdc.gov/clean-hands/hcp/clinical-safety/index.html documents the following recommendations: Immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.

Based on interview and record review the facility failed to safely transport 1 of 3 (R1) residents reviewed for accidents in a sample of 4. This failure resulted in R1's left foot getting caught in her wheelchair wheel during transport and resulted in R1 sustaining an acute mildly displaced fracture of the distal fibula and medial malleolus of the left leg.This past non-compliance occurred from 5/16/2026 to 5/18/2026.R1's admission Record documented an admission date of 4/4/2025 with diagnoses of type two diabetes mellitus, complete atrioventricular block, chronic kidney disease, non-st elevation myocardial infarction and weakness among others. R1's MDS (minimum data set) dated 3/23/26, documents R1 with a BIMS (brief interview for mental status) score of 10 out of 15 total which indicates R1 has moderate cognitive impairment. This same MDS documents R1 has impairment to both upper and low extremities, uses a wheelchair for locomotion and is dependent on staff for most activities of daily living, including locomotion in the wheelchair. On 6/2/2026 at 8:45am, R1 said V6 Certified Nursing Assistant (CNA) was pushing in her wheelchair to the dining room for breakfast, but R1's wheelchair footrests were not on her wheelchair. R1 said V6 was pushing her pretty fast and she could not hold her foot up and when it fell down it became caught in the wheelchair wheel and twisted. R1 said that's how her ankle broke in two places. R1 said her ankle didn't hurt at the time but started hurting right before lunch and it started to swell a bit. R1 said the nurse gave her some pain medications and called her doctor. R1 said her doctor wanted it x-rayed, and the x-ray showed it was broken in two places. On 6/3/2026 at 9:00am, V6 (CNA) said she was working on R1's hall on 5/16/2026 and was responsible for providing care to R1 that day. V6 said she and V5 (CNA) got R1 up that morning using a full body lifting machine and placed R1 into her wheelchair for the day. V6 said R1 usually has her foot pedals on her wheelchair every day, but that morning she forgot to apply them. V6 said when she pushed R1 out to the dining room, R1's left foot dropped and twisted up in the wheelchair wheel. V6 said R1 responded with ouch, that hurt when it happened but then denied any further pain at the time. V6 said after breakfast was over, R1 likes to rest in bed and visit with her roommate. V6 said V5 pushed R1 back to her room, R1 dropped her left foot again causing it to hit the floor during transport and R1's foot went under the wheelchair and bent back. V6 aid R1 denied any pain at the time. V6 said they put R1 into bed and told the nurse about the incident happening again. V6 said she and V5 went to get R1 up for lunch discovered R1's left ankle looked slightly swollen but had no bruising or tenderness at the time. On 6/2/2026 at 11:15am, V5 (CNA) said she worked on R1's hallway on 5/16/26 and provided R1's care that day, along with V6 (CNA). V5 said that morning they forgot to put R1's foot pedals on her wheelchair. V5 said she feels bad about what happened to R1's foot because she really cares about R1 and never wanted her to get hurt. V5 said she was transporting R1 in her wheelchair from the dining room after breakfast, when R1 left foot dropped and went a little bit under the wheelchair. V5 said it didn't twist or get caught in the wheel as it did earlier when V6 pushed her to breakfast that morning. On 6/2/2026 at 11:00am, V3 (Licensed Practical Nurse) said he was the nurse providing care for R1 on 5/16/2026 from 6:30am until 3:00pm. V3 said the facility was not short of staff and had three Certified Nursing Assistants (CNAs) for the dayshift. V3 said V6 (CNA) had transported R1 to the dining for breakfast in R1 wheelchair and did not put on the foot pedals and R1's left foot dropped down and got caught in the wheel of the wheelchair and twisted. V3 said V6 told him and he assessed R1's left foot and found nothing unusual about the foot/ankle. V3 said on the way back from breakfast, V5 (CNA) was pushing R1 back to her room to rest after breakfast and the same thing happened again. V3 said R1's foot slipped down and went under the wheelchair again. V3 said after R1 was put to bed, he assessed her left foot/ankle again and this time R1s ankle looked slightly swollen but R1 continued to deny having any pain. V3 said he notified R1's doctor and family of the incident. V3 said his shift ended around 2:30pm and V4 (LPN) took over R1's care.On 6/2/2026 at 11:45am, V4 (LPN) said V3 had reported to her the incident concerning R1. V4 said about 3:30pm, she reassessed R1 left foot and ankle and determined it was still slightly swollen with new bruising starting to emerge. V4 said R1 said she started to notice some pain in the left ankle area. V4 said she gave R1 some pain medication and called R1's doctor, who ordered mobile Xray company to come to the facility and Xray R1's left foot/ankle. V4 said the x-ray company came later that evening and R1's doctor had the results early the next morning. V4 said R1's doctor ordered an immobilizer and a stat orthopedic consult for the next day. R1's orthopedic consult office visit note dated 5/20/2026 documented the following in part: (R1) in clinic today for further orthopedic management of a left distal fibula fracture. (R1) resides at a skilled nursing facility and is wheelchair-bound, uses a (full body lifting machine) for transfers. (R1) stated she was in the wheelchair, and her footrests were not on the wheelchair at all and somehow her left foot got tangled up. X-rays done showed an obliquely oriented minimally displaced fracture of the distal fibula, she is taking (medication name) for pain. Assessment Plan for R1 included: to be placed in a tall immobilizer boot for added fracture protection and stability. The patient is non-weight bearing and wheelchair bound. Continued to use (full body lifting machine) for transfers. Return to clinic in 3 weeks to repeat x-rays of ankle at that time. Facility form titled State Report documented the following in part: Brief description of incident: resident twisted her foot/ankle during transfer, bruising to top of left foot with 3+ edema. The resident was being taken via wheelchair from the dining room to lay down after breakfast. She put her foot down and it went on the floor and went slightly backwards. When staff started to get her up for lunch the nurse was notified, and head-to-toe assessment was completed. MD (medical doctor) notified and order for x-ray received. The resident was interviewed but was unable to describe what happened. Staff were interviewed and said while being taken to her room from the dining room in her wheelchair the resident put her foot down and her foot went back. The nurse was interviewed. He stated the staff reported the resident put her foot down during transport in wheelchair and it went on the floor. She (R1) complained of discomfort. The nurse immediately completed a head-to-toe assessment and noted swelling. Nurse stated he then called the MD to notify him. The IDT (interdisciplinary team) reviewed the incident. Based on statements from staff, it was determined that the root cause of the incident was due to the resident 's footrests not being placed on w/c (wheelchair). Resident placed feet on the ground as she was being pushed in w/c. The facility's investigation file included witness statements from V5 and V6. V6's written statement documented the following: 5/16/26, I (V6) was pushing (R1) down to the dining room (for breakfast) and her left foot got caught in the wheelchair wheel. (R1) laid down after breakfast and when we (V5 and V6) got her up she was complaining of pain in her ankle. V5's written statement documented the following: 5/16/26, When I (V5) brought (R1) back from dining room this morning, she put her feet down and the left one went under the wheelchair a little bit. I laid her down (after breakfast) and when I got her up for lunch she complained of pain. On 6/3/2026 at 9:45am, V1 (Administrator) said the facility did not have a policy on wheelchair usage. V1 said she expected all residents who need to have foot pedals on their wheelchairs to have them applied as needed. Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 5/18/2026 with V1 (Administrator), V10 (Assistant Director of Nursing), V11 (Human Resources), V12 (Minimum Data Set Coordinator), V13 (Medical Doctor/Medical Director), V14 (Licensed Practical Nurse/Minimum Data Set Coordinator), V16 (Registered Nurse), V17 (Activities Director), V18 (admission Coordinator) and V19 (Admissions Coordinator) in attendance. The QAPI Ad Hoc form under Immediate Corrective Actions included: (R1's) care plan was reviewed, and interventions were added to ensure pedals are placed on her wheelchair for transportation, All staff that have the potential to push a resident in a wheelchair were in-serviced regarding the use of footrests on wheelchairs, with emphasis on the following: Residents must have footrests in place if they are unable to propel the wheelchair on their own and Staff members directly involved with the deficient practice received corrective action. Identifying Other with the potential to be affected: All residents that use wheelchairs for transportation have the potential to be affected by the deficient practice. Systematic Changes to ensure deficient practice does not recur: All current residents' care plans were reviewed to ensure they reflect appropriate individualized interventions, All wheelchairs were audited to ensure footrests are in place for those residents that are unable to propel themselves, Director of Nursing or designee educated all staff that interventions should be put in place to prevent resident injuries based on individual need and the interventions should be reflected on their care plan. The facility held an Ad Hoc QAPI on 5/18/2026 to discuss the identified issue and at this time it was determined that a plan would be put into place and that the facility would allege past noncompliance. An additional meeting was held to discuss the progression of the past noncompliance plan, and it was determined that the facility would allege compliance as of 5/18/2026. The Medical Director was updated on 5/18/2026 on the identified issue and the plan to address the issue and development of a past noncompliance. The medical Director was updated on the facility alleging compliance as of 5/18/2026. System Maintenance: Director of Nursing or designee will review 5 residents weekly for the next 60 days to audit that appropriate individualized safety prevention interventions are in place and reflected on the resident's care plan, Residents will be reviewed as needed and quarterly during QA weekly risk meetings to review that appropriate individualized safety prevention interventions are in place and reflected on the resident's care plan. [NAME] deficient practice will be corrected immediately. Patterns or trends will be reported to the QAPI Committee for further recommendations and follow-up. Compliance achieved 5/18/2026.2. Documentation of all residents who use wheelchairs were assessed for the need of footrests and were completed by 5/18/2026.3. Staff education/in-service documentation shows facility staff were educated on all residents should have foot pedals on wheelchairs when being pushed by staff unless they self-propel and was completed on 5/17/2026.4. Individual staff involved received corrective action completed 5/18/2026.

Based on interview and record review, the facility failed to notify the family of a change in condition for 1 (R1) of 3 residents reviewed for notification of changes in the sample of 4. The Findings Include:R1's admission Record documented an admission date of 09/17/2024 and included diagnoses of acute osteomyelitis of right ankle and foot, chronic obstructive pulmonary disease, type 2 diabetes mellitus, generalized anxiety, end stage renal disease, chronic diastolic heart failure, anemia in chronic kidney disease, and dependance on renal dialysis.R1's Care Plan documented a focus area of R1 needs dialysis related to renal failure. Corresponding intervention included, do not draw blood or take blood pressure in the right arm with graft, encourage resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday, and monitor labs and report to the doctor as needed.R1's Progress Note dated 03/27/2026 with a time of 4:58 A.M. authored by V8 (Licensed Practical Nurse/LPN) documented R1 refused to get up for dialysis treatment this morning. R1's Progress Note dated 03/30/2026 with a time of 5:24 A.M. authored by V9 (LPN) documented R1 refused multiple attempts to take R1 to dialysis by 4 staff members.R1's Progress Note dated 03//31/2026 with a time of 9:09 A.M. authored by V2 (Director of Nursing/DON) documented V4 (Family Member/Power of Attorney/POA) was notified R1 has refused to go to dialysis. Will wait return call.On 04/09/2026 at 4:17 PM, V3 (Family Member) stated R1 was in the facility for 18 months. V3 stated the facility did not notify V3, V4 (POA) or V5 (Family Member) of R1's refusal to go to dialysis. V3 stated the facility usually called every time there was a change in R1. V3 stated on 03/27/2026, R1 refused to go to dialysis and the facility did not call. V3 stated on 03/27/2026 at 11:30 AM, V5 was in the facility for R1's hearing aide consult and no one from the facility told V5 that R1 did not go to dialysis that day. V3 stated that V5 was in the facility on 03/29/2026 around breakfast time and no staff told her then that R1 did not go to dialysis on 03/27/2026. V3 stated no one was notified on 03/30/2026 that R1 did not attend dialysis that day. V3 said on 03/31/2026, V2 (DON) called V4 and explained that R1 had refused dialysis and was pretty confused and wanted a referral to hospice. V3 stated that V5 had called the dialysis center on 03/30/2026 and confirmed R1 had missed two treatments and that on 03/25/202, R1 became unruly and his treatment was cutoff an hour earlier than usual. V3 stated the facility did not notify them of this either. V3 stated she feels like the facility took away their ability to talk to R1 when he was more alert because they had not notified the family of the dialysis refusals.On 04/10/2026 at 1:09 PM, V1 (Administrator) stated she was not aware R1 did not complete his entire treatment on 03/25/2026. V1 stated the family and physician should both be made aware when a resident refuses dialysis or any other medication or treatment. On 04/10/2026 at 1:27 PM, V2 (DON) stated she notified the family as soon as she was made aware that R1 had been refusing his dialysis treatments. V2 stated she called the family because when she looked at the chart, there was no documentation of R1's family or physician being notified. V2 stated she is not sure that the doctor was notified because there is no documentation of it. V2 stated all staff should know to notify the physician and the family when a resident refuses care, treatments and especially dialysis. V2 stated it is her expectation that nursing staff follow the policy and notify family and physicians when there is a change in condition. On 04/10/2026 at 1:52 PM, V9 (LPN) stated she was R1's nurse the morning of 03/30/2026. V9 stated R1 was up in his wheelchair and when the transport driver came to take him to dialysis, R1 refused to go. V9 stated she attempted to get him to go as well as 3 other staff members. V9 stated all attempts were unsuccessful. V9 stated she passed it on in report that R1 had refused to go to dialysis and that she had not notified the physician or the family. V9 stated she thought the oncoming nurse would notify the family and the physician. V9 stated that she probably should have been the one to notify the family and the physician. V9 stated she is not sure what the policy states about notification.On 04/10/2026 at 2:00 PM, V8 (LPN) stated she was the nurse working when R1 refused to go to dialysis. V8 stated she did not notify the family because R1 was alert and oriented and could make his own decisions. V8 stated she thinks she notified the physician, but she did not document it. V8 stated she is not aware what the policy says about notifying the family or physician when a change happens. On 04/10/2026 at 2:32 PM, V11 (LPN) stated she was the nurse who was caring for R1 on 03/30/2026. V11 stated she does not recall the night shift nurse asking her to notify the family or physician. V11 stated she would notify the family and the physician if she would have been made aware. V11 stated anytime a resident refuses they are supposed to notify the family and the physician.A facility policy titled Significant Condition Change and Notification documented the purpose of the policy is to ensure that residents' family and/or representative and medical practitioner are notified of resident changes. Under Procedure, the policy documents calls will be made to the resident's representative until they are reached. Under Documentation, the policy documents charting will include an assessment of the resident's current status as it relates to the change of condition. Charting will be done each shift for 72 hours for residents who have a change.

Based on observation, interview, and record review the facility failed to ensure residents were turned and repositioned to prevent skin breakdown for 1 of 3 (R4) residents reviewed for quality of care in the sample of 14. Findings Include: R4's admission Record with a print date of 04/02/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include heart disease, diabetes, kidney disease, hypertension, osteoarthritis, and dementia. R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating a moderate cognitive deficit. Section H, Bladder and Bowel, documents that R4 is always incontinent of urine and bowel. Section M, Skin Conditions, documents that R4 has Moisture Associated Skin Damage (MASD) with skin and ulcer/injury treatments of a pressure reducing device for chair and bed, applications of nonsurgical dressings, and application of ointments/medications.R4's current Care Plan documents a Focus area of, (R4) has an ADL (activities of daily living) Self Care Performance Deficit. Date Initiated: 04/15/2025. This Focus area includes the interventions of, Bed Mobility: The resident requires 2 staff participation to reposition and turn in bed. Date Initiated: 04/15/2025, Transfer: The resident requires 2 staff participation with transfers. Hoyer. Date Initiated: 04/15/2025. This same Care Plan documents a Focus area of, The resident has potential impairment to skin integrity r/t (related to) impaired mobility. Date Initiated: 09/045/2025 This Focus area interventions do not address how often R4 should be turned and repositioned. This same Care Plan also documents a Focus area dated 4/15/25 of (R4) has bladder incontinence with a Goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions dated 4/15/25 include: Check the resident q (every shift) and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.R4's Skin Issues assessment in the Electronic Health Record dated 3/30/26 documents R4 has moisture associated skin damage on her coccyx, acquired at the facility that measures 0.65 x 0.33 x 0.1 centimeters (cm). On 3/30/26 at 10:13 AM, R4 was sitting next to her bed in a wheelchair. R4 stated she has a gash on her tail bone and it hurts when she sits in her chair too long. R4 stated she had been up for 2-3 hours. R4 stated she cannot transfer independently.On 3/30/26 at 3:00 PM, R4 was in bed and stated she was up in her wheelchair until after she ate lunch. R4 stated her bottom was hurting where she had the gash. R4 stated she didn't like staying up in her wheelchair that long because it hurts. On 3/31/26 at 10:50 AM, R4 was observed sitting in her wheelchair in her room with R14 (family member of R4) present in the room. R4 stated she had been up in her wheelchair since about 6 am. R14, who was alert and oriented to person, place, and time, confirmed this and stated R4 is usually up in her chair from before breakfast until after lunch because they don't want to put her in bed since she will have to get up for lunch. R14 stated then R4 has to wait her turn to lay down after lunch. R14 stated R4 is usually up in her chair from about 6 am until about 2:00 PM. R14 stated that is too long for her to be up in her chair. On 3/31/26 at 1:42 PM, R4 was sitting in her wheelchair in her room with V12 and V17 (Certified Nursing Assistants/CNA) present. V12 and V17 transferred R4 to bed using a mechanical lift per current standards of practice. V12 and V17 removed R4's incontinence brief which was wet with urine and cleaned R4 up using current standards of practice. R4's buttocks were observed with a small open area noted on the coccyx. There were no signs of tunneling, undermining, or infection present. R4's buttocks and upper legs had red creases across them. V12 and V17 stated they were the CNA's responsible for R4's care and she had been in her wheelchair since about 7 am. V12 and V17 stated R4 lets them know if she wants to lay down or if she had been incontinent of urine.On 3/31/26 at 2:13 PM, R4 stated the CNA's had not asked her if she wanted to lay down or needed to be changed during the time she was up in the wheelchair on 3/31/26. On 4/1/26 at 1:10 PM, V12 (CNA) stated she didn't transfer R4 out of her chair yesterday (3/31/26) from the time she got up around 7 am until 1:42 PM. When asked if R4 should have been repositioned into bed prior to 1:42 PM, V12 stated she should have been. V12 stated they should be repositioned every two hours. When asked why she wasn't repositioned, V12 stated there was no real reason. On 3/31/26 at 2:17 PM, V2 (Director of Nurses) stated a resident who is alert and oriented should put their call light on so staff can check and change them. The facility was unable to provide this surveyor with a policy regarding this deficient practice.

Based on interview and record review the facility failed to ensure physician orders were followed and referrals to specialist were obtained for treatment of a Urinary Tract Infection (UTI) for 1 of 3 (R1) residents reviewed for urinary infections in the sample of 14.Findings Include:R1's admission Record with a print date of 4/2/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, Chronic Kidney Disease (Stage 5), hypertension, morbid obesity, muscle weakness, hydrocele, and compression fracture of vertebrae. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 01, indicating a severe cognitive deficit. Section H, Bladder and Bowel, documents that R1 has occasional urinary incontinence. R1's Care Plan documents a Focus area of, The resident has bladder incontinence R/T (related to) confusion. Date Initiated: 09/27/2024. This Focus area includes the intervention of, Monitor/document for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color increase pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 09/27/2024.R1's Progress Notes document the following 10/01/24: Received orders from (name of physician office) to collect UA (urinalysis) with CNS (culture and sensitivity) via straight cath.10/2/2024: (name of staff from physician office) called from (name of physician office) to inform staff of resident having a UTI. Waiting for CNS before orders are given d/t (due to) CKD (chronic kidney disease) Dx (diagnosis). Will cont (continue) to monitor. 10/06/2024: .Pending UA C&S, continues to have thick pale green discharge from penis, peri-care provided by staff. A/O (alert and oriented) x (times) 4, verbal able to make needs known.The facility Infection Control Log for 10/2024 was reviewed and did not document a urinalysis or culture and sensitivity result for R1's urinalysis that was obtained on 10/01/24. R1's Urine Culture result dated 10/04/2024 documents greater than 100,000 colonies/milliliter streptococcus viridian's species susceptibility not routinely performed. Under Document History this culture documents, He had pus coming for [sic] penis, thick yellow/green, increased tremors. Do you want to do any antibiotics? urology (referral) topical bacitracin.R1's Order Summary Report for 10/01/24 to 10/31/2024 does not document an order for antibiotics or bacitracin to treat the urinary tract infection. R1's medical record does not document a referral to urology. R1's Progress Note documents on 10/10/24, CNA's (Certified Nursing Assistants) (V3) and (V4) came out of resident's room saying that the resident says they cannot move their right leg. The nurse walked into the room and the patient stated, I woke up and I couldn't move my leg .EMT (emergency medical technician) was called and the resident was transferred to (name of local hospital). R1's local hospital record dated 10/10/24 documents R1 was admitted for decompression of T10 and T11 and throughout his hospital stay it is noted he had a small amount of purulent drainage from his penis and was treated with antibiotics.On 3/321/26 at 2:17 PM, V2 (Director of Nurses) located R1's urinalysis from 10/01/24 that documented a urinary tract infection and the culture and sensitivity. When asked if there was ever any treatment for the urinalysis, V2 stated she couldn't locate any treatment. When asked what her expectations would be, V2 stated to monitor the drainage, notify the physician, gets urinalysis as ordered, and monitor for any other signs of infection. V2 continued to review R1's medical record with the assistance of V16 (Licensed Practical Nurse/Infection Preventionist). V2 stated they located an order for bacitracin after the culture results were obtained and to schedule a follow up with urology. V2 stated she did not see an order for bacitracin in R1's physician orders or on R1's Medication Administration Record, or information regarding a follow up appointment with urology. On 4/1/26 at 1:57 PM, V16 (LPN/IP- Licensed Practical Nurse/Infection Preventionist) stated she didn't remember any specific details related to R1's condition or treatment. V16 stated the drainage from his penis and/or culture and sensitivity results were not on the infection control log and there was no treatment documented. V16 stated she knew he was treated in the hospital with antibiotics for the urinary tract infection. When asked what her expectation as the IP nurse would be, V16 stated the nurse should have clarified the order, and it should have been followed up on. The facility Significant Condition Change and Notification policy dated 12/2024 documents, Purpose: to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes .Documentation: All significant changes will be recorded on the Communication Board in (name of electronic records) and in the resident record

Based on interviews and record reviews, the facility failed to prepare potatoes according to the recipe for 3 of 4 (R2, R15, R24) residents reviewed for meal service in the sample of 26.Findings include: 1.R2's admission Record with a print date of 3/5/2026 documents R2 was admitted to the facility on [DATE] and included diagnoses of cerebrovascular disease, aphasia, cerebral infarction, dysphagia, and hemiplegia and hemiparesis following cerebra infarction affecting right dominant side.R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, which indicates R2 has a moderate cognitive deficit.R2's current Care plan documents a Focus area of (R2) has a swallowing problem Coughing or choking during meals or swallowing med (medications). Dated 03/06/2025. This Focus area includes the interventions of, All staff to be informed of resident's special dietary and safety needs. Date Initiated: 03/06/2025. Instruct the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Date Initiated: 03/06/2025. (R2) and power of attorney (POA) educated on risks of (R2) continuing with regular diet. POA gave verbal understanding and (R2) wishes to have an against medical advice (AMA) for regular diet. Date Initiated: 02/13/2026. Monitor for shortness of breath, choking, labored respirations, lung congestion. Date Initiated: 03/06/2025.R2's Medication Review Report documents a physician order of, Regular diet Regular texture, Regular Liquid consistency, N/A (not applicable) for Signed AMA (against medical advice) to stay regular diet, with a start date of 2/18/23.On 3/4/2026 at 1:13 p.m., R2 stated on 2/13/2026, he choked on a piece of potato during dinner time. R2 stated the potato was hard and he believed it was raw.R2's Progress Notes/SBAR (Situation, background, assessment, recommendation) dated 2/13/2026 at 18:10 (6:10) p.m. documents, This nurse was on 400 hall trying to transfer call to main dining room when 300 hall nurse stated on the phone, I need your help, resident is choking. Staff nurse ran to main dining room and noted resident blue in color, difficulty breathing, with no notable breaths coming out. This nurse then performed the Heimlich to resident. Staff nurse compressed x2 when resident elbowed me away and put his arm up. Resident started coughing and said, G** D*** resident started to become blue in color again and no notable breaths were coming out. This nurse then compressed x3 (times 3) more times when a large piece of potato-not cutable with fork came out. Full assessment completed--Crackles to all R (right) lobes.R2's health status note dated 2/13/2026 at 19:00 (7:00) p.m. documents R2 denied needing to go to the hospital and POA (power of attorney) agreed with STAT chest Xray.On 3/4/2026 at 2:02 p.m., V9 Licensed Practical Nurse (LPN) stated she was working on 400 hall on 2/13/2026 in the evening when the CNA (Certified Nursing Assistant) came and got her to help in the dining room because a resident (R2) was choking. V9 stated the nurse that was in the dining room was pregnant and could not go around the resident that was choking. V4 stated when she got to the dining room, R2 was trying to cough but was not able to and no air was coming out. V9 stated she tried to do an abdominal thrust and R2 raised his hand and said, G** d**n. V9 stated R2 became unable to breathe again, and she performed the Heimlich Maneuver and R2 was able to expel a piece of potato. V9 stated R2 was having Au Gratin potato for dinner that evening and the piece that came out was about 2cm (centimeter) x 1cm x 1.25 cm. V9 stated the potato was hard, she tried to cut it with a fork and could not break it. V9 stated she did not check the remaining food for R2 because there was only a little bit of it left. V9 stated she was not aware of any other complaints from the other residents regarding food. V9 stated she was aware R2 had difficulty swallowing and she usually reminded him to take small bites but R2 eats his food quickly. V9 stated staff does a lot of education with R2 but he doesn't follow the recommendations.2.R15's admission Record with a print date of 3/5/2026 documents R15's admission date to the facility as 12/24/2024 and included diagnoses of cerebral infarction, obesity, type 2 diabetes, chronic kidney disease stage 3, and anemia.R15's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R15 is cognitively intact.R15's Medication Review Report printed date 3/5/2026 documents R15's diet order as regular consistency with an order date of 4/22/2024.On 3/2/26 at 12:54 PM, R15 stated they were served au gratin potatoes about 2 weeks ago and they were hard like they were still raw. R15 stated that is the day R2 choked. R15 stated they reported the potatoes were raw and nothing was done to fix them.3.R24's admission Record with a print date of 3/5/2026 documents R25 was admitted to the facility on [DATE] and included diagnoses of heart failure, chronic obstructive pulmonary disease, atrial fibrillation, arthritis, and anemia.R24's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, which indicates R24 is cognitively intact.R24's Care plan documents a focus area of (R24) has nutritional problem or potential nutritional problem. At risk for wt (weight) loss r/t (related to) edema in extremities. Res (resident) has a 1500 ml (milliliter) fluid restriction. Date Initiated: 12/22/2021. Revision on 1/11/2024. This focus includes the interventions Monitor/document/report to medical director for signs and symptoms of dysphagia. Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 01/12/2021.R24's Medication Review Report printed date 3/5/2026 documents R24's diet order as regular consistency with an order date of 02/21/2025.On 3/5/26 at 10:15 AM, R24 stated she was sitting at the table when R2 choked. R24 stated R2 put a large piece of potato in his mouth, and he is not supposed to do that. R24 stated she tells him, but he doesn't listen. R24 stated he got choked, the staff came to assist him, and did the Heimlich maneuver. When asked how the potatoes were cooked, R24 stated not so good, they were not tender. R24 stated sometimes the food is cooked well and sometimes it is not.The facility Fall/Winter 25/26 Week 3 menu documents the dinner meal for 2/13/26 was roll, chicken baked thighs, potato au gratin brussel sprouts, and brownies.The facility Kitchen Production Report dated 2/13/26 documents no temperatures were documented for the evening meal items to determine if the menu was cooked thoroughly.The facility Recipe for Potato Au Gratin documents, whole fresh potatoes are to be peeled and sliced then boiled/steamed until they are softened but not totally cooked. After adding margarine, flour, salt, paprika, milk, and cheese, the potatoes are to be baked until tender.On 3/5/26 at 3:22 PM, V4 (Dietary Manager) stated the cook on 2/13/26 was V13. V4 stated the potatoes should be sliced, put in the steamer, seasoned, and then baked. V4 stated after baking the potatoes should be soft. V4 stated the potatoes should be soft enough to break apart with a fork. When asked if V13 was working so this surveyor could interview him, V4 stated V13 just got angry and walked out of the facility.On 3/5/26 at 3:33 PM, this surveyor attempted to contact V13 (Cook) by phone, a voicemail was left with a return call requested. V13 did not return the call.The facility undated Standardized Recipes documents, Guideline: Standardized recipes will be used for all menu items, including pureed and therapeutic diets.

Based on observation, interview, and record review the facility failed to ensure menus were followed for 4 of 6 (R57, R24, R13, and R119) residents reviewed for nutrition in the sample of 56. Findings include:1. R57's admission Record with a print date of 7/24/25 documents R57 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, morbid obesity, dementia, and gastroesophageal reflux disease.R57's MDS (Minimum Data Set) dated 5/31/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating a severe cognitive deficit.R57's current undated Care Plan documents a Focus area of (R57) has nutritional problem or potential nutritional problem, altered diet. Regular diet, pureed texture, nectar thick liquids. This same Focus area includes an intervention to Provide, serve diet as ordered. Monitor intake and record q (every) meal.R57's Medication Review Report dated 7/24/25 documents a physician order for regular diet, pureed texture, nectar thick liquids with a start date of 5/22/25.On 07/21/2025 at 1:10 PM, R57 was served a pureed diet in three bowls. One bowl with catfish, one with rice, and one with vegetables and a small dessert bowl with pudding. There was no pureed bread served to R57 with this meal.2. R24's admission Record with a print date of 7/24/25 documents R24 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease and dysphagia.R24's MDS dated [DATE] documents a BIMS score of 10, indicating a moderate cognitive deficit.R24's current undated Care Plan documents a Focus area of (R24) has potential nutritional problem. At risk for wt (weight) loss r/t (related to) dementia. This same Focus area includes an intervention of, Provide, serve diet as ordered. Monitor intake and record q (every) meal.R24's Medication Review Report dated 7/24/25 documents a physician order for regular diet, pureed texture, nectar thick liquids, no straws, intolerance to red dye for nutrition with a start date of 6/24/24.On 07/21/2025 at 1:10 PM, R24 was served pureed foods in three separate bowls. One bowl with what appeared to be fish, one with what appeared to be rice, one with what appeared to be vegetables, and a dessert bowl with what appeared to be pudding. R24 was not served a pureed dinner roll.3. R13's admission Record with a print date of 7/24/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include age related cognitive decline, dementia, and gastroesophageal reflux disease.R13's MDS dated [DATE] documents a BIMS score of 08, indicating a moderate cognitive impairment.R13's undated current Care Plan documents a Focus area of, (R13) has nutritional problem on altered diet, at risk for wt loss. Regular diet, pureed texture, nectar thick liquids.R13's Medication Review Report dated 7/24/25 documents a physician order for regular diet pureed texture, nectar thick liquids with a start date of 7/19/25. On 07/21/2025 at 12:56 PM, R13 was served four bowls of pureed food. One appeared to be fish, one rice, one a vegetable, and one pudding.4. R119's admission Record with a print date of 7/24/25 documents R119 was admitted to the facility on [DATE] with diagnoses that include heart disease, gastroesophageal reflux disease, and pneumonitis due to inhalation of food and vomit.R119's undated current Care Plan documents a Focus area of, The resident has nutritional problem, or potential nutritional problem . This same Focus area includes the intervention of Provide, serve diet as ordered.R119's Medication Review Report dated 7/24/25 documents a physician order for regular diet pureed texture, nectar thick liquids with a start date of 7/21/25.On 7/21/2025 at 1:30pm, R119 was served a pureed diet and was assisted to eat by V7 (Infection Preventionist). R119's tray was noted to have pureed fish, pureed wild rice, pureed mixed vegetables, and banana pudding, but did not include a pureed roll. When V7 was asked what R119 was served for his noon meal, V7 replied, fish, veggies, rice, and banana pudding.The facility Master Menu dated 7/23/25 documents the pureed diet for 7/21/25 as roll wheat .fried catfish deep fried, rice long grain and wild, veg (vegetable) mix roasted [NAME], pudding banana On 07/23/2025 at 1:40 PM, when asked why R13, R24, R57, and R119 were not served a pureed dinner roll with their noon meal on 7/21/25, V3 (Dietary Manager) stated they were probably just missed.On 7/24/25 at 2:01 PM, V1 (Administrator) stated she would expect residents who are served a pureed diet to get all of the menu items as they should.The facility Therapeutic Diets policy dated 12/2024 documents, Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possible dietary restrictions. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. 2. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. 3. A therapeutic diet must be prescribed by the resident's Attending Physician. The Physician's diet order should match the terminology used by Food Services.

Based on observation, interview, and record review the facility failed to ensure proper infection prevention and control practices were used during resident care for 2 of 5 residents (R117 and R118) observed for infection prevention and control in the sample of 56.Findings include:1. R117's admission Record documents an initial admission date of 10/23/2023 and diagnoses including in part sepsis, infection, and inflammatory reaction due to indwelling urethral catheter, stage 3 pressure ulcer of right heel and left heel, and osteomyelitis of ankle and foot.R117's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 indicating R117 has intact cognition.R117's Order Summary Report dated 7/24/2025 documents and order to flush Peripherally Inserted Central Catheter (PICC) with 10 milliliters (ml) of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/21/25, R117 required enhanced barrier precautions related to wounds, urinary catheter, and PICC line with an order date of 7/15/25, and Daptomycin sodium chloride intravenous (IV) solution one time a day for sepsis/osteomyelitis for 35 days with a start date of 7/19/25. R117's most recent Care Plan documents a focus area of R117 is on enhanced barrier precautions due to urinary catheter, wounds, and PICC line with an initiated date of 7/18/2025 and interventions including in part staff will wear gown and gloves when performing high-contact resident care activities. Focus areas from the same Care Plan document R117 is on IV daptomycin for osteomyelitis with an initiated date of 7/18/2025 and R117 has a PICC line with an initiated date of 7/18/2025.On 7/23/2025 at 8:41 AM, V10 (Registered Nurse) administered IV medication to R117. V10 applied gloves at the doorway without performing hand hygiene first when entering the room to give R117 IV medication. V10 then moved the IV pole closer to R117 then pulled all the supplies out of her pocket and organized things on the bed side table with the same gloves on. With the same gloves on V10 then prepped the IV medication solution and hung the IV medication bag on the pole, removed the cap from the PICC line access and scrubbed the end of the PICC line with an alcohol pad, and connected the IV tubing to the PICC access site. V10 did not change gloves or wear a gown throughout the entire observation. On 7/23/2025 at 9:58 AM, V11 (Certified Nursing Assistant/CNA) and V12 (CNA) performed urinary catheter care on R117. V11 cleaned R117 with a soapy wet washcloth, then changed gloves without performing hand hygiene between glove changes, wiped R117 with a wet washcloth, changed gloves without performing hand hygiene between glove changes, then dried R117 with a dry towel. V11 and V12 then removed gloves and performed hand hygiene. On 7/24/2025 at 1:16 PM, V11 stated she usually performs hand hygiene when she changes gloves, but she must have forgotten. V11 stated the hand sanitizer was in her pocket. V11 stated she should have performed hand hygiene between glove changes.2. R118's admission Record documents an initial admission date of 5/6/2021 and diagnoses including in part sepsis, urinary tract infection, infection, and inflammatory reaction due to indwelling urethral catheter, and pneumonia.R118's MDS dated [DATE] documents a BIMS score of 14 indicating R118 has intact cognition.R118's Order Summary Report dated 7/24/2025 documents flush PICC line with 10 ml of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/23/25 and R118 requires enhanced barrier precautions per Illinois Department of Public Health guidelines related to urinary catheter and IV site with an order date of 7/22/25. R118's Order Details documents Ertapenem Sodium Solution Reconstituted 1 gram, give one gram intravenously every 24 hours for infection for 12 days with an order date of 7/11/25.R118's most recent Care Plan documents a focus area of R118 is on enhanced barrier precautions due to urinary catheter, wounds, and IV access and R118 has IV antibiotics both with a revision date of 7/14/25. Documented interventions include staff will wear gown and gloves when performing high-contact resident care with an initiation date of 04/05/2024.On 7/23/2025 at 9:05 AM, V10 administered IV medication to R118. V10 applied a gown at the door then performed hand hygiene and applied gloves to give R118 IV medication. V10 then went into the bathroom and grabbed the IV pole and brought it next to R118, then V10 reached into her shirt pocket and took out supplies with the same gloves on. With the same gloves on V10 then prepped the IV medication and tubing then hung it on the IV pole, then removed the cap from the PICC line access, cleaned it with alcohol and then connected the IV tubing to the PICC line access. V10 did not change gloves throughout the entire observation. On 7/23/2025 at 10:43 AM, V10 stated she forgot to put on a gown before she entered R117's room to administer the IV medication. V10 stated she should have worn a gown into R117's room because he is on contact isolation and enhanced barrier isolation. V10 stated she usually puts on gloves when she gets into the room then gathers supplies and prepares supplies for use and does not usually change gloves before she accesses the IV access line. V10 stated she doesn't know what the policy says about when to change her gloves.On 7/24/2025 at 10:09 AM, V2 (Director of Nursing) stated it is the standards of practice to perform hand hygiene between glove changes and she expects hand washing to occur between glove changes. V2 stated she expects the nurse to wear clean gloves when accessing the IV and if the nurse touches anything else prior to accessing the IV line then they should change their gloves and perform hand hygiene right before they access the IV. V2 stated R117 is on contact isolation and enhanced barrier isolation and a gown should be worn by all staff anytime care is being performed so V10 should have worn a gown when administrating the IV medication.A facility policy titled Infection Prevention and Control Manual dated 2019 documents under Policy 3. sterile gloves and examination gloves are removed: d. before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated.An undated facility policy titled Infection prevention and Control Manual-Enhanced Barrier Precautions documents under Policy enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as resident that have wounds or indwelling medical devices). Enhanced barrier precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. In the same policy it documents high-contact resident care activities where a gown and gloves should be used include Caring for or using an indwelling medical device.

Based on observation, interview, and record review the facility failed to administer intravenous medications according to professional standards of practice to 2 of 2 residents (R117 and R118) reviewed for intravenous medications in the sample of 56. Findings include:1. R117's admission Record documents an initial admission date of 10/23/2023 and diagnoses including in part sepsis, infection, and inflammatory reaction due to indwelling urethral catheter, stage 3 pressure ulcer of right heel and left heel, and osteomyelitis of ankle and foot.R117's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 indicating R117 has intact cognition.R117's Order Summary Report dated 7/24/2025 documents and order to flush Peripherally Inserted Central Catheter (PICC) with 10 milliliters (ml) of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/21/25, R117 required enhanced barrier precautions related to wounds, urinary catheter, and PICC line with an order date of 7/15/25, and Daptomycin sodium chloride intravenous (IV) solution one time a day for sepsis/osteomyelitis for 35 days with a start date of 7/19/25. R117's most recent Care Plan documents a focus area of R117 is on enhanced barrier precautions due to urinary catheter, wounds, and PICC line with an initiated date of 7/18/2025 and interventions including in part staff will wear gown and gloves when performing high-contact resident care activities. Focus areas from the same Care Plan document R117 is on IV daptomycin for osteomyelitis with an initiated date of 7/18/2025 and R117 has a PICC line with an initiated date of 7/18/2025. On 7/23/2025 at 8:41 AM, V10 (Registered Nurse) administered IV medication to R117. V10 applied gloves at the doorway without performing hand hygiene first when entering the room to give R117 IV medication. V10 then moved the IV pole closer to R117 then pulled all the supplies out of her pocket and organized things on the bed side table with the same gloves on. With the same gloves on V10 then prepped the IV medication solution and hung the IV medication bag on the pole, removed the cap from the PICC line access and scrubbed the end of the PICC line with an alcohol pad, and connected the IV tubing to the PICC access site. V10 did not change gloves or wear a gown throughout the entire observation. 2. R118's admission Record documents an initial admission date of 5/6/2021 and diagnoses including in part sepsis, urinary tract infection, infection, and inflammatory reaction due to indwelling urethral catheter, and pneumonia. R118's MDS dated [DATE] documents a score of 14 indicating R118 has intact cognition.R118's Order Summary Report dated 7/24/2025 documents flush PICC line with 10 ml of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/23/25 and R118 requires enhanced barrier precautions per Illinois Department of Public Health guidelines related to urinary catheter and IV site with an order date of 7/22/25. R118's Order Details documents Ertapenem Sodium Solution Reconstituted 1 gram, give one gram intravenously every 24 hours for infection for 12 days with an order date of 7/11/25.R118's most recent Care Plan documents a focus area of R118 is on enhanced barrier precautions due to urinary catheter, wounds, and IV access and R118 has IV antibiotics both with a revision date of 7/14/25. Documented interventions include staff will wear gown and gloves when performing high-contact resident care with an initiation date of 04/05/2024.On 7/23/2025 at 9:05 AM, V10 administered IV medication to R118. V10 applied a gown at the door then performed hand hygiene and applied gloves to give R118 IV medication. V10 then went into the bathroom and grabbed the IV pole and brought it next to R118, then V10 reached into her shirt pocket and took out supplies with the same gloves on. With the same gloves on V10 then prepped the IV medication and tubing then hung it on the IV pole, then removed the cap from the PICC line access, cleaned it with alcohol and then connected the IV tubing to the PICC line access. V10 did not change gloves throughout the entire observation. On 7/23/2025 at 10:43 AM, V10 stated she forgot to put on a gown before she entered R117's room to administer the IV medication. V10 stated she should have worn a gown into R117's room because he is on contact isolation and enhanced barrier isolation. V10 stated she usually puts on gloves when she gets into the room then gathers supplies and gets the supplies ready for use and does not usually change gloves before she accesses the IV access line. V10 stated she doesn't know what the policy says about when to change her gloves and she didn't receive any special training on the procedure of accessing IV's at the facility.On 7/24/2025 at 10:09 AM, V2 (Director of Nursing) stated she expects the nurse to wear clean gloves when accessing the IV and if the nurse touches anything else prior to accessing the IV line then they should change their gloves and perform hand hygiene right before they access the IV. V2 stated R117 is on contact isolation and enhanced barrier isolation and a gown should be worn by all staff anytime care is being performed so V10 should have worn a gown when administrating the IV medication. V2 stated the facility does not have a policy or procedure for preparation, administration, or maintenance related to IV therapy. V10 stated they do not provide training at the facility on administrating IV therapy, the nurse should already know how to do that.

Based on interview and record review, the facility failed to prevent peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. This failure resulted in R1, who is cognitively impaired and incapable of giving informed consent to inappropriate sexual touching and having unsolicited sexual comments directed toward her. These actions would cause a reasonable person to experience feelings of guilt, embarrassment, anger, and shame. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. R2's Face Sheet documented an admitted [DATE] and listed diagnoses including Diabetes Type 2 and End Stage Renal Disease Dependent on Dialysis. R2's MDS dated [DATE] documented a BIMS score of 14, indicating R2 is cognitively intact. R2's Nursing Progress Notes, authored by V9, Licensed Practical Nurse, documented the following: 1/11/25 at 12:25pm: (R2) is in common area visiting with a female resident . (R2) is rubbing up her right leg and arm and sweet talking her. Separated patients, asked female if she needed any help, female said she did not know who he was, but was not upset, but wanted separated. Staff took her to dining area for lunch. Will continue to monitor. 1/11/25 at 12:53pm: (R2) propelled self to dining area found same female patient. Female patient had her leg up on a chair and (R2) was rubbing her leg and above knee, he pulled her pant leg up. Touching inappropriately. Immediately separated again. Took female to different table different location. Had CNA (Certified Nursing Assistant) stay close by female. Asked female if she was upset about him touching her leg. She said she was not and didn't know who he was. 1/11/25 at 2:27pm: (R2) started to propel self to female patient again by common area. I told (R2) to keep his hands to himself and not touch her. He yelled at me that he planned on keeping his hands to himself and to leave him alone. R2's (Psychiatric Provider) Visit-Mental Status Exam dated 1/23/25 documented, (Daughter) notes variable cognitive function as does facility with sundowning like behavior and significant confusion which appears randomly and not associated with dialysis days or otherwise. Per facility reports, has increased fixation on another female resident, has noted this behavior within the last couple of weeks, last noted per chart review was 1/11/25. Increased sexual comments toward female staff, never attempting to make physical contact, last noted chart review was 1/12/25. Increased aggression and combativeness noted on 1/19/25, at this time he was noted to be actively exit seeking. Care Plan: Increase Sertraline to 100mg daily and add Hydroxyzine (antihistamine) 10mg one tablet every 6 hours as needed for agitation for 14 days while dosage adjustment is ongoing. On 2/14/25 at 1:45pm, V9, Licensed Practical Nurse, stated the female resident referred to in the 1/11/25 Nurse's Notes is R1. V9 stated, It was inappropriate of a man to touch a woman's leg, but she (V9) did not see it as sexual abuse as they were both clothed and he was just talking to her. V9 stated 1/11/25 was on a Saturday, and she reported the incident to either V2, Director of Nurses, or V7, Assistant Director of Nurses, one or the other of which was the Weekend Manager on Duty. On 2/14/25 at 9:20am, V7, Assistant Director of Nurses, stated she recalls in early January 2025 one of the nursing staff, whose identity she can't remember, had notified V7 that R2 was pushing R1 down the hall in her wheelchair, and V7 told staff to separate them as R2's gait is unsteady and both residents are a fall risk. V7 stated on 1/13/24, V3 and another CNA, possibly V4, told V7 that R2 had been seeking R1 out, talking to her, and getting possessive of her. V7 stated she notified V6, Social Services Designee, to begin tracking R2 for behaviors related to R1. V7 stated R2 had a history of being sexually inappropriate with staff, but not peers, so she did not think this behavior would progress into sexual abuse. On 2/13/25 at 10:40am, V3, Certified Nursing Assistant (CNA), stated on 1/28/25, R1 was sitting in her wheelchair in the doorway of her room as she enjoys doing. V3 stated he then witnessed R2, who had been self-propelling in the hallway, lift R1's shirt and touch R1's breast. V3 stated he and V4, CNA, who also witnessed the incident, immediately separated the residents and then immediately reported it to V2, Director of Nurses, as V1, Administrator was off that day. V3 stated both residents were separated for the remainder of the day. V3 stated he had not witnessed R2 ever act out in this way, but V3 stated he had previously reported to nursing staff that he felt R2 was showing too much interest in R1, seeking her out, trying to hold her hand, and being possessive of her. V3 stated the ongoing interventions in relation to R1 and R2 are to separate them if they are seen in close proximity. On 2/13/25 at 11:00am, V4, CNA, corroborated V3's account of the incident on 1/28/25. V4 stated as staff were separating R1 and R2, V4 heard R2 say to R1, Lets go have sex. V4 stated she had been, Noticing they (R1 and R2) had been becoming 'too friendly' for a couple weeks. V4 stated she has not known R2 to display this behavior toward peers, but he is very inappropriate with female staff, attempting to touch their breasts and buttocks and making sexual comments. V4 stated when transferring R2 the morning of 2/13/25, R2 had grabbed V4's buttocks, and when she pointed out the behavior, R2 stated, Yes I know, it was intentional. V4 stated interventions to prevent further abuse is that if R1 and R2 are seen in close proximity they are to be separated, and they are not to be seated together in the dining room or common areas. On 2/13/25 at 11:40am, V9, Licensed Practical Nurse, stated when she worked on 1/30/25, she heard about the incident in report. V9 corroborated V3 and V4's account of noticing R2 seeking R1 out, and We told the supervisors. V9 stated after the 1/28/25 incident, R2 has stated to her that, 'I know you're watching me and I don't have a woman in my room.' V9 stated R1 and R2 are no longer on 15 minute checks nor have either been on one on one monitoring. V9 stated staff are to, Monitor him (R2) and keep an eye on where he's going, and separate him from any female residents. R2's Progress Notes also document the following: 1/30/25 at 4:00pm, authored by V9: Following female residents around. CNA's helped him into recliner to rest. 1/30/25 at 4:30pm, authored by V2, Director of Nurses: After talking to CNA's it was noted that (R2) was behind a female resident in the hallway. He stopped to talk to her but there was no inappropriate actions and he did not make any inappropriate comments. On 2/13/25 at 12:40pm, V6, Social Services Designee, stated after the incident on 1/28/25, R2's Care Plan was updated to include the potential for sexual acting out behavior, and this was also added to R2's behavior tracking. V6 stated R2 has not had any further behaviors of this type. On 2/13/25 at 1:25pm, V2, Director of Nurses, stated CNA staff reported the incident on 1/28/25 to her immediately, and the residents had already been separated. V2 stated she began an immediate investigation in the absence of V1, who is the facility's Abuse Coordinator. V2 stated R1 and R2 were both placed on 15 minute checks. V2 stated R1 was moved to be closer to the nurse's station, and R2's Psychiatric Nurse Practitioner was contacted and gave an order to change his Hydroxyzine to 10mg one tablet twice daily. V2 stated both residents were assessed, and neither was injured. V2 stated immediately following the incident, neither resident remembered it. V2 stated none of the staff had informed her before the incident that R2 had been seeking R1 out. V2 stated R1 is always confused and R2 has periods of confusion especially during the evening with sundowning behavior. On 2/14/25 at 10:50am, V10, R1's Family Member, stated he was contacted about the incident on 1/28/25 by V2. V10 stated the solution the facility came up with was to move R1 to a room closer to the nurse's station. V10 stated he feels uneasy about R2 still moving freely about the facility, and potentially able to sexually abuse R1 or other female residents. V10 stated R1 is extremely confused and as such she is not capable of giving consent to sexual activity. V10 stated if R1 was not confused, she would not have agreed to sexual activity, and, She would have been extremely upset and angry, she would have been embarrassed, and she probably would have punched him (R1) in the throat. R1's Care Plan dated 1/31/25 documented a problem area, The resident has a behavior problem 1/28/25, (R1) involved in a resident to resident touching incident with corresponding interventions, Changed (R1's) room, added 1/28/25, and Every 15 minute checks for 24 hours, added 1/28/25. R2's Care Plan dated 1/31/25 documented a problem area, (R2) may display inappropriate sexual behavior, may make sexually inappropriate comments, with corresponding interventions, 1. Remove (R1) from the environment; 2. Ensure others safety- remove other resident from environment. 3. Ensure (R1's) safety. 4. Encourage to discuss feelings. 5. Try a different caregiver. 6. Offer to call family. On 2/13/25 at 9:45am, R1 was observed lying in her bed. R1 was alert only to herself, R1 could only give her name, and could not give the date or the name of the facility. On 2/13/25 at 9:55am, R2 was observed up in a wheelchair in his room. R2 stated he is currently in a hospital, gave the date as February 2024 date and day of the week unknown, but could name the current President. R2 stated he does like to self-propel out of his room and go out into the hall and dining room. When asked if R2 had displayed any sexually inappropriate behavior toward residents or staff, R2 stated I assume you mean molesting. Anytime I am alone with a woman, staff finds a reason to separate us. They don't like us being more than friends. When asked if there are any female peers with whom he is more than friends, R2 stated, There is one lady, they thought we were too close, I can't remember her name, but anyway nothing happened. R2 denied touching any peers inappropriately, nor any peers touching him inappropriately. A Final Report submitted to Illinois Department of Public Health (IDPH) dated 2/3/25 documented, The purpose of this letter is to notify the Department of our conclusion of an incident that occurred in the facility on 1/28/25. (R2) was in his wheelchair in the hall. He was observed stopping near (R1) and placed his hand under her shirt and touched her breast. (R1) then placed her hand in (R2's) lap. They were immediately separated by staff. As staff were separating them, (R1) stated, That's my boyfriend. Licensed staff initiated a head to toe assessment on both residents noting no injury. The facility's Abuse, Prevention, and Prohibition Policy dated December, 2024 documented, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident capacity to consent to sexual activity: Generally, sexual contact is nonconsensual if the resident either appears to want the contact to occur, but lacks cognitive ability to consent, or does not want the contact to occur.

Based on interview, observation, and record review, the facility failed to report to the facility Administrator or his/her designated representative an incident of peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. The same MDS documented that R1 is dependent on staff for transfers and wheelchair mobility. R1's Care Plan dated 1/31/25 documented a problem area, The resident has a behavior problem 1/28/25, (R1) involved in a resident to resident touching incident with corresponding interventions, Changed (R1's) room, added 1/28/25, and Every 15 minute checks for 24 hours, added 1/28/25. R2's Face Sheet documented an admitted [DATE] and listed diagnoses including Diabetes Type 2 and End Stage Renal Disease Dependent on Dialysis. R2's MDS dated [DATE] documented a BIMS score of 14, indicating R2 is cognitively intact. The same MDS documented that R2 uses a manual wheelchair independently. R2's Care Plan dated 1/31/25 documented a problem area, (R2) may display inappropriate sexual behavior, may make sexually inappropriate comments, with corresponding interventions, 1. Remove (R1) from the environment; 2. Ensure others safety- remove other resident from environment. 3. Ensure (R1's) safety. 4. Encourage to discuss feelings. 5.Try a different caregiver. 6. Offer to call family. R2's Nursing Progress Notes, authored by V9, Licensed Practical Nurse, documented the following: 1/11/25 at 12:25pm: (R2) is in common area visiting with a female resident. (R2) is rubbing up her right leg and arm and sweet talking her. Separated patients, asked female if she needed any help, female said she did not know who he was, but was not upset, but wanted separated. Staff took her to dining area for lunch. Will continue to monitor. 1/11/25 at 12:53pm: (R2) propelled self to dining area found same female patient. Female patient had her leg up on a chair and (R2) was rubbing her leg and above knee, he pulled her pant leg up. Touching inappropriately. Immediately separated again. Took female to different table different location. Had CNA (Certified Nursing Assistant) stay close by female. Asked female if she was upset about him touching her leg. She said she was not and didn't know who he was. 1/11/25 at 2:27pm: (R2) started to propel self to female patient again by common area. I told (R2) to keep his hands to himself and not touch her. He yelled at me that he planned on keeping his hands to himself and to leave him alone. There was no documentation in the medical record to indicate these interactions were reported to the facility's Abuse Coordinator. On 2/13/25 at 9:45am, R1 was observed lying in her bed. R1 was alert only to herself, R1 could only give her name, and could not give the date or the name of the facility. On 2/13/25 at 9:55am, R2 was observed up to the wheelchair in his room. R2 stated he is currently in a hospital, gave the date as February 2024 date and day of the week unknown, but could name the current President. R2 stated he does like to self-propel out of his room and go out into the hall and dining room. When asked if R2 had displayed any sexually inappropriate behavior toward residents or staff, R2 stated I assume you mean molesting. Anytime I am alone with a woman, staff finds a reason to separate us. They don't like us being more than friends. When asked if there are any female peers with whom he is more than friends, R2 stated, There is one lady, they thought we were too close, I can't remember her name, but anyway nothing happened. R2 denied touching any peers inappropriately, nor any peers touching him inappropriately. On 2/14/25 at 1:45pm, V9 stated the female resident referred to in the 1/11/25 Nurse's Notes is R1. V9 stated, It was inappropriate of a man to touch a woman's leg, but she (V9) did not see it as sexual abuse as they were both clothed and he was just talking to her. V9 stated 1/11/25 was on a Saturday, and she reported the incident to either V2, Director of Nurses, or V7, Assistant Director of Nurses, one or the other of which was the Weekend Manager on Duty. On 2/14/25 at 1:55pm, V1, Administrator, confirmed she is the facility's Abuse Coordinator. V1 stated she had not been made aware of the interactions between R1 and R2 as outlined in R2's Nurse's Notes on 1/11/25, and there was no abuse investigation initiated . V1 stated V9 did not believe the interactions qualified as sexual abuse. V1 stated even if V9 reported it to V2 or V7, V9 should have immediately reported it to V1. On 2/14/25 at 9:20am, V7, Assistant Director of Nurses, stated she recalls in early January 2025 one of the nursing staff, whose identity she can't remember, had notified V7 that R2 was pushing R1 down the hall in her wheelchair, and V7 told staff to separate them as R2's gait is unsteady and both residents are a fall risk. V7 stated on 1/13/24, V3 and another CNA, possibly V4, told V7 that R2 had been seeking R1 out, talking to her, and getting possessive of her. V7 stated she notified V6, Social Services Designee, to begin tracking R2 for behaviors related to R1. V7 stated R2 had a history of being sexually inappropriate with staff, but not peers, so she did not think this behavior would progress into sexual abuse. The facility's Abuse, Prevention, and Prohibition Policy dated December, 2024 documented The facility Administrator will be designated as the facility's Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Reporting/Response: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence.

Based on interview and record review, the facility failed to report, investigate, and further prevent peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. The same MDS documented that R1 is dependent on staff for transfers and wheelchair mobility. R1's Care Plan dated 1/31/25 documented a problem area, The resident has a behavior problem 1/28/25, (R1) involved in a resident to resident touching incident with corresponding interventions, Changed (R1's) room, added 1/28/25, and Every 15 minute checks for 24 hours, added 1/28/25. R2's Face Sheet documented an admitted [DATE] and listed diagnoses including Diabetes Type 2 and End Stage Renal Disease Dependent on Dialysis. R2's MDS dated [DATE] documented a BIMS score of 14, indicating R2 is cognitively intact. The same MDS documented that R2 uses a manual wheelchair independently. R2's Care Plan dated 1/31/25 documented a problem area, (R2) may display inappropriate sexual behavior, may make sexually inappropriate comments, with corresponding interventions, 1. Remove (R1) from the environment; 2. Ensure others safety- remove other resident from environment. 3. Ensure (R1's) safety. 4. Encourage to discuss feelings. 5.Try a different caregiver. 6. Offer to call family. R2's Nursing Progress Notes, authored by V9, Licensed Practical Nurse, documented the following: 1/11/25 at 12:25pm: (R2) is in common area visiting with a female resident. (R2) is rubbing up her right leg and arm and sweet talking her. Separated patients, asked female if she needed any help, female said she did not know who he was, but was not upset, but wanted separated. Staff took her to dining area for lunch. Will continue to monitor. 1/11/25 at 12:53pm: (R2) propelled self to dining area found same female patient. Female patient had her leg up on a chair and (R2) was rubbing her leg and above knee, he pulled her pant leg up. Touching inappropriately. Immediately separated again. Took female to different table different location. Had CNA (Certified Nursing Assistant) stay close by female. Asked female if she was upset about him touching her leg. She said she was not and didn't know who he was. 1/11/25 at 2:27pm: (R2) started to propel self to female patient again by common area. I told (R2) to keep his hands to himself and not touch her. He yelled at me that he planned on keeping his hands to himself and to leave him alone. There was no documentation in the medical record to indicate these interactions were reported to the facility's Abuse Coordinator. R2's (Psychiatric Provider) Visit-Mental Status Exam dated 1/23/25 documented, (Daughter) notes variable cognitive function as does facility with sundowning like behavior and significant confusion which appears randomly and not associated with dialysis days or otherwise. Per facility reports, has increased fixation on another female resident, has noted this behavior within the last couple of weeks, last noted per chart review was 1/11/25. Increased sexual comments toward female staff, never attempting to make physical contact, last noted chart review was 1/12/25. Increased aggression and combativeness noted on 1/19/25, at this time he was noted to be actively exit seeking. Care Plan: Increase Sertraline to 100mg daily and add Hydroxyzine (antihistamine) 10mg one tablet every 6 hours as needed for agitation for 14 days while dosage adjustment is ongoing. On 2/14/25 at 1:45pm, V9, Licensed Practical Nurse, stated the female resident referred to in the 1/11/25 Nurse's Notes is R1. V9 stated, It was inappropriate of a man to touch a woman's leg, but she (V9) did not see it as sexual abuse as they were both clothed and he was just talking to her. V9 stated 1/11/25 was on a Saturday, and she reported the incident to either V2, Director of Nurses, or V7, Assistant Director of Nurses, one or the other of which was the Weekend Manager on Duty. On 2/14/25 at 9:20am, V7, Assistant Director of Nurses, stated she recalls in early January 2025 one of the nursing staff, whose identity she can't remember, had notified V7 that R2 was pushing R1 down the hall in her wheelchair, and V7 told staff to separate them as R2's gait is unsteady and both residents are a fall risk. V7 stated on 1/13/24, V3 and another CNA, possibly V4, told V7 that R2 had been seeking R1 out, talking to her, and getting possessive of her. V7 stated she notified V6, Social Services Designee, to begin tracking R2 for behaviors related to R1. V7 stated R2 had a history of being sexually inappropriate with staff, but not peers, so she did not think this behavior would progress into sexual abuse. A Final Report submitted to Illinois Department of Public Health (IDPH) dated 2/3/25 documented, The purpose of this letter is to notify the Department of our conclusion of an incident that occurred in the facility on 1/28/25. (R2) was in his wheelchair in the hall. he was observed stopping near (R1) and placed his hand under her shirt and touched her breast. (R1) then placed her hand in (R2's) lap. They were immediately separated by staff. As staff were separating them, (R1) stated, That's my boyfriend. Licensed staff initiated a head to toe assessment on both residents noting no injury. On 2/13/25 at 10:40am, V3, Certified Nursing Assistant (CNA), V3 stated he had previously reported to nursing staff that he felt R2 was showing too much interest in R1, seeking her out, trying to hold her hand, and being possessive of her. V3 stated the ongoing interventions in relation to R1 and R2 are to separate them if they are seen in close proximity. On 2/13/25 at 11:00am, V4 stated she had been, Noticing they (R1 and R2) had been becoming 'too friendly' for a couple weeks. V4 stated she has not known R2 to display this behavior toward peers, but he is very inappropriate with female staff, attempting to touch their breasts and buttocks and making sexual comments. V4 stated when transferring R2 the morning of 2/13/25, R2 had grabbed V4's buttocks, and when she pointed out the behavior, R2 stated, Yes I know, it was intentional. V4 stated interventions to prevent further abuse is that if R1 and R2 are seen in close proximity they are to be separated, and they are not to be seated together in the dining room or common areas. On 2/13/25 at 12:40pm, V6, Social Services Designee, stated after the incident on 1/28/25, R2's Care Plan was updated to include the potential for sexual acting out behavior, and this was also added to R2's behavior tracking. V6 stated R2 has not had any further behaviors of this type. On 2/13/25 at 1:25pm, V2, Director of Nurses, stated CNA's staff reported the 1/28/25 incident to her immediately, and the residents had already been separated. V2 stated she began an immediate investigation in the absence of V1, who is the facility's Abuse Coordinator. V2 stated to her knowledge, R2 had no previous history of peer to peer sexually inappropriate behavior. When asked what ongoing interventions are in place to prevent further abuse, V2 stated staff are to, Make sure he (R2) is not near any female residents and check on him, not necessarily within any specific time frame. But if staff are going by his room, they are to look in and see what he's doing and if he has any more sexual behaviors, staff are to report it to me. V2 stated none of the staff had informed her before the 1/28/25 incident that R2 had been seeking R1 out. V2 stated when R2 was seen on 1/30/25 following female residents around, he was not placed back on 15 minute checks. V2 stated at no time was R2 getting one to one staff supervision. V2 stated, We don't provide that here, if a resident needs one on one, we notify the family that they will need to provide it. On 2/14/25 at 1:55pm, V1, Administrator, confirmed she is the facility's Abuse Coordinator. V1 stated she had not been made aware of the interactions between R1 and R2 on 1/11/25, and there was no abuse investigation initiated. V1 stated V9 did not believe the interactions qualified as sexual abuse. V1 stated even if V9 reported it to V2 or V7, V9 should have immediately reported it to V1. On 9:45am at 2/13/25, R1 was observed lying in her bed. R1 was alert only to herself, R1 could only give her name, and could not give the date or the name of the facility. On 2/13/25 at 9:55am, R2 was observed up to the wheelchair in his room. R2 stated he is currently in a hospital, gave the date as February 2024 date and day of the week unknown, but could name the current President. R2 stated he does like to self-propel out of his room and go out into the hall and dining room. When asked if R2 had displayed any sexually inappropriate behavior toward residents or staff, R2 stated I assume you mean molesting. Anytime I am alone with a woman, staff finds a reason to separate us. They don't like us being more than friends. When asked if there are any female peers with whom he is more than friends, R2 stated, There is one lady, they thought we were too close, I can't remember her name, but anyway nothing happened. R2 denied touching any peers inappropriately, nor any peers touching him inappropriately. The facility's Abuse, Prevention, and Prohibition Policy dated December, 2024 documented, Investigation: Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is underway, steps will be taken to prevent further abuse. Resident Capacity to Consent to Sexual Activity: Generally, sexual contact is nonconsensual if the resident either appears to want the contact to occur, but lacks cognitive ability to consent, or does not want the contact to occur. The facility Administrator will be designated as the facility's Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Reporting/Response: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence.

Based on interview, and record review the facility failed to ensure residents were safe from misappropriation of a controlled substance medication for 1 of 3 residents (R2) reviewed for misappropriation in a sample of 8. The findings include: R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been made. The facility has initiated an investigation into the matter. A final report will follow. R2's facility Final Report dated 8/26/24 documents in part: The purpose of this letter is to notify The Department of our conclusion of the investigation into a possible drug diversion. Licensed staff had administered the resident's 8 am dose. At 10 am when the Licensed Nurse went to administer the morphine, the bottle of morphine could not be located. The physician, POA (Power of Attorney), (City) Police and the Ombudsman were notified. The Administrator and Nursing Administration initiated a search of the facility and facility grounds. The medication was not located. An investigation was initiated. The Licensed Nurse, (V4) was overseeing the medication cart. He was suspended pending the outcome of the facility. The hospice nurse was notified of the Morphine bottle not being located. The facility asked Hospice to replace the Morphine and bill the facility. The Morphine was replaced. Licensed staff initiated a pain assessment. (R2) showed no changes in his pain level. Residents were interviewed. Residents were not aware of any issues with medications and had not observed the medication. All staff working were interviewed. Staff stated that they had not observed the morphine out of the cart and had no knowledge of where the medication was. (V11) LPN (Licensed Practical Nurse) was the night shift nurse and was still working till approximately 10:30 am finishing the charting for her shift. (V11) stated that the medication cart was in front of the nurse's station. She stated that (V4) had administered the 8 am dose of Morphine. (V11) said that she did not observe (V4) place the Morphine bottle in the cart and lock it as she had her back to him charting at the nurse's desk. (V11) stated at approximately 10:00 am (V4) went to the medication cart to administer the 10:00 am dose of Morphine and he stated it was not in the cart. She stated that he began looking for the medication and Nurse Management was notified. (V11) was asked if she observed the bottle of Morphine on top the cart and she stated No, she did not. She was also asked if the medication cart was locked. She stated that she was finishing charting, and her back was toward the cart. (V4) LPN was interviewed by the Director of Nursing and Regional Nurse via phone. He stated that he had given the resident his 8 am dose of medication. (V4) stated he placed the empty syringe back into the morphine box and placed everything in the medication cart and locked the cart. He stated that at approximately 10 am he went to the cart, unlocked the cart, and was going to give the medication but was unable to locate the morphine in the cart. (V4) stated that he searched the cart and could still not locate the medication. He stated that he checked the trash can on the med cart and at the nurse's desk. (V4) stated that he checked the second medication cart and the treatment cart but was not able to locate the medication. He then notified Nurse Management and Nurse Management began looking for the Morphine. (V4) was asked if he placed the medication back in the cart and locked the cart after administering the 8 am dose and he said yes, that is my routine. He was asked if he unlocked the cart when he was getting ready to administer the 10 am dose and he said yes. (V4) said after he was sent home, he was retracing his steps in his head and was second guessing everything he did. (V4) denied taking the medication and volunteered for drug testing. (V4) submitted a drug test, and the results were negative. An audit of all narcotics in the facility was completed and no other issues were noted. Following the investigation, based on interviews, the facility is not able to determine what happened to the morphine and cannot substantiate drug diversion. There is no evidence indicating (V4) took the medication. The facility is unable to locate the Morphine, and the search is ongoing. The morphine was replaced at the cost of the facility. All Licensed staff were educated by the Director of Nursing regarding Medication Administration, medication storage, and narcotic count between shifts. (V4) will be allowed to return to work. Prior to returning to work, the Director of Nursing completed education regarding Medication Administration, medication storage, and narcotic count between shifts. R2's admission record documents an admitted [DATE] and a discharge date of [DATE]. with diagnoses in part; encounter for palliative care (admitting diagnosis), atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, chronic pain, colostomy status, cervicalgia, osteoarthritis, chronic pulmonary embolism. R2's order summary report documents in part an order dated 7/29/24, resident is under Transition hospice care. R2's Medication Administration Record (MAR) for September, with a print date of 10/8/24 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 2 hours for pain with a start date of 8/24/24. R2's MAR documents that he received his scheduled doses of Morphine at 8:00 and 10:00am on 9/20/24. A facility document titled INDIVIDUAL RESIDENT CONTROLLED SUBSTANCE RECORD dated 8/19/24 with R2's name handwritten on it documents the medication as Morphine Sulfate 20mg/ml and the quantity received as 30ml. The last documented dose administered on this document is on 8/20/24 at 9:00am, the amount given is 0.5 with 24ml remaining. R2's ordered dose was 0.5mg, indicating there were 48 doses left in the bottle. On 10/8/24 at 12:03pm, V5 (Licensed Practical Nurse/LPN) stated she was here the day the morphine went missing, everyone was looking for it. It was never found. There was big investigation done and lots of education and inservice. On 10/9/24 at 12:29pm, V2 (Director of Nursing) stated as soon as they were alerted that morphine was missing, they contacted hospice and started the process of getting a replacement. V2 stated they received the medication very quickly; the pharmacy delivered it and R2 received the dose within the appropriate time frame. V2 stated R2 was being assessed for pain frequently while waiting for the replacement bottle. V2 stated the missing bottle was never located after a search of the property and investigation. On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and V11 (LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything was fine. V4 stated he is certain he drew up R2's medication and locked the bottle back into the cart, as that is his common practice. V4 stated that since this incident happened, he has been replaying it in his mind and second guessing himself, however he stated he sees no reason why he would have done things any differently. V4 stated he was the only one suspended and investigated. V4 stated the other nurse working with him told him and administration there was a CNA that does transport standing by his cart, she then went to the bathroom and went to a patient room. V4 stated that this CNA was questioned, but not investigated. V4 stated the medication was never found. The Facility's Abuse, Prevention and Prohibition Policy revised 1/24 documents in part, This facility prohibits mistreatment, neglect, or abuse of residents. This 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. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property.

Based on interview and record review the facility failed to prevent residents from receiving medical treatment without a doctor's order for 1 (R1) of 3 residents reviewed for physician's orders in a sample of 8. Findings include: R1's admission record documents an admitted [DATE] with diagnoses in part; type II diabetes mellitus with hypoglycemia without coma, paroxysmal atrial fibrillation, other seizures, unspecified convulsions. R1's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview for mental status) of 12, indicating that R1 is cognitively intact . R1's order summary sheet documents an order for ACCUCHECK every two hours from the ER (emergency room ) for hypoglycemia with a start date of 3/4/24 and a discontinue date of 6/20/24. On 3/19/24 R1's Medication Administration Record documented accuchecks every two hours, most of R1's accuchecks were between 80 and 162, which is not considered to be hypoglycemic. There is an accucheck at 12pm of 46, which is considered hypoglycemia, but there is no further documentation in R1's clinical record, including progress notes. R1's order summary sheet documents an order for Glucagon Emergency Injection Kit, 1 MG (milligram) (Glucagon (rDNA))-Inject 1 application intramuscularly as needed for low blood sugar with a start date of 2/20/24. There is no documentation that the glucagon was administered on 3/19/24. On 10/8/24 at 1:40pm, R1 stated his blood sugars have been pretty good lately and he could not recall if anyone tried to start an IV on him in this facility. On 10/8/24 at 1:51pm, V2 (Director of Nursing/DON) stated they had an incident in March involving V3 (Licensed Practical Nurse/LPN) attempting to start an IV (intravenous) without a physician's order. V2 stated V3 was not successful starting the IV, no medications were administered, but V3 was disciplined, and staff education was done. V2 stated V3 had spoken with V6 (the nurse at the doctor's office) previously about this resident and V6 stated if R1 continued to have such drastic drops in his blood sugar they would need to get a standing order to give dextrose via IV. V2 stated V6 did not give a standing order at that time. V2 stated that they do not have a specific policy or protocol to low blood sugars, but each resident who is under blood glucose monitoring should have standing orders for such situations. On 10/08/24 at 1:51pm, V2 (DON) provided a copy of facility document titled Employee disciplinary action form for V3 with an incident date of 03/19/24 stated V3 did not follow departmental Policies and procedures. This document further stated that V3 did not get an order from MD prior to initiating a medical procedure/medication and that there was no documentation of residents low CBG (Capillary Blood Glucose). V2 provided a statement from V6 that she did not give a standing order for IV dextrose and a signature sheet from their staff in-service.

Based on interview and record review the facility failed to provide adequate supervision for residents with dementia for 2 (R3 and R4) of 5 residents reviewed for dementia care services in the sample of 8. Findings include: A facility incident report dated and timed 9/15/24 at 11:08am, documents the following incident description in part: A Housekeeper helping another patient to her room walking in room [ROOM NUMBER]. When opened room [ROOM NUMBER] housekeeper witnessed (R4) standing in front of female patient with his pants open and down-with suspenders holding pants part way up. Female resident was in her room on her bed, fully clothed. Female patient had her mouth open providing oral sex to (R4). (R4) turned around and pulled up his pants, he told staff he was receiving help with is belt. Both patients immediately separated themselves, he went to his room. Female patient states she thinks (R4) is her husband and she wants to be with him. When staff asked (R4) if he knew her, he says he doesn't know her, just some lady around here. He said he needed help adjusting his belt. He denied what was going on. He asked if they were in trouble . An investigation was initiated following the interaction. Staff present at the time of the incident were interviewed. (R3) stated she didn't understand why staff won't let me be with my husband. Both residents were put on 1:1 for 24 hours after the incident. Both resident's Physicians were notified, and no new orders were received. There have been no further incidents. Residents were interviewed. The residents interviewed have had no issues with either of the residents involved. (R3) was interviewed. She does not recall the incident. (R4) was interviewed. He does not recall the incident. The Ombudsman was notified and stated that both parties were consenting. A trauma assessment was completed for both residents, identifying no new issues. Behavior tracking was initiated for both residents. Their care plans were reviewed and updated. Social services will visit with each resident twice weekly for 30 days. After reviewing the incident, it is our conclusion that during the incident both residents were consenting adults. A facility correspondence with IDPH titled Final Report dated 09/20/24 documents in part: The purpose of this letter is to notify The Department of our conclusion to a reported incident. On 9/15/24, staff observed an interaction between two residents, (R3) and (R4). Staff immediately separated the residents. Licensed Staff initiated a head-to-toe assessment noting no injuries. MD( Medical Doctor) and POA (Power od Attorney) made aware. Local police were notified. Ombudsman was notified. On 10/08/24 at 2:51pm, V1 Administrator stated that the incident on 9/15/24, between R3 and R4 was consensual, but provided no evidence during this investigation that R3 and R4 had been screened and identified as having the cognitive ability to provide consent. 1. R4's admission record documents an admitted [DATE] with the diagnoses in part: Alzheimer's disease, other symptoms and signs involving cognitive functions and awareness, altered mental status. R4's Minimum data set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 3, indicating that R4 is severely cognitively impaired. R4's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of 9/16/24 and a revision date of 9/27/24 with interventions including in part: Behavior #1: Inappropriate sexual conduct towards others (i.e.: inappropriate touching, purposeful exposure of genitals to others, etc.) Remove from area, ensure (R4)'s safety, encourage to discuss feelings, try a different care giver, offer to call family. Monitor behavior episodes and attempt to determine underlying cause. R4's POC response history with a print date of 10/8/24 documents that R4 displayed inappropriate sexual conduct toward others on 9/24/24 and 10/1/24, intervention used for both occurrences was redirection. R4's progress notes document in part the following: On 9/15/24 at 1:42pm, (R4) was looking for female friend and went into her room looking for her .staff asked him to get out of her room and he became agitated. On 9/15/24 at 2:02pm, (R4) was standing outside lady friend's room, waiting on her to come to her room it appears. Staff asked him what he was doing. He said he's looking for someone. Asked to stay out of room [ROOM NUMBER]. Informed him 121 was a female room. He opened the door twice and was inside once. On 09/16/2024 at 4:20pm, SSD (Social Services Director) met with (R4) today and conducted BIMS, PHQ9 (Patient Health Questionnaire-9) , and trauma informed consent. (R4) states he feels safe in his environment. No other concerns at this time. On 9/22/24 at 2:48am, Resident was seen wandering into another resident's room, resident went into a female resident's room and was trying to wake her to leave, resident was redirected back to bed by staff, continue to monitor closely. Continue current plan of care. On 9/27/24 at 9:05am, Resident went into a female resident's room and was trying to get her to go with him. On 9/27/24 at 1:59pm, Resident was in another female resident's room. Redirected back to his room. On 10/1/24 at 10:01am, Resident tried to get female resident to go in his room. The other resident refused, and he stated, I guess you don't want to have sex with me. On 10/9/24 at 12:30pm, V8 (Registered Nurse/RN) stated it is known that they are supposed to keep a close eye on R4 but there really isn't anything specifically laid out in his care plan or behavior tracking related to his level of supervision. V8 stated that R4 was supposed to be one on one for the first 24 hours after the incident happened. V8 stated she was not familiar if there was anything that the CNA's were supposed to chart specifically but nurses were expected to chart on R4 any time a behavior is observed. On 10/9/24 at 1:15pm, V9 (Restorative Aide) stated that everyone on the unit is to be under close supervision. V9 stated he was not sure if there was any specific supervision in place for R4. 2. R3's admission record documents an admitted [DATE] with diagnoses including in part; Alzheimer's and dementia. R3's Minimum Data Set (MDS) documents a Brief Interview for Mental status (BIMS) of 07, indicating that R3 is severely cognitively impaired. R3's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of 9/16/24 with interventions including in part: Behavior #1: Inappropriate sexual conduct towards others (i.e.: inappropriate touching, purposeful exposure of genitals to others, etc.) Remove from area, ensure (R3)'s safety, encourage to discuss feelings, try a different care giver, offer to call family. Monitor behavior episodes and attempt to determine underlying cause. On 9/15/2024 at 11am, Roommate came to housekeeper and said she needed help getting in her room. Housekeeper was helping 121-2 patient back to her room, she knocked on the door 121 and opened it for roommate to walk in. Housekeeper witnessed (R3) sitting on bed fully clothed with her mouth open giving oral sex to a male patient. Male patient was standing in front of her with his pants open and down-with suspenders holding pants part way up. Male resident turned around and pulled up his pants, he said he was receiving help with is belt. (R3) and male patient immediately separated themselves, he went to his room. (R3)'s face was red. She appeared embarrassed. She asked why she can't be with her husband . (her husband is not here/alive) Re-oriented her that she is in nursing home and her husband is no longer around. (R3) insist we separated her from her husband and is asking why. (R3) said she brought him to her room. Male patient says he doesn't know her, just some lady around here he said . On 9/16/24 at 4:17pm, SSD (Social services director) met with (R3) today. Conducted BIMS, PHQ9 (Patient Health Questionnaire-9), and trauma informed consent. (R3) was very confused today and displayed disorganized thinking. She states she feels safe in her environment. On 10/9/24 at 1:21pm, R3 was observed ambulating down the hallway away from her room. R3 stopped and proceeded to stand in R4's doorway and then walked inside while R4 was laying on his bed. Staff was alerted and redirected R3. On 10/9/24 at 1:27pm, V10 (CNA/Certified Nursing Assistant) stated everyone on the locked unit is under close supervision. V10 stated R3 and R4 were both in the unit on 9/15/24. V10 stated R3 and R4 were both one on one supervision for the first 24 hours after the incident. V10 stated they really try to prevent anyone going into the room of someone of the opposite sex. V10 stated that they do chart behaviors if R4 has them, but that they do not have any specific time frame for checking on him. There is no documentation in R3 or R4's current clinical records of any discussion or education with them, their representative, or physician regarding consent. There is nothing in R3 and R4's care plans regarding consent. Facility document titled, Abuse, Prevention and Prohibition with a revision date of 1/24, under the section titled Protection, The facility will immediately remove any alleged perpetrator from any further contact with any resident. Further on in this document in the section Resident capacity to consent to sexual activity it states generally, sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. This document states that if there are 2 residents who wish to have a sexual relationship, the following steps will be followed: A one-on-one discussion with each individual must be held to ensure they are consenting to an intimate relationship with the other resident. The discussion will define the type of relationship that is desired. For a resident who DOES NOT have the capacity to consent, the Resident Representative will be contacted to discuss resident wishes. If the Resident Representative DOES NOT AGREE with the resident choice, then there will be a resident, Resident Representative, IDT meeting to discuss plan of care. Provider will be notified of resident and Resident Representative wishes. Discussion and consents to be documented in the clinical record and care plan updated to reflect the resident and/or Resident Representative wishes. Education will be provided to both residents involved and when appropriate the Resident Representative on risk vs. benefits of the relationship, what is consented by both parties, and any safety information needed. The Education provided will be documented in the clinical record and the care plan updated.

Based on interview and record review, the facility failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for 1 of 3 residents (R2) reviewed for narcotic medication in a sample of 8. The findings include: R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been made. The facility has initiated an investigation into the matter. A final report will follow. R2's facility Final Report dated 8/26/24 documents in part an undated and untimed interview with V11 (LPN/Licensed Practical Nurse). V11 stated she stayed over from midnight shift to help pass the back half of 300 hall medications. V11 stated she and V4 (LPN) counted the narcotics for the front part of the hallway but not the back because she was still using the cart to pass medications. V11 stated R2's narcotic medication was on the cart for the back half of the hall. V11 stated she gave V4 the keys for the cart for the back half between 9:00am and 9:15am and they did not perform a count. On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and V11 (LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything was fine. On 10/8/24 at 12:03pm, V5 (LPN) stated count should be done anytime a nurse is taking over responsibility of a med cart from another nurse. On 10/9/24 at 10:07am, V7 (RN/Registered Nurse) stated count should be done anytime you are assuming responsibility from someone else for those medications. On 10/09/24 at 2:20pm, V2 (DON) stated that narcotics should be counted any time that a nurse is taking over responsibility for the cart and before anyone leaves. A facility document titled, Employee corrective action form for V4 dated 8/20/24 documents in part a failure to follow departmental policies and procedures, by not counting narcotics with nurse from previous shift and not properly storing narcotics after administration. A facility document titled, Employee corrective action form for V11, dated 08/20/24 documents in part a failure to follow departmental policies and procedures, by not counting narcotics with oncoming nurse. Facility controlled substance policy documents in part; The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the oncoming licensed nurse here applicable and the off-going licensed nurse where applicable.

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 3 (R3) residents reviewed for abuse in a sample of 11. This failure resulted in (V21), Registered Nurse telling R3 to go away and get lost she was too tired for this nonsense and if he didn't she was going to kick him in the forehead. This would cause a reasonable person to react with feelings of fear, anxiety, and humiliation. This past non-compliance occurred between 5/26/24 and 5/28/24. Findings Include: The initial incident report received by the Illinois Department of Public Health on 5/26/24 documents an incident date of 5/26/24. The Initial Incident Description documents Resident: (R3). The purpose of this letter is to notify the Department of allegations reported by staff regarding alleged verbal abuse between a nurse and resident. The untitled document dated 5/31/24 documents it is the Final report of an abuse allegation related to R3. This same report documents, It was immediately reported to the Director of Nursing that (R3) had propelled himself to the nurse's desk where two staff members were sitting and asked if they knew anything about small motors. The C.N.A. (Certified Nursing Assistant-V4) sitting at the desk reported it was at that time the Registered Nurse (V21) said to the resident (R3) 'go away, and get lost, I am too tired for this nonsense.' She also stated that if he didn't, she would 'kick him in the forehead.' This nurse was immediately suspended, and her agency was notified of the incident. POA (power of attorney), ombudsman, local police, and MD (physician) were notified. An investigation was initiated. (R3) was interviewed. He does not recall the incident. Staff were interviewed. Other than the staff member reporting the incident, no one had knowledge of the incident and reported that they have not heard or observed (V21) be abusive. Residents were interviewed. Residents had no concerns regarding care by this nurse. Residents interviewed were not aware of any abuse. Following the investigation, based on statements, the facility substantiated the allegation. The abuse was reported to the agency she (V21) works for. She was put on a DO NOT return list for our facility. Social services will follow up with (R3) twice a week for 30 days to ensure no further issues. R3's Admission Record with a print date of 6/24/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include heart disease, dementia, anxiety disorder, and mild cognitive impairment. R3's Minimum Data Set, dated dated dated [DATE] documents R3 has a severe cognitive impairment. R3's current undated Care Plan documents a Focus area of (R3) has a potential psychosocial well-being problem .5/27/24 (R3) was in an incident with a staff member with an allegation of verbal abuse The Interventions include, Social services will meet with (R3) twice weekly for 60 days to ensure he has no effects of alleged verbal abuse. On 6/20/24 at 2:53 PM, V4 (Certified Nursing Assistant/CNA) stated she was working with V21 (RN/Registered Nurse) and she had been stand-offish towards the residents. V4 stated she was sitting at the nurse's station charting and R3 rolled behind the desk and was sitting next to her. V4 stated R3 asked if they knew anything about small motors and V21 stated to R3, get out of here. V4 stated she suggested R3 go to his room or the dining room. V4 stated R3 stayed at the nurse's station and V21 told R3, I said get out of here, go on, get. V4 stated then V21 stated, If you don't get out of here on the count of 5, I am going to kick you in the forehead. V4 stated V21 then said and you don't know how high I can jump. V4 stated she backed R3 up and rolled him to his room and asked him to stay there. V4 stated she answered a call light and told V21 she would be back. V4 stated she went to the other hall and told the other nurse what had happened who reported it to the charge nurse. V4 stated the administrator was called and the other nurse's working walked V21 to the conference room. V4 stated they talked with V21 and then walked with her down the hall to do a narcotics count before walking her out the door. When asked if she felt like what occurred was abuse, V4 stated, Yes, the look on her (V21) face made it look like she meant it. V4 stated it was a hey, get away from me or else I am going to hurt you. When asked if she felt like the facility handled it appropriately, V4 stated, Yes, they walked her out. V4 stated as far as she knows V21 had not been back to the facility. The untitled statement included in the abuse investigation signed by V21 (RN,Registered Nurse ) documents, (R3) approached desk CNA and nurse were at. He (R3) said something very sexual. I was upset, as I've been assaulted before and have not slept in nearly 24 hours. I don't recall what I said beyond trying to get him away On 6/25/24 at 2:03 PM, V2 (Director of Nurses) stated administration was notified V21 had threatened to kick R3 in the forehead. V2 stated they immediately got V21 and had her count narcotics with another nurse, and then sent V21 home. V2 stated they contacted V21's agency employer and told them they had sent her home due to an allegation of abuse. V2 stated they started the investigation and determined abuse had occurred. V2 stated they notified V21's employer that the allegation was founded. V2 stated V21 said she didn't recall her exact words to R3. V2 stated they educated all staff on abuse/neglect on 5/27/24, they conducted a QAPI (Quality Assurance and Performance Improvement) meeting on 5/28/24, interviewed the residents on 5/27/24, and are completing on-going audits. The facility Abuse, Prevention and Prohibition Policy dated 01/24 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This 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. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Under Prevention the policy documents, the resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. R3 was assessed and no injuries were noted. R3 was interviewed and does not recall the incident. 2. The nurse, V21 was immediately sent home. 3. Direct care staff were provided education on the abuse policy and customer service on 5/27/24. 4. All residents have the potential to be affected by the alleged deficient practice. Only one (R3) was identified. 5. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 5/28/24, with the IDT (Interdisciplinary) team, the plan to address the area of concern was discussed. 7. On 5/26/24 and 5/27/24 interviewed all alert residents on (R3's) hall to ask if they have had any issues with staff abuse. 6. Administrative team will monitor 3 times weekly for 60 days using monitoring form designated for this PNC (past non-compliance). All patterns and trends will be brought to QAPI for changes as needed.

Based on interview and record review, the facility failed to remove surgical staples and to obtain an x-ray as ordered for 1 of 11 residents (R1) reviewed for quality of care in the sample of eleven. This failure resulted in R1's surgical hip incision becoming infected and requiring antibiotic therapy. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Congestive Heart Failure, Anxiety Disorder, and Chronic Kidney Disease. R1's 1/5/24 Minimum Data Set (MDS) documented that R1 had severe deficits in cognitive function. R1's Nursing Progress Notes documented the following: On 1/29/24 at 8:10am: Continues to complain of severe pain right hip/right leg. Had hydrocodone and ativan around 3:20am, then Tylenol at 7:12am. No relief. Moaning. Will not sit up in wheelchair straight. Total assist with toileting and transfer this morning, unable to stand on right leg. No internal/external rotation of extremities noted. Complains of pain when right leg or hip touched or when right leg is moved. Called (V14, Physician) office and notified of severe pain and no relief from pain medications. Asked for Xrays. New order received to send patient to ER (emergency room ) for evaluation for severe right hip pain. On 1/29/23 at 11:37am: Called (local hospital) ER to check on patient, daughter at ER. Patient has Right hip fracture and will be admitted . On 2/5/24 at 4:38pm: (R1) was (re)admitted to our community. A 2/5/24 Hospital After Visit Summary documented, Reason for admission: Hip fracture due to Osteoporosis. Discharge instructions: Schedule an appointment with (V15, Orthopedic Surgeon) as soon as possible for a visit. Remove (surgical) staples (to right hip incision) on 2/8/24. X-ray hip 2/8/24. Does not have to come to the office unless there are problems, as needed. Keep dressing in place for seven days. R1's February 2024 Treatment Administration Record (TAR) documented, 2/5/24: Keep (right hip) dressing in place for seven days, (check) every shift. The TAR documented that this was done on all three shifts from 2/5/24 through 2/16/24. The same TAR documented, 2/5/24: On 2/8/24: Remove staples to right hip. There were no initials documented on the TAR on 2/8/24, indicating the staples had not been removed as ordered. R1's Nursing Progress Notes further documented the following: On 2/9/24 at 2:02pm: (Portable Xray Provider) Technician called stated he is so sick and cannot come to do her follow up x-ray, will come tomorrow. On 2/10/24 at 5:00pm: Called (x-ray provider) (to) follow up x-ray ordered was not done yet. Reminded them (facility) called to set this up early in week. (Provider) reports no technicians to send out right now, they will send one out when they get someone. On 2/11/24 at 9:15pm: (Portable x-ray provider) was here to do follow-up x-ray of residents fractured right hip. There was no documentation in these notes to indicate V15 (Orthopedic Surgeon) had been notified that the x-ray was not able to be obtained per V15's order. R1's Progress Notes further document the following: On 2/12/24 at 9:33am: X-ray (right) hip done yesterday. Results came in last night. Sent report to (V15) for review. X-ray noted a total right hip replacement intact. Surrounding soft tissues normal. On 2/16/24 at 2:15pm: Right hip: Possible infection: Incision is red, warm to touch, has purulent drainage and a little swollen. Noted 24 staples. Called (V15's) office and spoke to his nurse (V6, Registered Nurse). (V6) said that she will call (V15) because he is on vacation and will get back to us. On 2/16/2024 at 2:38pm: (V6) called and she said that (V15) would like us to remove the staples and if we can take pictures to send. (V6) was advised that we are not allowed to take pictures. (V6) then stated if she can come over to take the pictures herself, she was advised that she can. On 2/16/2024 at 2:40pm: 24 staples were removed, resident tolerated it well. Incision is approximated and no dehisce (dehiscence) noted. On 2/16/2024 at 2:44pm: (V6) is here to assess and take pictures to the right hip incision to send to (V15). On 2/16/2024 at 3:05pm: (V6) gave an order (from V15) to start the following orders: Cefadroxil Oral Capsule 500 mg (milligrams) one tablet twice daily, (and) to the right hip incision: Cleanse wound with wound cleanser, apply (skin barrier) to peri (perimeter of ) wound, apply triple antibiotic ointment, cover with abdominal pad and secure with gauze and tape. R1's February 2024 Medication Administration Record (MAR) documented an order with a start date of 2/17/24 at 8:00am for Cefadroxil Oral Capsule Give 500 mg by mouth every morning and at bedtime for infection to right hip for 7 Days. A Physician's Note from V15 dated 2/19/24 documented, Patient (R1) has superficial irritation and/or infection at staple sites. Wound appears better today than it did on 2/16, now that staples are out. Contact (V14, Medical Doctor) regarding bilateral leg edema. Continue (Cefadroxil) 500mg BID (twice daily) until one week course completed. Return to office in one week if wound looks suspicious. On 6/6/24 at 1:35pm, V3, Licensed Practical Nurse/Wound Care Nurse, stated on 2/16/24 she had assessed the hip incision, which appeared red, warm, and swollen with purulent drainage, and the staples were still intact. V3 stated prior to 2/16/24 she had not evaluated or treated the wound. V3 stated one of the floor nurses, she is not sure which one, had asked her to assess the wound when it was realized it was probably infected. V3 stated V6 gave them orders from V15 to remove the staples, apply a dressing, and begin an antibiotic. V3 stated she removed the staples and applied the dressing. V3 stated she left on maternity leave on 2/17/24 and does not know anything about R1's care after that point. On 6/6/24 at 2:45pm, V2, Director of Nurses, stated she was not very familiar with R1's care, and does not recall ever having gone into her room. V2 stated she did not know why the staples were not removed on 2/8/24 as ordered. V2 stated to her knowledge, the issue was not identified until V3 evaluated the wound on 2/16/24. V2 stated the issue was discussed in the facility's Quality Assurance Meeting but the root cause of the failure was not determined. V2 stated when she reviewed the discharge summary, the orders were confusing as they were to take the staples out on 2/8/24 but leave the dressing in place for 7 days, which would have been 2/12/24. V2 stated an x-ray was ordered for 2/8/24 but was not done due to scheduling problems with the x-ray provider. V2 stated the x-ray was finally done on 2/11/24. V2 confirmed staff had not contacted V15 to clarify the discharge orders nor report that a portable x-ray could not be done, but they should have. On 6/11/24 at 8:00am, V6 stated that V15 was currently on vacation and would be unable to speak to the Surveyor. V6 confirmed the office was called on 2/16/24 and she inspected the incision as stated in the Nursing Progress Notes. V6 stated when she saw the wound, the staples had been removed, and the incision was reddened and obviously irritated at the sites where the staples had been. V6 stated she took photos of the wound and V15 reviewed the photos and V15 stated to V6 that the staples being left in too long had caused it to get irritated and infected, and he ordered an antibiotic. V6 stated the facility staff had also told her the x-ray had not been done on 2/8/24 as ordered. V6 stated V15's standard orders on hip replacement surgery are to leave the dressing in place for 7 days after the surgery, then at that time get the x-ray and remove the staples. V6 confirmed the staples were to have been removed and an x-ray obtained on 2/8/24. V6 stated upon discharge, the resident did not need to make an appointment with V15 unless there were problems, but since the incision had become infected V15 had seen R1 on 2/19/24. V6 stated staff should have called to say the x-ray could not be done on the date it was ordered, but they did not. V6 further stated the facility could have called them to clarify the orders if needed but they did not. On 6/11/24 at 10:00am, V1, Administrator, stated the facility does not have policies for surgical wound care, following physician's orders, or readmitting residents following hospitalization .

Based on interview and record review, the facility failed to provide daily denture/oral hygiene care for 4 of 4 residents (R1, R7, R5, R6) reviewed for ADL (Activities of Daily Living) care in the sample of eleven. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Congestive Heart Failure, Anxiety Disorder, and Chronic Kidney Disease. R1's 1/5/24 Minimum Data Set (MDS) documented that R1 had severe deficits in cognitive function and required moderate assistance from staff for oral hygiene and denture care . On 6/4/24 at 8:20am, V4, Family Member of R1, stated she had noted on several occasions that R1's dentures were yellow, odorous, and covered with layers of caked on food particles. 2. R7's Face Sheet documented an admitted [DATE] and listed diagnoses including Multiple Sclerosis and Diabetes Type 2. R7's 3/2/24 MDS documented that R6 had minimal deficits in cognitive functioning, had range of motion impairment to both upper extremities, and requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 9:40am, R7 was alert and oriented. R7 stated staff do not offer to help or remind her to clean her dentures. R7 stated staff will help her to clean them only if she asks, and, Some (staff) are more willing than others. 3. R5's Face Sheet documented an admitted [DATE] and listed diagnoses including Diabetes Type 2 and history of Cerebral Infarction. R5's 4/18/24 MDS documented that R5 had minimal deficits in cognitive functioning, and that R5 requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 10:10am, R5 was alert and oriented. R5 stated she took out her top dentures and put them on the bedside table 2 weeks ago and hasn't seen them since, despite staff searching for them. R5 stated she has a dental appointment later this week to get impressions made for a new set. R5 stated she has some of her own teeth on the bottom. R5 stated the only time staff assist her with denture and oral care is when they have CNA (Certified Nursing Assistant) students working. R5 stated CNA staff are usually too busy to assist with denture care. 4. R6's Face Sheet documented an admitted [DATE] and listed diagnoses including Atrial Fibrillation, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. R6's 5/6/24 MDS documented that R6 had severe deficits in cognitive functioning, had restricted range of motion in both upper extremities, and that R6 required set up and clean up assistance for oral hygiene and denture care. A Grievance Form dated 5/12/24 completed by V5, Power of Attorney for R6, documents I am still not seeing workers posting on (R6's) calendar when they are brushing her teeth. On 6/6/24 at 12:45pm, V5 stated R6 has memory problems as well as a torn right rotator cuff and cannot lift her arm to do her own denture care. V5 stated when she took R6 to the dentist shortly after her May 2022 admission to the facility, the dentist showed her R6's top partial denture plate, Which was caked with layer upon layer of old food. He said she needed to have her teeth and dentures cleaned at least once daily. They (staff) weren't doing it so finally I put a calendar in her room and asked the CNA's to initial it whenever they did her oral care. I haven't put the June (2024) one up, there is probably no point, because nobody is initialing the calendar. I guess it's possible they're doing it but forgetting to mark it down. Whenever I ask the CNA's about why they're not doing it, whichever shift I'm talking to blames another shift. I did a grievance with the Administrator about it about mid May 2024. On 6/6/24 at 1:10pm, a large May 2024 calendar was observed in R6's room, which had been initialed on 5/2/24, 5/13/24, 5/16/24, and 5/20/24. On 6/6/24 at 1:20pm, V1, Administrator, confirmed V5 filed a grievance on 5/12/24 stating that CNA's were not taking care of R6's dentures and teeth, and that V5 had put a calendar in R6's room to initial when they performed oral care. V1 stated she believes staff are doing the oral care but not initialing it on the calendar. V1 stated there is nowhere in the electronic medical records to document when oral/denture care is done. On 6/5/25 at 2:20pm, V13, CNA, stated CNA's are to take out the dentures at bedtime, brush them, and soak them overnight with a cleaning tablet. V13 stated there have been occasions during morning care when he has noted that residents dentures have not been cleaned and soaked overnight. On 6/6/24 at 11:50am, V12, CNA, stated at bedtime, dentures are to be removed, cleaned, and soaked overnight. V12 stated dentures and teeth should also be brushed after meals. On 6/11/24 at 10:00am, V1 stated the facility does not have a denture care/oral hygiene policy.

Based on interview and record review the facility failed to ensure timely assistance was provided for toileting needs for 1 (R56) of 6 reviewed for Activities of Daily Living in the sample of 51. This failure resulted in R56 expressing undue feelings of frustration, embarrassment, and neck pain. Findings Include: R56's Admission Record documented an original admitted to the facility as 7/1/22. R56 is documented as being a [AGE] year old female with diagnoses including but not limited to: Secondary Parkinsonism, Unspecified; End Stage Renal Disease; Nontraumatic Subarachnoid Hemorrhage, Unspecified, etc. R56's Minimum Data Set (MDS) with an Assessment Reference Date of 2/27/24 documented a Brief Interview for Mental Status Score of 13, indicating she's cognitively intact. The same MDS documented in Section GG0130, Dependent care for toileting hygiene. Section GG0170 also documented a dependent status for toileting transfer. Section H0300 documented R56 as being frequently incontinent. R56's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care Performance Deficit with a date initiated as 7/2/23. Interventions listed for this focus area document, The resident requires 2 staff participation to use toilet. On 05/21/24 at 09:53 AM, R56 was observed sitting in her wheelchair in her room, with a mechanical lift sling underneath her. R56 was observed being alert and oriented to person, place, and time. R56 stated her only concern with the facility is the amount of time it takes staff to answer call lights, specifically to use or get off the toilet. R56 stated that the average time it takes for call lights to be answered is 30 minutes she would say, but up to 2 hours. R56 stated she can confirm these times by the use of the clocks in her room, where were visualized during this interview. R56 stated this seems to be the worst first thing in the morning, and then after lunch and around 2 PM. R56 stated she has experienced incontinence episodes waiting for staff to take her to the restroom, as well as neck pain, waiting so long for staff to get her off the commode. R56 stated she finds it frustrating and embarrassing when she experiences incontinence and must be changed out of wet clothes and cleaned up. On 5/23/24 at 1:55 PM, R56 was alert and oriented to person, place and time. R56 again confirmed that she utilizes a commode for toileting needs. R56 stated that when left on the commode for prolonged periods of time, waiting for staff to come back and tend to her after being placed on the commode, she will experience a pain level in her neck she rates as a 7 on a 10 point scale, with 10 being the worst. R56 stated that she does not receive pain medication at these times for her neck, as the pain is relieved once repositioned off the commode. R56 confirmed that she does experience incontinence, but stated she knows when she is experiencing incontinence for the most part, and the incontinence stems from waiting for staff assistance. On 5/23/24 at 2:00 PM, V6 (Certified Nurse Assistant) stated that she worked the 2 PM - 10 PM shift, frequently on the 200 hall. V6 stated that R56 does utilize a commode for toileting needs and can appropriately utilize her call light. V6 stated that R56 is frequently incontinent by the time staff answer her call light. V6 stated that R56 has previously had a stroke so she isn't sure if R56 doesn't push her call light early enough for staff to get to her before she's incontinent but confirms there are times R56 is continent on the commode, even after experiencing incontinence. V6 stated although she cannot give specific resident names, she acknowledges she has had residents complain to her regarding call light answer times and recognizes staff response times could be improved. V6 stated that on the 200 hall for the 2 PM- 10 PM shift, there are usually 3 CNA's scheduled and one nurse. V6 stated that 200 hall has heavy care resident's that require a lot of staff time. On 5/22/24 at 12:31 PM, V3 (Certified Nurse Assistant, CNA) stated that she works from 6 AM - 2 PM at the facility, usually on 200 hall. V3 stated that she feels like the facility has enough staff, as there are generally 4 CNA's and a nurse staffed on 200 hall. V3 stated that 200 hallway is just heavy care with several residents requiring the assistance of two staff at a time for tasks. V3 stated she answers the call lights in the order she sees them illuminate, and as quickly as possible. V3 stated at times residents are having to wait for staff assistance, it is because staff are busy working with other residents. On 5/22/24 at 12:38 PM, V4 (CNA) stated that he normally works from 6 AM - 2 PM on the 200 hall. V4 stated that he feels like the facility has enough staff. V4 stated that there are just times when multiple heavy care residents needs assistance, which takes up time and the amount of staff available to assist others. V4 stated when residents are having to wait for assistance, it is due to staff being with other resident's, not that they are just standing around. On 5/22/24 at 12:54 PM, V1 (Administrator) stated that the facility does not have a staffing policy, and the facility follows regulatory guidelines for staffing needs. V1 stated that there have been concerns presented to her on and off, stemming from resident council meetings regarding long call light wait times. V1 stated that the facility will go through periods where the times will be reported as being better, then worse again. V1 stated the facility has explored different options to try and improve call light wait times, including dispersing heavy care residents on different halls in the facility, looking at the staffing needs, staff productivity, etc. On 5/23/24 at 1:50 PM, V1 stated that her expectation is that call light be acknowledged by staff within 5 minutes. On 05/23/24 at 02:51 PM, V7 (Medical Director) agreed that his expectations would be for staff to tend to call light answer times as soon as possible. V7 acknowledges that a commode could potentially be uncomfortable and if a resident was expressing discomfort and unsatisfactory wait times, those concerns would need addressed and evaluated.

Based on interview and record review, the facility failed to ensure residents are free from abuse for two of three residents (R2 and R6) reviewed for abuse in the sample of 3. This failure resulted in R6 experiencing having clothing placed over his mouth twice in an attempt to quiet him. A reasonable person would also experience feelings of humiliation, intimidation, fear, emotional distress, and helplessness as a result. This past non-compliance occurred between 4/13/24 and 4/16/24. Findings include: 1.R6's face Sheet documented an admitted [DATE], and diagnoses including Autistic Disorder, Dysphagia, Repeated Falls, and Unspecified Intellectual Disabilities. R6's Minimum Data Set (MDS) dated for 3/12/2024, documents that R6 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that R6 has severe cognitive impairment. The same MDS documents that R6 is totally dependent on at least two persons assist for upper and lower body dressing. On 5/10/2024 at 1:40pm, attempted interview with R6 but due to severe cognitive impairment, R6 was unable to answer questions appropriately. On 5/10/2024 at 10:26am, V1 (Administrator) stated she was notified on 4/13/2024 at approximately 9:00am by V21 (Licensed Practical Nurse/ LPN) about an allegation of abuse. The allegation of abuse involved staff V23 (Certified Nurse's Assistant/ CNA) to R6. V1 stated V21 reported the allegation of abuse to her and that V23 was escorted out of the facility and R6 was assessed. V1 stated that R6 is unable to recall the event due to his diagnoses and appears to be doing well. V1 stated that V23's employment was terminated due to substantiated abuse allegation. V1 stated that it was reported to her by V21 that V12 (Certified Nurse Assistant/CNA) witnessed an abuse situation between V23 and R6. V1 stated that R6 has verbal outbursts regularly due to his diagnosis and V23 covered his mouth with clothing two different times while getting him ready for supper. V1 stated that she has never had any issues with V23 having abused any residents before, and was surprised and saddened that this was reported. V1 stated that V21 had V23 leave the facility as soon as this was reported. On 5/10/24 at 11:07AM, V12 (CNA) stated that on 4/13/24 she and V23 were assisting R6 in getting ready for supper. V12 stated that R6 was not acting different that his normal state of yelling out. V12 states that R6 at times yells and is not having any distress or pain but is just part of his verbal outbursts associated with autism. V12 stated that as she and V23 were assisting R6 with getting dressed, V23 placed his pants and shirt at two different times over his mouth to quiet him while saying when you stop, I'll stop. V23 stated that R6 was not acting any different than normal behavior and was not harming himself or anyone. V12 feels that emotionally R6 is doing better now that V23 no longer works here. V12 stated that R6 is unable to communicate how he feels or what happened that day due to his speech impairments, but he appears to be doing well. On 5/10/24 at 11:37AM, V21 stated that V12 came and reported the incident of abuse to her as soon as it happened. V21 stated that she immediately checked on R6 and he was eating dinner and appeared to be doing well and could not recall the situation. V21 stated that she then had V23 write a statement of what occurred and was walked out of the building and she reported the incident to V1 who is the abuse coordinator. On 5/14/24 at 11:15AM, V24 (Family Member) stated that the facility reported to him on the day that the abuse occurred and told him the employee was terminated. V24 has no concerns with the facility and feels they take great care of R6. The Abuse Investigation provided by the facility was reviewed regarding the incident between V23 and R6. A typed statement dated 4/13/24 from V21 documents the following: On 4/13/24, I was assigned as floor nurse on 200 hall. I started work at 1530 (3:30PM). Began passing meds (medications) around 1600 (4:00 PM). Around 1615 (4:15 PM) V12 approached me at the med (medication) cart and stated I need to tell you something about V23 when we get to the dining room. I stated okay and passed the medication. V12 stated that while V23 and I were getting R6 up for dinner, he was screaming and V23 held his shirt over his mouth and said, 'you stop and I'll stop. Then we got R6 transferred into his wheelchair, he began screaming again and V23 took R6's pants and again put it over his mouth and stated, you stop and I'll stop. I (V21) immediately locked my medication cart and went to find V23 and asked her to speak with me. V23 admitted that she did indeed hold his shirt, and then his pants over his mouth in an effort to get him to stop screaming, and then stated, well it wasn't covering his nose. I (V21) replied in question do we cover our resident's mouths in order to quiet or console them? She (V23) replied well, I have before. I (V21) questioned her stating do you understand this is abuse and you legally cannot do that? she (V23) stated she hadn't done it at this facility before today. I (V21) replied we are going to have to ask you to clock out and leave the facility, I am required to report this to V1, our administrator and she will be in contact with you if she needs anything further. She (V23) stated I will call V1 myself. I (V21) stated that is fine, but I am still required to contact her myself. V23 left the facility with no issues. 2. R2's admission record documents an admitted [DATE]. This same document has a date of birth as 6/25/33 and includes the following diagnoses: Acute Respiratory Failure, Major Depressive Disorder, and vascular dementia. R2's 4/4/24 MDS Section C documents a BIMS of 3 indicating a cognitive impairment. On 5/7/24 at 1:05PM, V10 (CNA) stated that she was working the day the incident occurred when R5 wandered into R2's room. When R2 told him to leave he mumbled something and shoved R2 which caused her to stumble and fall hitting her back on the bed. V10 stated that she witnessed R2 stumble and fall on her bottom but did not hit her head. V10 went on to state that R2 does not remember the incident and has not had any behavioral concerns resulting from this happening to her, nor has she had any lasting effects. V10 stated that she was assessed immediately. Nursing progress note from 5/3/2024 by V29 (LPN) documents R5 entered R2's room and R2 stood up and told R5 to get out and R5 shoved her in the chest causing R2 to fall. R2 landed on her bottom. R2 hit her mid back on the side rail of the bed but did not hit her head. V29 notified POA (Power of Attorney) and physician. No new orders at this time due to no injury noted. On 5/7/24 at 10:26 AM, V1 stated that she substantiated the resident-to-resident abuse between R5 to R2. V1 stated that the police, the emergency contact and the physician were all notified and that R2 did not sustain any injuries from the physical abuse. V1 stated that R5 has had behaviors resulting in her initiating an involuntary discharge in January but could not find a facility that would accept him. V1 stated that after some medication changes his behaviors had slightly diminished so he was allowed to stay longer than expected, but after this incident he was sent to the local emergency room and not allowed to return. On 5/7/24 at 10:32AM, V25 (Family Member) stated that she was notified that R2 had a fall and that a resident had pushed her (R2) down in her room. V25 stated that she did not sustain any physical injury from this incident but is concerned that R5 would come back to the facility. V25 stated that she had not seen him since the call where she was informed, he wouldn't be returning, but she wanted to make sure. V25 stated that she felt he was unsafe to be around these elderly confused residents and is worried for her aunt and all the other resident's safety. On 5/7/24 at 1:30PM, R2 was attempted to be interviewed regarding the incident. However, due to cognitive impairment R2 was unable to answer questions appropriately. The facility policy titled Abuse Prevention and Prohibition Policy, with a revision date 11/24, documents under the statement of intent, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 4/16/24. In attendance - V1, V8 (Director of Nursing), V17 (CNA), V2 (RN/MDSC - Minimum Data Set Coordinator/Care Plan Coordinator), and V18 (LPN), V27 (Physician). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1 was educated on the abuse and neglect policy , resident rights by the regional nurse on 4/16/24. All residents were asked if they had any issues with staff abuse and all staff were educated on the abuse and neglect policy, resident rights by V1 on 4/16/24. 4. Plan to monitor performance to ensure solutions are sustained: V1 or designee will question 5 staff weekly for the next 60 days on the abuse policy to monitor for understanding. V1 or designee will question 5 residents weekly for the next 60 days to monitor for instances of abuse towards them.

Based on record review, interview and observation, the facility failed to transfer one resident (R11) safely, bumping R11's ankle during transfer which resulted in a fractured distal left fibula of the1 of 7 in house residents reviewed for fractures.from the sample of 21. Findings include: 1. R11's [DIAGNOSES REDACTED]. is assessed as severely impaired. The nurse note of 11/15/10 indicated R11 "res (resident) bed positioned away from wall, res has been kicking wall". The nurse note of 11/24/10 indicated R11 had a "bruise on L (left) ankle". On 11/30/10 (nurse note) the physician was notified of left foot, increased edema and ecchymosis left lateral aspect, toe cyanotic, no pedal pulse, good capillary refill left toes, grimaces and flinches with touch left foot. R11 was sent to the hospital for Xray which indicated a fracture distal fibula. On 03/08/11 at 10:40 A.M., R11 was observed in a low bed, a mat on the floor and wedge cushions placed on mattress on each side of the bed. The left side of the bed was observed next to the wall. Interview with E10 (CNA) on 03/08/11 at 11:45 A.M., E10 stated the fracture did not occur with R11 kicking the wall. E10 stated it occurred with improper transfer of (R11). Review of the incident report dated 11/24/11, the report had a conclusion dated 12/01/10, stated, "it seems that CNA recalls bumping the resident's ankle on her (reclining) chair arm rest while transferring the resident to bed. CNA stated that resident is unable to assist with transfer and that three CNA's were used for this transfer. Resident is in a low bed which make her unable to be transferred with a (mechanical) lift". On 03/08/11 at 1:50 P.M., three CNA's (E4, E5, E11) were observed transferring R11 from the reclining chair to the bed. The bed was in a low position with the wedge cushions on the mattress on each side of the bed. Two CNA's on each side of the chair placed their arm under R11's arms and the third CNA lifted R11's feet. The CNA's then swung R11 from the chair to the low bed. This transfer of R11 from the chair to the low bed was discussed with E2 on 03/08/11 at 3:30 P.M. On 03/09/11, R11 was provided an electric bed that could be placed in a high position for transfer with a mechanical lift.